Street Outreach for STD/HIV Prevention -- Colorado Springs, Colorado, 1987-1991

Strategies to identify and influence persons at increased risk for infection with human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) require outreach to provide prevention messages directly to persons at risk, assist them to obtain prevention services, and encourage them to reduce risks. Street outreach programs complement CDC's information and education campaign "America Responds to AIDS" by providing persons with specific risk-reduction messages and materials (1). This report describes efforts to implement such approaches in Colorado Springs, Colorado, and presents preliminary results regarding the prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis infections among female street prostitutes in that community.

Since 1969, women who identified themselves or were referred to the health department as prostitutes in Colorado Springs (El Paso County) have been offered voluntary screening for gonorrhea and syphilis (2,3). From 1970 through 1986, 19% of specimens cultured for N. gonorrhoeae were positive; 20 cases of syphilis were also diagnosed. In June 1985, screenings were augmented by voluntary counseling and testing for HIV antibody and in June 1987 for C. trachomatis.

In 1987, after a cross-sectional study established the prevalence of HIV and other STDs in 98 prostitutes (4), the El Paso County Health Department began an intensive program of risk-reduction counseling and condom distribution for female prostitutes in Colorado Springs. Health workers visited sites where prostitutes congregate to 1) present and reinforce messages about STDs and HIV infection prevention, 2) encourage prostitutes and their sex partners to visit the local health department clinic for HIV-antibody testing and screening for other STDs, 3) refer drug users to local drug-treatment programs, and 4) dispense free condoms and bottles of bleach (for injecting-drug users (IDUs) to use in cleaning needles and syringes). On average, one worker spent approximately 1 hour per day in the field, spoke with approximately five prostitutes per day, and distributed approximately 300 condoms per week.

In 1990, the prevalence of N. gonorrhoeae infections among prostitutes declined substantially and remained lower in 1991 (Table 1). An analysis based on a logistic regression model (5) suggested that the prevalence of both N. gonorrhoeae and C. trachomatis infections in 118 different prostitutes was inversely related to frequency of testing. When an adjustment was made in the model for the effect of the year of testing, 32 prostitutes who were tested five or more times were significantly less likely to be infected with N. gonorrhoeae than 86 prostitutes who were tested less frequently (odds ratio=0.2; 95% confidence interval=0.1-0.6).

From 1987 to 1990, reported cases of gonorrhea among prostitutes, their sex partners, and all others in Colorado Springs declined 16%, from 1001 cases to 840 cases. From 1987 through 1990, three cases of early syphilis were diagnosed among prostitutes. Of 252 prostitutes tested for HIV antibody from 1985 through 1990, 11 (4.4%) were positive; of the 10 interviewed, nine were IDUs.

Reported by: DE Woodhouse, JD, JJ Potterat, JB Muth, MD, JU Reynolds, MD, El Paso County Dept of Health and Environment, Colorado Springs; J Douglas, MD, FN Judson, MD, Denver Dept of Health and Hospitals, Denver. Office of the Director, National Center for Chronic Disease Prevention and Health Promotion; Div of HIV/AIDS, National Center for Infectious Diseases; Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The increased risk for gonorrhea and other STDs among prostitutes reflects their increased exposure to infected sex partners. In Colorado Springs, street outreach, the active distribution of condoms, and repeated testing and counseling to reinforce risk-reduction messages were key components of the program initiated in 1987 to promote the proper and consistent use of condoms to prevent sexual transmission of HIV. Although direct measures of condom use are unavailable, the recent decline in gonorrhea may indicate, in part, increased condom use by sex partners of prostitutes.

The more than 2-year period between implementation of the outreach program and the decline in the prevalence of gonorrhea may reflect gradual changes in attitudes and behaviors among prostitutes that were associated with increasing interaction with health-care workers. One possibility for the decline in the number of infections with N. gonorrhoeae could be that more proper and consistent condom use occurred among prostitutes and their sex partners. However, neither attitude nor behavior changes were measured directly. Other factors that may have affected the decrease in gonorrhea among prostitutes are unknown.

In New York City (6) and Kinshasa, Zaire (7), shifts in attitudes and behaviors followed the implementation of similar programs to promote condom use in targeted populations. However, because the program in Colorado Springs was not conducted as part of a randomized trial with control communities, the effectiveness of outreach, message reinforcement, and repeated testing could not be rigorously evaluated. Nevertheless, in Denver (approximately 60 miles (100 km) north of Colorado Springs), infections with N. gonorrhoeae among STD clinic patients declined 21% (8), but infections with N. gonorrhoeae among prostitutes fluctuated.

Street outreach programs such as the one described in this report must be evaluated rigorously by state and local health departments, community-based organizations, and CDC. Future outreach evaluations should assess behavior changes in IDUs not in treatment and young persons at high risk for HIV infection and other STDs.

References

1. CDC. HIV-infection prevention messages for injecting drug users: sources of information and use of mass media--Baltimore, 1989. MMWR 1991;40:465-9.

2. Potterat JJ, Rothenberg R, Bross DC. Gonorrhea in street prostitutes: epidemiologic and legal implications. Sex Transm Dis 1979;6:58-63.

3. Potterat JJ, Woodhouse DE, Muth JB, Muth SQ. Estimating the prevalence and career longevity of prostitute women. The Journal of Sex Research 1990;27:233-43.

4. Darrow WW, CDC Collaborative Group. Prostitution, intravenous drug use and HIV-1 infection in the United States. In: Plant M, ed. AIDS, drugs, and prostitution. London: Routledge, 1990:18-40.

5. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:13-22.

6. Friedman SR, Jose B, Neaigus A, et al. Peer mobilization and widespread condom use by drug injectors (Abstract). Vol 2. VII International AIDS Conference. Florence, Italy, June 16-21, 1991:36.

7. Tuliza M, Manoka AT, Nzila N, et al. The impact of STD control and condom promotion on the incidence of HIV in Kinshasa prostitutes (Abstract). Vol 1. VII International AIDS Conference. Florence, Italy, June 16-21, 1991:20.

8. Judson F, Cohn D, Douglas J. Fear of AIDS and incidence of gonorrhea, syphilis, and hepatitis B, 1982-90 (Abstract). Vol 2. VII International AIDS Conference. Florence, Italy, June 16-21, 1991:303.

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