Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana

Objective: To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana. Design: The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention. Setting: The community-based intervention was initiated in Accra, Ghana in 1987. Participants: Self-identified female prostitutes who volunteered participation. Intervention: The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributers to their peers. Outcome measures: Self-reported condom use with clients. Results: Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use. Conclusions: Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.