Talking the talk, walking the walk: Social network norms, communication patterns, and condom use among the male partners of female sex workers in La Romana, Dominican Republic

Abstract

Male partners of female sex workers are rarely targeted by HIV prevention interventions in the commercial sex industry, despite recognition of their central role and power in condom use negotiation. Social networks offer a naturally existing social structure to increase male participation in preventing HIV. The purpose of this study was to explore the relationship between social network norms and condom use among male partners of female sex workers in La Romana, Dominican Republic. Male partners (N = 318) were recruited from 36 sex establishments to participate in a personal network survey. Measures of social network norms included 1) perceived condom use by male social network members and 2) encouragement to use condoms from social network members. Other social network characteristics included composition, density, social support, and communication. The primary behavioral outcome was consistent condom use by male partners with their most recent female sex worker partner during the last 3 months. In general, men reported small, dense networks with high levels of communication about condoms and consistent condom use. Multivariate logistic regression revealed consistent condom use was significantly more likely among male partners who perceived that some or all of their male social network members used condoms consistently. Perceived condom use was, in turn, significantly associated with dense networks, expressing dislike for condoms, and encouragement to use condoms from social network members. Findings suggest that the tight social networks of male partners may help to explain the high level of condom use and could provide an entry point for HIV prevention efforts with men. Such efforts should tap into existing social dynamics and patterns of communication to promote pro-condom norms and reduce HIV-related vulnerability among men and their sexual partners.

Introduction

The Dominican Republic (DR) has a long history of innovative HIV prevention programs in the female commercial sex industry. An environmental–structural intervention integrating community solidarity and government policy strategies demonstrated significant reductions in sexually transmitted infections (STI) and increases in condom use among female sex workers in the DR (Kerrigan et al., 2006). Continued HIV-related vulnerability, however, as documented by the frequency of STI and gaps in consistent condom use with regular partners, indicates the need to continue building upon these efforts. Dominican women working in the sex industry have articulated the need to directly address the sexual behaviors of men, within and beyond the sex establishment (Kerrigan, Moreno, et al., 2003). The non-governmental organizations that implemented the aforementioned environmental–structural HIV prevention program in the DR, the Centro de Orientación e Investigación Integral and the Centro de Promoción y Solidaridad Humana, have also utilized theater and street outreach to reach men. While these activities have been met with high levels of acceptance, they have not been conducted in a systematic fashion and have never been evaluated for their influence on HIV risk behaviors. This study sought to understand how the dynamics of social influence processes among men may abet or impede sexual risk reduction practices in order to develop more effective HIV prevention interventions.

Male clients of female sex workers (both paying and non-paying) who have unprotected sex with multiple, concurrent partners are especially vulnerable to infection with HIV and other sexually transmitted infections (Hor et al., 2005, Wang et al., 2007). They have also been referred to in the epidemiological literature as a “bridge population” in the transmission of HIV due to their central role in sexual networks that include a range of partners (e.g. wives, girlfriends, sex workers) with varying levels of condom use (Chetwynd and Plumridge, 1994, Lowndes et al., 2000, Mills, 2000). Traditional approaches to HIV prevention in the context of female sex work generally place the responsibility for condom use solely on the woman. In turn, such efforts fail to address the gender, economic, and social inequalities implicit in the relationships between sex workers and their clients and other sex partners (Lowndes et al., 2000). Additionally, norms of masculinity across and within cultures may increase pressure to engage in sexual risk behaviors and/or impede HIV prevention efforts to reduce these behaviors among men (Courtenay, 2000, UNAIDS, 2001).

While investigators have emphasized the need to include male clients in HIV prevention interventions (Fajans et al., 1995, Lowndes et al., 2000, Wilson et al., 1989), few empirical intervention studies have been conducted with this population (Leonard et al., 2000, Lowndes et al., 2007, Walden et al., 1999). Lowndes et al. (2007) reported significant reductions in STI and increases in condom use among male clients in Benin following an intervention entailing outreach by male peer educators in sex establishments and a free STI clinic for men. As peer based approaches inherently rely on connections between individuals as a way to reach and influence people, the results from Benin highlight the potential impact of HIV prevention efforts to reach men through their existing social networks. Following the previously mentioned environmental–structural HIV prevention intervention in the DR (Kerrigan et al., 2006), qualitative interviews and focus groups were conducted with ninety male clients of female sex workers to identify approaches to improve their participation in prevention efforts (Catino et al., 2003). The majority of male clients expressed openness to participating in HIV/STI prevention efforts, which according to them have historically targeted women. Many participants suggested tapping into their existing social networks to facilitate outreach efforts, which motivated the need to improve understanding of social networks and social influence patterns among men in this setting.

The relationships and interactions that occur within social networks are considered critical to understanding sexual behavior and HIV risk (Bond et al., 1999, Friedman et al., 2001, Latkin and Knowlton, 2000, Youm and Laumann, 2002). These interactions inform perceptions of the “normal” or most prevalent behaviors among network members, referred to as descriptive norms, and perceptions of acceptable behaviors, referred to as injunctive norms (Cialdini, Reno, & Kallgren, 1990). Cialdini et al. (1990) have proposed that descriptive norms motivate behavior by conveying the idea of what is normal and inspiring others to do the same, while injunctive norms motivate people to do what they perceive they should do in order to avoid social sanction. Both descriptive and injunctive norms have been associated with public (e.g. needle sharing) and private (e.g. condom use) HIV-related behaviors (Buunk and Bakker, 1995, Davey-Rothwell and Latkin, 2007a, Hawkins et al., 1999, Latkin et al., 2003). Interventions that strive to alter social network norms to promote HIV protective behaviors have been proposed as a sustainable way to change behavior by tapping into naturally existing social structures and forms of interaction to stimulate normative influence processes (Celentano et al., 2000, Latkin et al., 2003).

Few studies have specifically examined the influence of norms on the sexual behaviors of male partners of female sex workers. Ford et al. (2002) conducted a study among male clients of female sex workers in Bali that measured two perceived condom norms: 1) friends use condoms with sex workers and 2) friends give advice to use condoms. These investigators found significant associations between both measures of perceived condom norms and condom use. Although this study offers insight into the potential influence of perceived norms on sexual risk behaviors among male clients, the perceived norms were not measured in reference to specific social network contacts, but rather at the more general level of “friends”.

While the literature includes several studies examining associations between peer or social network norms and sexual risk behaviors, the question of which social network characteristics (i.e. size, composition, cohesion) influence perceptions of normative beliefs and behaviors within networks has received less attention (Boer and Westhoff, 2006, Davey-Rothwell and Latkin, 2007b, Latkin et al., 2003). Identifying the social network characteristics that contribute to perceptions of network norms can improve understanding of how these norms influence behavior and provide insights for the development of social network-based HIV prevention interventions. Social network cohesion, for example, reflects the density of ties in the network, as well as the strength of ties between network members, and is an indicator of the potential availability of social support (Carpentier and White, 2002, West et al., 1999). While the content of cohesive ties can be beneficial for health outcomes by providing opportunities for social interaction (Carpentier & White, 2002) and promoting healthy norms (Kawachi & Berkman, 2001), cohesive networks can also perpetuate the norms that HIV prevention efforts are trying to change, especially in terms of gender and sexual behavior (Latkin et al., 2003, Reid, 2000).

In addition to the potential role of structural network properties in shaping perceived norms, communication between social network contacts has been proposed as the overarching mechanism through which social networks inform the development of normative perceptions and influence behavior, especially private behaviors such as condom use (Hogg and Reid, 2006, Rimal and Real, 2003). Talking or joking about condoms and sexual risk behaviors reflects what Noar, Carlyle, and Cole (2006) refer to as “warm up” discussions that may create the opportunity for more persuasive communication, such as encouragement to use condoms (Noar et al., 2006). Studies have reported both positive and negative associations between communication and HIV-related behaviors among drug using populations, highlighting the need for context-specific research (El-Bassel et al., 2006, Kang et al., 2005, Latkin et al., 2003).

The purpose of this study was to improve understanding of social network influences on sexual risk behavior among the male partners of female sex workers in La Romana, DR. The three study aims were to: 1) describe the individual and social network characteristics of male partners; 2) examine the association between social network norms and consistent condom use and 3) identify social network characteristics that are associated with perceived condom use.