NIH Public Access Author Manuscript AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. NIH-PA Author Manuscript Published in final edited form as: AIDS Educ Prev. 2010 October ; 22(5): 455–465. doi:10.1521/aeap.2010.22.5.455. Condom Access: Associations with Consistent Condom Use among Female Sex Workers in Two Northern Border Cities of Mexico Fátima A. Muñoz, MD1, Robin A. Pollini, PhD1, María Luisa Zúñiga, PhD1, Steffanie A. Strathdee, PhD1, Remedios Lozada, MD2, Gustavo A. Martínez, MD3, Ana M. VallesMedina, MPH4, Nicole Sirotin, MD1, and Thomas L. Patterson, PhD5 1Division of Global Public Health, School of Medicine, University of California, San Diego 2Patronato Pro-COMUSIDA, Tijuana, Mexico 3Community NIH-PA Author Manuscript Health & Development of Ciudad Juarez (SADEC) and Mexican Federation of Private Associations (FEMAP), Ciudad Juarez, Chihuahua, Mexico 4Master in Public Health Program, Autonomous University of Baja California, Tijuana, Mexico 5Department of Psychiatry University of California, San Diego and MIRECC, VA Medical Center, San Diego, California Abstract NIH-PA Author Manuscript To determine whether condom access is associated with consistent condom use among FSWs in Tijuana and Ciudad Juarez, between 2004 and 2006 we administered a questionnaire to 924 FSWs who reported unprotected sex with a client in the past two months. Of these women, 43% reported consistent (“often” or “always”) condom use; 74% said condoms were available; and 38% reported having access to free condoms. In a logistic regression, factors positively associated with consistent condom use were condom availability (AdjOR = 2.00; 95% CI: 1.32–3.03), condom affordability (AdjOR = 1.72; 95% CI: 1.25–2.38) and self–efficacy (AdjOR = 2.16; 95% CI: 1.54– 3.04). Factors inversely associated with consistent condom use included poor financial status (AdjOR = 0.65; 95% CI: 0.47–0.90), methamphetamine use (AdjOR = 0.58; 95% CI: 0.40–0.83), alcohol use (AdjOR = 0.68; 95% CI: 0.49–0.96), and recent injection drug use (AdjOR = 0.62; 95% CI: 0.39–0.97). While increased condom availability may improve condom use among FSWs in general, interventions to broaden condom use among lower-income and drug-using FSWs are critically needed. Keywords female sex workers; condom use; prevention; HIV/AIDS; behavioral interventions; Mexico According to the United Nations Program on HIV/AIDS (UNAIDS), unprotected sex is the main vehicle of HIV transmission in Mexico and Latin America (Cohen, 2006; ONUSIDA, 2008). In 2008, the Mexican state of Chihuahua, where Ciudad Juarez is located, ranked fifth nationally with an HIV prevalence of 0.5%, while Baja California, where Tijuana is located, ranked 7th at 0.4%; both rates stand well above Mexico’s national prevalence of 0.3% (CENSIDA, 2008). Corresponding Author: Thomas L. Patterson, Mail Code 0680, 9500 Gilman Drive, La Jolla, CA 92093-0680. Telephone: (858) 534-3354. FAX: (858) 534-7723. tpatterson@ucsd.edu. Muñoz et al. Page 2 NIH-PA Author Manuscript The sex work industry thrives in many cities of northern Mexico, with female sex workers (FSWs) frequently servicing clients from both the United States and Mexico. FSWs are considered a high risk group for acquiring and transmitting HIV (Jimenez, Lara, & Rosado, 2001; Patterson, Semple, et al., 2008), and HIV prevalence among FSWs in the Mexico– U.S. border region is increasing. In 1997, only 0.6% of FSWs tested positive for HIV (del Rio & Sepúlveda, 2002); by 2008, 6.0% tested positive (Patterson, Semple, et al., 2008). Factors such as low socioeconomic status, migration, low education levels, drug use, and knowledge and perceptions about HIV and condom use all have been linked to risky sexual behaviors among FSWs (Basuki et al., 2002; Cohen, 2006; Dandona et al., 2005; Jimenez et al., 2001; Patterson et al., 2006b; Rhodes et al., 2007; Strathdee, Lozada, Semple, et al., 2008). However, condom access also plays a role, particularly in developing countries, because FSWs must have access to condoms in order to use them consistently (Morris, Morris, & Ferguson, 2009). NIH-PA Author Manuscript Consistent condom use plays a vital role in preventing sexual transmission of HIV and has consequently become the primary focus of interventions targeting vulnerable groups such as FSWs (Cohen, 1999; Kayembe et al., 2008; ONUSIDA, 2001; Zhao, Wang, Fang, Li, & Stanton, 2008). In Mexico, the Secretariat of Health, through the national HIV/AIDS program, promotes condom use and provides free condoms at community health centers, but these programs cannot ensure access to condoms for sex workers who do not attend these centers. In a recent behavioral intervention to promote condom use among FSWs in Tijuana and Ciudad Juarez, Mexico, of the 924 FSWs who completed the study, the intervention group had a 40% lower cumulative HIV/STI incidence after six months of follow-up, which was significantly lower than the control group. Incidence density for the intervention vs. control was 13.8 vs. 24.92 per 100 person years (py) for STIs combined, and 0 vs. 2.01 per 100 py for HIV, with concomitant increases in total numbers and percentages of protected sex acts and decreases in total numbers of unprotected sex acts with clients (Patterson, Mausbach, et al., 2008). Another study in Louisiana showed that a condom social marketing intervention improved condom use by increasing condom distribution and availability (Cohen et al., 1999). NIH-PA Author Manuscript Lack of access to condoms has become a significant barrier to safer sexual practices, particularly in developing countries (Cohen, 1999; Little, Myer, & Mathews, 2002; Myer, Mathews, & Little, 2002). Some persons with low income rely upon free condoms and use them to engage in sexual services to fulfill economic needs; for them, limited access leads to high-risk behavior (Little et al., 2002; Rhodes et al., 2007; Sunmola, Adebayo, & Ogungbemi, 2008). Individuals who both purchase condoms and can obtain them free of charge may report more consistent condom use than those who rely on purchase alone (Sunmola et al., 2008); however, in developing countries, low availability of condoms has been associated with unprotected sexual practices (Morris et al., 2009). Other barriers to condom use that specifically affect FSWs should also be taken into account. Clients’ demands; poor condom negotiation skills; higher pay for unprotected sex; lack of knowledge about HIV; and negative attitudes toward condom use may also significantly hinder FSWs’ adoption of safer sex practices (Bucardo, Semple, Fraga-Vallejo, Davila, & Patterson, 2004; Eva, Munakata, & Onuoha, 2007; Garcia, Yam, & Firestone, 2006; Ntumbanzondo, Dubrow, Niccolai, Mwandagalirwa, & Merson, 2006). Few studies have examined the association between condom access and condom use while controlling for these factors, particularly in low and middle income countries where there is a close relationship between sex work and HIV transmission (Kayembe et al., 2008). In this study, we examine the association between condom access and consistent condom use among FSWs in Tijuana and Ciudad Juarez, Mexico. AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Muñoz et al. Page 3 METHODS STUDY SETTINGS NIH-PA Author Manuscript The data for this analysis were taken from a multi-site, randomized trial of a condom-use intervention (Patterson, Mausbach, et al., 2008). The first phase of the intervention study was conducted in two cities, Tijuana and Ciudad Juarez, between 2004 and 2006. Tijuana is the largest city in the state of Baja California, Mexico, and is situated on the U.S. border adjacent to San Diego, California. Tijuana, one of Mexico’s fastest growing cities, had a population of 1,410,700 in 2005; roughly half of Baja California’s population lives in Tijuana (INEGI, 2005), although over half of Tijuana’s inhabitants were born outside the state. The Tijuana–San Diego border crossing has become one of the busiest in the world, with over 48.6 million people crossing in 2007 (SANDAG, 2007). Sex work is quasi-legal in Tijuana, and researchers estimate that between 4,850 and 9,000 registered sex workers operate in the city (Brouwer et al., 2006). Not surprisingly, Tijuana is also a common destination for sexual tourism, especially among U.S. residents. NIH-PA Author Manuscript Ciudad Juarez is located in the Mexican state of Chihuahua, across the U.S. border from El Paso, Texas. In 2005, it had a population of 1,313,338, with 36% of its residents reporting that they were born outside Chihuahua (INEGI, 2005). In 2007, a reported 32.4 million people crossed the border from Ciudad Juarez to El Paso. In Ciudad Juarez as in Tijuana, sex work is quasi-legal, and an estimated 4,000 FSWs work in the city (Patterson et al., 2006b). STUDY POPULATION Between January 2004 and January 2006, 924 FSWs were recruited into a behavioral intervention study intended to increase condom use in Tijuana and Ciudad Juarez (Patterson et al., 2006a). Outreach workers approached women in the zona roja (red light district) of each city, and women who expressed interest in participating in a safer-sex study answered a series of screening questions to establish their eligibility. Women could also learn about the study from municipal or community health clinics and present themselves at the study office for screening. A number of “red herring” questions were included in the screener to make the eligibility criteria less easy to guess. The eligibility criteria included being at least 18 years of age; having exchanged sex for drugs, money or other commodities within the past 2 months; and having had unprotected vaginal or anal sex with at least one client within the past four weeks. All study participants provided written informed consent prior to giving data. Women were excluded if they reported that they had previously tested HIV-positive. DATA COLLECTION NIH-PA Author Manuscript Trained, Spanish-speaking, female counselors administered the baseline survey face-to-face in private clinic rooms or outreach offices (Patterson et al., 2006a). The structured questionnaire took approximately 35 to 40 minutes to complete. Interview variables included sexual risk behaviors, working conditions, financial need, use of alcohol and drugs, social support, social influence, life experiences, social cognitive factors, and sociodemographics. Behavioral outcomes were also assessed, including frequency of unprotected sex with clients, number of clients, number of sex partners who inject drugs, and how much money the participant earned per sex act with and without a condom. Study protocols were reviewed and approved by institutional review boards in San Diego, Tijuana, and Ciudad Juarez. Participants were compensated US$30 the baseline visit and US$30 for the six-month follow-up visit. AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Muñoz et al. Page 4 STATISTICAL ANALYSIS NIH-PA Author Manuscript The primary outcome variable in this study was consistent condom use by FSWs with their clients. Participants used a scale (never, sometimes, often, always) to report how often they used a condom for vaginal sex with clients. These values were collapsed to create a binary outcome for consistent (always or often) vs. inconsistent (never or sometimes) condom use with clients. Because one of the eligibility criteria for the intervention study was having had unprotected sex (either vaginal or anal) with a client at least once in the past four weeks, it was predictable that only a very small number of participants would endorse “always” using a condom with a client for vaginal sex (presumably those women whose eligibility for the study was established by their having had unprotected anal rather than vaginal sex with a client in the past four weeks). In fact, only 26 participants (3% of the sample) stated that they “always” used a condom for vaginal sex with clients, so that the subsample of “consistent” condom users consisted mainly of women who stated that they use condoms “often” for vaginal sex with clients. Given this binary outcome, we examined the extent to which FSWs with consistent and inconsistent condom use with clients differed in the following five domains: (1) sociodemographics; (2) social environment, including financial situation, working conditions, client characteristics (e.g. nationality, drug use), number of clients, and main work venue (e.g., brothel, street, bar); (3) condom access, including whether they could afford their own condoms or had access to free ones; (4) use of alcohol and illicit drugs, including whether drugs and alcohol were used before or during sex with clients; and (5) perceptions and beliefs about condom use, including a five-item self-efficacy measure for proper use of condoms with clients (e.g. “I can use a condom properly”); and a five-item outcome expectancies measure on the benefits of using condoms (e.g. “I believe that condoms will protect me from catching HIV”). Responses to both of these measures were on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). The alpha for the self-efficacy scale for this sample was 0.85; that for the outcome expectancies scale was 0.79 (Patterson et al., 2006a). NIH-PA Author Manuscript Baseline data were analyzed to compare FSWs who reported consistent condom use with those who did not. Continuous variables were examined using the Wilcoxon rank sum test, while categorical data were examined using Fisher exact tests or chi-square tests. Logistic regression was used to identify factors associated with consistent condom use. Multivariate models were developed by a manual procedure according to which all variables of interest that attained a significance level of <10% were considered stepwise, beginning with those with the highest p-value. The likelihood ratio test was used to compare nested models, using a significance level of 5% to select variables for inclusion in the final model. We also explored interactions between variables in the final model, including interactions by site. NIH-PA Author Manuscript RESULTS The study enrolled a total of 924 FSWs (474 in Tijuana and 450 in Ciudad Juarez). In comparing participants from Tijuana and Ciudad Juarez (Table 1), we found significant site differences for age, marital status, whether they had only Mexican or also some U.S. clients, main work venue, methamphetamine use in the last month, and lifetime use of cocaine. Median age was 32 years; most participants (87%) were born outside the state in which they participated in the study. About one-fourth (24%) were married or reported living in common-law relationships, and the majority (94%) had children. In terms of work environment, FSWs were most likely to report working on the street (44%) rather than in a bar (35%). The majority (91%) reported sex work as their main source of income; one-third of the FSWs (36%) considered their financial situation “bad,” 55% reported “neither good nor bad,” and a lower percentage (9%) considered their financial situation “good.” Almost all (95%) attributed their involvement in sex work to financial need. AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Muñoz et al. Page 5 NIH-PA Author Manuscript Three-quarters of FSWs (74%) reported having condoms available every time that they had vaginal sex with clients; 69% said they could afford to buy their own condoms (average cost of a condom in Ciudad Juarez and Tijuana is 14–16 pesos (about US$1). Access to free condoms was limited, with a low percentage (6%) reporting getting free condoms “always,” 4% reporting “often,” 28% “sometimes,” and 62% “never.” Use of alcohol in the past month was reported by a majority of FSWs (73%). The illicit drug that was most frequently used in the last month was methamphetamine (endorsed by 21% of participants), followed by cocaine (20%), marijuana (19%), and heroin (14%). Significant numbers of participants also reported using alcohol (59%) and illicit drugs (32%) before or during sexual encounters with clients. NIH-PA Author Manuscript Table 1 also compares the characteristics of FSWs who reported consistent condom use with clients (43%) and those who did not (57%). Consistent condom users (n = 401) were more likely to be married or living in common-law relationships (29% vs. 20%, p = 0.004), report having access to condoms (87% vs. 65%, p < 0.001), be able to buy their own condoms (79% vs. 62%, p < 0.001), and have U.S. clients (31% vs. 23%, p = 0.006). FSWs who reported consistent condom use were also significantly more likely to demonstrate higher self-efficacy regarding condom use with clients, including using condoms properly (93% vs. 85%, p < 0.001), using condoms every time they had vaginal or anal sex (97% vs. 83%, p < 0.001), and using condoms while under the influence of drugs (80% vs. 66%, p < 0.001). FSWs who reported consistent condom use were also significantly less likely to report being in a bad financial situation (28% vs. 41%, p < 0.001) (Table 1). In the final multivariate model (Table 2), after controlling for significant potential confounders among the demographic variables shown in Table 1 (i.e., place of birth, marital status, and education), a number of factors were independently associated with consistent condom use. Those positively associated with consistent condom use were having access to condoms (AdjOR = 2.12, 95% CI: 1.38–3.25), being able to afford condoms (AdjOR = 1.57, 95% CI: 1.12–2.20), self-efficacy regarding condom use per unit increase in score (AdjOR = 2.16, 95% CI: 1.54–3.04) and lifetime use of cocaine (AdjOR = 1.46, 95% CI: 1.06–2.02). Factors independently but negatively associated with consistent condom use were being in a bad financial situation (AdjOR = 0.65, 95% CI: 0.47–0.89), having used methamphetamine at least once in one’s lifetime (AdjOR = 0.68, 95% CI: 0.40–0.83), having used alcohol in the past month (AdjOR = 0.68, 95% CI: 0.49–0.96), and using injected drugs within the last month (AdjOR = 0.62, 95% CI: 0.39–0.97). No significant interactions were observed. DISCUSSION NIH-PA Author Manuscript Our study of FSWs in Tijuana and Ciudad Juarez indicates that fewer than half of these women used condoms consistently with clients. We found that condom availability, condom affordability, and condom use self-efficacy were independently and positively associated with consistent condom use with clients. One of the most important findings to emerge from these data was the strong link between condom availability and use of condoms with clients. Specifically, we observed that for FSWs in Tijuana and Ciudad Juarez, it was more important to have condoms available than to get them for free. Perhaps for this reason, we also found an association between consistent condom use and being able to afford condoms. From a behavioral intention perspective, it is reasonable to hypothesize that availability serves as a proxy for intention, in that study participants who reported condom availability may have had condoms available precisely because they took measures to ensure that availability prior to need. AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Muñoz et al. Page 6 NIH-PA Author Manuscript These results are consistent with those of studies performed in Indonesia (Basuki et al., 2002), India (Dandona et al., 2005), Republic of Congo (Kayembe et al., 2008), Ghana (Adu-Oppong, Grimes, Ross, Risser, & Kessie, 2007), Kenya (Morris et al., 2009) and Louisiana (Bedimo, Pinkerton, Cohen, Gray, & Farley, 2002; Cohen & Farley, 2004; Cohen et al., 1999). These studies all found that access to condoms was a major predictor of safe sexual practices. These studies also documented an association between low prevalence of condom use and lack of access. According to the literature that supports our findings, even where purchasing condoms is not a problem (Sunmola et al., 2008), affordability is of little help unless FSWs have access to condoms at the moment they are needed. Lack of access to condoms leads FSWs to unprotected sexual practices with their clients, and this predicament is more probable among women who work on the streets (Gu et al., 2008). Larios et al. (2009), in a different study of our sample, found that rates of unprotected sex for FSWs who work in the street (compared to those who work in bars) were disproportionately affected by lack of access to condoms. Our study also shows that FSWs whose main work venue is the streets report slightly less consistency in condom use compared to women who work in bars and hotels. Taken together, these findings indicate that workplace venues are important areas of future research inquiry and that providing greater access to condoms allows for higher rates of protected sex acts (Adu-Oppong et al., 2007; Nai-Ying et al., 2008). NIH-PA Author Manuscript Our findings on ability to afford condoms are consistent with those of other studies that have shown an association of affordability with consistent condom use, an association that is even more important than that between consistent condom use and the availability of free condoms (Sunmola et al., 2008). However, in contrast with studies that found an association between obtaining free condoms and consistent condom use (Adu-Oppong et al., 2007; Cohen, 1999; Drezin, MA, & K, 2006; Kumar et al., 2006; Nai-Ying et al., 2008), we found no such significant association among FSWs in Tijuana and Ciudad Juarez. In Mexico, some prevention programs distribute free condoms; however, our study findings indicate that this is insufficient for ensuring consistent condom use among FSWs in the two cities that we studied. We found an independent association between higher levels of self-efficacy for using condoms and consistent condom use with clients. This finding is consistent with other studies (Gu et al., 2008; Knipper et al., 2007; Patterson, Mausbach, et al., 2008; Villarruel, Jemmott, Jemmott, & Ronis, 2004) that have demonstrated that self-efficacy to use a condom is correlated with lower sexual risk and is particularly predictive of condom use. Increasing condom self-efficacy through motivational interventions appears to be effective as well in increasing consistent condom use among FSWs. NIH-PA Author Manuscript Our study also found that the self-perception of being in a bad financial situation, having ever used methamphetamine, having used alcohol in the past month, and injecting illegal drugs in the past month were all independently and negatively associated with consistent condom use in the FSWs in our sample. Previous studies in Tijuana and Ciudad Juarez (Bucardo et al., 2004) and other cities (Dandona et al., 2005; Gu et al., 2008; Gutierrez, Molina-Yepez, Morrison, Samuels, & Bertozzi, 2006; Nemoto et al., 2008) have shown that financial difficulty can be a major reason for women to begin sex work, whereas other researchers have reported that some women are pressured by family or by the use of drugs to participate in risky sexual behaviors in exchange for money. FSWs often earn more money for having sex without condoms, as has been mentioned in previous studies targeting the same population (Strathdee, Philbin, et al., 2008). Numerous studies have demonstrated an association between substance use and risky sexual behavior (Eldemire-Shearer & Bailey, 2008; Morgenstern et al., 2009; Patterson, Semple, et al., 2008). In accordance with previous findings, the use of illicit drugs is associated with AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Muñoz et al. Page 7 NIH-PA Author Manuscript inconsistent condom use (Gu et al., 2008; Morgenstern et al., 2009; Strathdee, Philbin, et al., 2008). In our study, use of injected drugs and use of methamphetamine were both negatively associated with consistent condom use. Methamphetamine use is very common among FSWs in Tijuana (Patterson, Semple, et al., 2008), and it can affect the central nervous system, causing impaired judgment and higher-risk sexual behaviors (Corsi & Booth, 2008; Rusch et al., 2009). Interestingly, we found a positive association between lifetime cocaine use and consistent condom use. We expect this association is due to the higher association between both lifetime cocaine use and condom use with residence in Ciudad Juarez (vs. Tijuana), an association that persisted even after we controlled for recruitment site. It may also be that past cocaine use is associated with another risk variable that is not sufficiently controlled for in our model. NIH-PA Author Manuscript Limitations of our study include inability to measure sexual behaviors with clients directly, particularly the extent to which FSWs exchanged sex for drugs rather than for money, which has been reported elsewhere (Inciardi, 1995; McMahon, Tortu, Pouget, Hamid, & Neaigus, 2006; Strathdee, Lozada, Ojeda et al., 2008). Another limitation to consider is that condom availability was based on self-report and that “consistent condom use” in this study comprised both “often” and “always.” Certainly “always” using a condom is the desired behavioral outcome for primary prevention of HIV transmission; however, in light of the very high risk behavior reported by our study population, “often” using a condom is a step in the right direction and may be viewed as a success. Since participants were recruited through convenience sampling and because higher-risk women were selected by design, our findings may not reflect the experience of other FSWs and are likely not representative in each city. NIH-PA Author Manuscript The relationships we observed between drug use behaviors and consistency of condom use among FSWs are important and should be further investigated. Intensified behavioral interventions could be implemented to promote condom use among high risk FSW subgroups, although some aspects, such as FSWs’ poor economic status, would be difficult to alleviate. Greater access to drug and alcohol treatment may help by intervening upon the relationship between drug dependence and lower condom use. Understanding which types of client exert more pressure and are willing to pay more for sex without condoms could uncover avenues for interventions focused on clients. Further, our data emphasize the need to enhance both condom availability and FSWs’ access to condoms. Condoms can be made more readily available in bars, motels, and restrooms, to optimize their use. Moreover, our findings add to the existing evidence of the value of motivational interventions for enhancing FSWs’ self-efficacy, since self-efficacy is associated with consistent condom use in this population. Acknowledgments Funding Sources The study that yielded the data for this paper was supported by NIH R01 MH065849 (Patterson). Certain individual co-authors were also supported by the following NIH grants: R25 DA025571 (Muñoz); K01 DA022923 (Pollini); R01 DA023877 (Strathdee); K01 MH072353-05 (Zúñiga). REFERENCES Adu-Oppong A, Grimes RM, Ross MW, Risser J, Kessie G. Social and behavioral determinants of consistent condom use among female commercial sex workers in Ghana. AIDS Education & Prevention. 2007; 19(2):160–172. [PubMed: 17411418] AIDS Educ Prev. 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Participant sociodemographic and risk characteristics Demographics Median age (years) (IQR) AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Born in study location: Tijuana 61 (7%) 33 (8%) 28 (5%) Years lived in study city (IQR) Ciudad Juarez 13 (5,25) 12 (5,24) 14 (6,27) 0.103 Married or living with common-law spouse 222 (24%) 115 (29%) 107 (20%) 0.004 6 (4,8) 6 (5,9) 6 (4,8) 0.033 Had children 862 (94%) 370 (92%) 492 (95%) 0.110 Speak English 181 (20%) 85 (21%) 96 (19%) 0.300 411 (44%) 170 (42%) 241 (46%) 0.209 Educational attainment (Years) (IQR) Social Environment Main workplace Street Bar or cantina 325 (35%) 131 (33%) 194 (37%) 0.163 Hotel or other 188 (21%) 100 (25%) 88 (17%) 0.002 Bad financial situation 328 (36%) 114 (28%) 214 (41%) < 0.001 Financial need drives sex work 881 (95%) 379 (96%) 502 (96%) 0.372 Condom availability 683 (74%) 347 (87%) 336 (65%) < 0.001 Can afford to buy own condoms 634 (69%) 316 (79%) 318 (62%) < 0.001 Never 570 (62%) 244 (61%) 326 (63%) 0.001 Sometimes 258 (28%) 100 (25%) 158 (30%) Obtain free condoms: Often 40 (4%) 20 (5%) 20 (4%) Always 55 (6%) 37 (9%) 18 (3%) Had Mexican Clients 810 (88%) 341 (86%) 469 (90%) 0.034 Had US Clients 248 (27%) 126 (31%) 122 (23%) 0.006 Had clients who used drugs 676 (73%) 294 (73%) 382 (73%) 0.925 Had clients who injected drugs 292 (32%) 118 (30%) 174 (33%) 0.208 Smoked marijuana in the last month 173 (19%) 79 (20%) 94 (18%) 0.502 Used heroin in the last month 130 (14%) 49 (12%) 81 (16%) 0.158 Drug and alcohol use Page 11 NIH-PA Author Manuscript NIH-PA Author Manuscript Always or often use condom (n = 401) Never or sometimes use condom (n = 523) p-value Used cocaine in the last month 181 (20%) Ever used methamphetamine 282 (31%) 104 (26%) 77 (15%) < 0.001 104 (26%) 178 (34%) 0.008 Used methamphetamine in the last month Used alcohol in the last month 197 (21%) 73 (18%) 124 (24%) 0.043 673 (73%) 280 (71%) 393 (76%) 0.072 Injected illegal drugs in the past month 114 (12%) Used alcohol during or before sex 546 (59%) 52 (12%) 62 (12%) 0.167 225 (56%) 321 (61%) 0.116 Used illegal drugs during or before sex 297 (32%) 135 (34%) 162 (31%) 0.393 Muñoz et al. NIH-PA Author Manuscript AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1. Baseline Characteristics Total (n = 924) FSW beliefs about condom use I can use condom properly 817 (89%) 372 (93%) 445 (85%) < 0.001 I can use condom every time I have vaginal or anal sex 819 (89%) 387 (97%) 432 (83%) < 0.001 I can use condoms under influence of drugs 664 (72%) 319 (80%) 345 (66%) < 0.001 Condoms protect me against HIV 807 (88%) 359 (90%) 448 (86%) 0.099 Condoms interfere with sexual pleasure 518 (56%) 243 (61%) 275 (53%) 0.016 Page 12 Muñoz et al. Page 13 Table 2 NIH-PA Author Manuscript Factors independently associated with consistent condom use among female sex workers in two Northern Cities in Mexico Variable* Availability of condoms (yes vs. no) Adjusted Odds Ratio 95% Confidence Interval 2.12 1.38–3.25 Can afford their own condoms 1.57 1.12–2.20 Self-efficacy to use of condom (per unit increase) 2.16 1.54–3.04 Bad financial situation (yes vs. no) 0.65 0.47–0.89 Had ever used cocaine 1.46 1.06–2.02 Had ever used methamphetamine 0.68 0.40–0.83 Used alcohol in the past month 0.68 0.49–0.96 Injected illegal drugs in the past month 0.62 0.39–0.97 * The following variables that were significant in univariate analyses were controlled for in the multivariate analyses: birthplace (inside or outside of the study city), marital status, and years of education. NIH-PA Author Manuscript NIH-PA Author Manuscript AIDS Educ Prev. Author manuscript; available in PMC 2011 October 1.