J Primary Prevent (2014) 35:93–102 DOI 10.1007/s10935-013-0333-0
ORIGINAL PAPER
Getting the Shots: Methods to Gain Adherence to a Multi-Dose Vaccination Program for Inner City, Drug-Involved Prostitution Communities Giffin W. Daughtridge • Timothy W. Ross Paola A. Ceballos • Carmen E. Stellar
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Published online: 21 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Street-based sex-work and poly-substance drug use, coupled with low vaccination rates and limited utilization of the mainstream health care system, put the sex worker communities of Bogota´’s city center at extreme risk of infection with the hepatitis B virus (HBV). Vaccination is critical to maintaining low prevalence of the disease and low incidence of new cases, yet the floating and inconsistent nature of Bogota´’s drug-involved female and transsexual prostitution communities make it difficult to complete a
G. W. Daughtridge Perelman School of Medicine at the University of Pennsylvania, 3620 Hamilton Walk, Philadelphia, PA 19104, USA G. W. Daughtridge (&) 2400 Chestnut St. Apt. 1704, Philadelphia, PA 19103, USA e-mail: [email protected] T. W. Ross Fundacio´n Social Fe´nix, Carrera 3a, No. 21-46, Apto. 2604-A, Bogota´, Colombia e-mail: [email protected] P. A. Ceballos Universidad de La Salle, Carrera 5 N. 59A 44, Bogota´, Colombia e-mail: [email protected] C. E. Stellar Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA e-mail: [email protected]
3-dose vaccination program. Between December 2011 and March of 2012, the Fe´nix Foundation collaborated with the Bogota´ Health Department to deliver free HBV vaccines to this vulnerable population. This paper outlines methods used in the vaccination program to generate a 37.7 % adherence rate, significantly higher than that previously reported for HBV vaccination programs also targeting marginalized populations. This program’s practices are based on the Fe´nix peer leader method, and are offered as a model that can be applied to other health interventions operating in analogous contexts, with similarly high-risk populations. Keywords Hepatitis B Vaccination Prostitution Peer leaders Health intervention adherence Street communities
Introduction In Colombia, prostitution is a legally permitted activity for people over the age of 18. Sex workers are required to receive intermittent health assessments to identify and treat sexually transmitted infections (STI). However, street-based sex workers who are unaffiliated with brothels are largely unregulated, represent a highrisk population with a variety of unmet health needs, and were the primary target of an STI vaccination program. A 2009 study conducted in Bogota´, Colombia, found that 24 % of 514 female sex workers (FSW) described themselves as female street-based sex
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workers (FSSW). Relative to sex workers who worked in bars, brothels, and clubs, these women reported a greater number of clients per week, and were typically younger, more likely to use illegal drugs, less likely to use a condom during vaginal sex with clients, more likely to have a syphilis infection, and more likely to belong to a lower socio-economic stratum (Mejia et al., 2009). FSW under the age of 18, whether street-based or in clandestine brothels, are at a particularly high risk of disease (Pinzo´n-Rondo´n et al., 2009). Due to frequent engagement in high-risk activities, female and transsexual street-based sex workers are in great danger of contracting and transmitting pathogens through infected bodily fluids. High-risk behaviors endemic to this population include: unprotected sexual intercourse with multiple partners, extensive drug use resulting in bio-fluid contact, tattoos and piercings using shared instruments, and physical transformation operations performed by unlicensed amateur surgeons (Gust, 1996; Lavanchy, 2004). It is therefore especially important to target this population in vaccination campaigns aimed at controlling viral disease. The transmission of hepatitis B via infected blood or other bodily fluids is a pressing global health problem and a particular concern for individuals involved in prostitution. About 350 million people worldwide suffer from chronic hepatitis B infection, and the virus is estimated to be 50–100 times more transmissible than HIV (WHO, 2012c). As Mast et al. (2006) have noted, ‘‘Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death’’ (p. 1). The vaccine has been available since the early 1980s (Francis et al., 1982; Szumeness et al., 1980). Studies have shown that seroprotection rates— defined as an antibody to hepatitis B antigen (anti-HBs) level of C10 mIU/mL—are achieved by at least 90 % of patients receiving three doses of the vaccine (Adkins & Wagstaff, 1998; He´rnandez-Bernal et al., 2011). Colombia initiated universal neonatal vaccination against hepatitis B in 1994 (Mayor Mora et al. 2010), but because the Colombian minimum legal age for prostitution is 18, almost no adult sex workers had received the full course of the vaccine when our vaccination program was initiated in 2011. The necessity of a completed hepatitis B vaccine course for this population was demonstrated by a Venezuelan study conducted in 2003, which found that 13.8 % of
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sex workers sampled tested positive for anti-HBc serologic markers, indicating previous or ongoing infection with hepatitis B. Based on these results, the authors recommended that the Venezuelan Ministry of Health initiate programs to vaccinate sex workers against hepatitis B (Camejo et al., 2003). A similar catch-up immunization course for the sex worker population in Bogota´ is also necessary. Unfortunately, it is very difficult to successfully implement such a program due to real and perceived obstacles to accessing healthcare for marginalized populations. Colombia’s most impoverished and indigent populations are eligible for a government-subsidized form of social security, which covers emergency and preventive health services for low-income citizens, including free vaccines (Caprecom, 2013). Many street-based sex workers have difficulty navigating the enrollment process, while others possess some form of health insurance, but remain infrequent consumers of healthcare services. Mejia et al. (2009) estimated that over 60 % of female sex workers in Bogota´ have health insurance, and noted that even insured sex workers seemed to underutilize available health services. It is possible that FSSW and transsexual sex workers have lower levels of health insurance as they are more socially excluded, but further research is needed in order to determine how discrimination and self-exclusion interact to produce low levels of healthcare-seeking behavior in this particularly vulnerable population (Dror & Jacquier, 1999; Jeal & Salisbury, 2004). In addition to barriers to accessing the healthcare system, completing the hepatitis B three-dose vaccine schedule is problematic in an unstable and floating population with high rates of poly-substance abuse, weak social support structures, frequent changes in locations of work and residence, and poor capacity to project into the future and to keep appointments. Consequently, we needed to develop new contact and communication techniques to gain maximum adherence to the vaccination schedule. This paper demonstrates that principles of participatory investigation and peer led interventions (Ritterbusch, 2011; Valente & Pumpuang, 2007; Wiebel, 1993) can be used to overcome barriers to healthcare access for high-risk groups. The strategies outlined for maintaining contact can be replicated or improved in future prophylactic programs for HBV and other infections. They can also be applied to other health
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interventions such as regular pap smears and HIV testing.
Methods Informal interviews—conducted by the Fe´nix organization in September of 2011, with a convenience sample of approximately 30 people recruited by chain referral (sometimes referred to as snowball sampling)—suggested that less than ten percent of sex workers in central Bogota´ had completed HBV vaccinations. Fe´nix is a non-governmental organization with which all four authors are affiliated. It has worked with drug-involved prostitution communities since 2008 to promote enhanced healthcare-seeking behavior, self-empowerment, and opportunities for exiting prostitution. Fe´nix supports peer leaders affiliated with the organization, and as yet unaffiliated FSWs, through peer-led community outreach. Peer leaders make their own transitions from prostitution towards vocational training and professional education by first learning to act as harm reduction health educators for other FSWs and then to identify, engage, and train new peer leaders from among them. To address the low number of HBV immunized sex workers, Fe´nix requested HBV vaccines from the Bogota´ Secretary of Health and proposed a collaborative campaign for free application in two areas within key prostitution zones. In December of 2011 and January and March of 2012, a vaccination team from a local hospital administered a three-dose (20 lg/mL) course of the Bharat Biotech Revac-B ? HBV vaccine. The vaccines were applied over two days in each of these months at El Refugio and La Mariposa square. They were also offered daily in a local hospital for those not attending the vaccination days. Participants in the three-dose vaccination campaign were recruited through peer network contacts and chain referrals. Contact details of all who attended one of the two vaccination days in December were listed, and their compliance with subsequent doses was tracked by means of a comprehensive database. Peer Leader Methodology Existing peer networks within the sex work community are central to Fe´nix0 outreach methods and to the
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recruitment and retention of participants in this vaccination program. Core peer leaders are engaged through the generation of mutual relationships, which encourage the personal development of peer leaders, as well as their involvement in advocacy for their street-based social groups (e.g. distribution of condoms or invitations to healthcare activities). The work of peer leaders has a dual purpose: to help reduce risks and to generate motion towards positive decision-making. The relationships between Fe´nix and street populations are built up through the work of four kinds of peer leaders: 1
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‘Embedded’ Peer Leaders are still enmeshed in prostitution but act as key informants and information diffusers. ‘Transitional’ Peer Leaders are trying to reduce involvement in prostitution, take Fe´nix-run training classes, and function as models for others. ‘Exited’ Peer Leaders have left prostitution, found other sources of income, and are usually completing their education. They act as educators, gatekeepers, mentors, and models. ‘Congruent’ Peer Leaders study health and social care professions, but come from similar backgrounds of poverty, neglect, dysfunctional or absent families, social exclusion, and sometimes sexual abuse or exploitation, giving them the ability to identify with and mentor street youth.
Embedded peer leaders are initially identified through ‘‘staff selection,’’ by which potential leaders are recognized through community observation, and ‘‘judge’s ratings,’’ whereby community members themselves identify individuals they believe to be leaders (Valente & Pumpuang, 2007). Selected leaders may attend any number of 60–80 min workshops, which cover topics ranging from the prevention, detection, and treatment of STIs, to opportunities for education and job training. Peer leaders who demonstrate interest are invited to attend workshops focused on outreach intervention methods, and may also be offered psychotherapeutic support through the Fe´nix network of clinicians. As self-efficacy and capacity for positive action advance, the peer leaders in turn begin to teach their friends and propose new candidates for leadership work. Natural diffusion of information on opportunities for change and possibilities for exiting prostitution encourage still others to volunteer for leadership roles.
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Throughout the course of the vaccination program, one ‘transitional’ and one ‘congruent’ peer leader, who were both closely affiliated with the organization, worked directly with the study’s authors. The effectiveness of this nuclear team was enhanced by ten ‘embedded’ and ‘transitional’ peer leaders who were very supportive of the program’s goals and motivated to assist with the recruitment and retention of participants. Members were able to exploit their existing peer networks to further circulate the message of health maintenance and disease prevention. In one case, an approximately 35-year-old ‘embedded’ peer leader received a dose on the first vaccination day and was then asked to look for friends to relay what she had learned about hepatitis B. She returned shortly with another FSW and was delighted to be congratulated. During the day, she arrived three more times with one to three others, explained the procedure, shepherded them into the vaccination tent, and introduced them to the coordinator.
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by sex workers in Bogota´, especially male-to-female transsexual sex workers. They regularly offer their facilities for HIV testing, pap smears, meetings, and other services. Due to the overlapping missions of the Fe´nix organization and El Refugio, the two frequently partner on outreach activities. Fe´nix provides the peer leader network, which facilitates access to the populations on the street. El Refugio offers its ideal location and reputation as a comfortable center for free healthcare, psychological support, and—especially important in a Catholic country—spiritual comfort. The participation of nuns in action with marginalized groups helps reduce their sense of exclusion and appears to provide important support and acceptance in a country where Catholic social values can contribute to stigmatization (Bindel & Kelly, 2003). This religious order, along with two others, provides a range of services that includes schooling, vocational training, and employment, and forms part of a network of organizations defending prostitution communities. This has led to conflicts with the Catholic hierarchy, particularly over condom advocacy.
Collaboration with Other Organizations Fe´nix has a strong peer leader network, but lacks several necessary components for carrying out an effective vaccination program. The three most critical are the following: vaccines, healthcare professionals, and a safe and comfortable space near the participants’ work place in which to deliver the vaccinations. The authors identified these needs prior to the onset of the program, and were able to address all three through meetings with the Bogota´ Health Department and El Refugio convent. The Bogota´ Secretary of Health coordinates, controls, and funds all public hospitals and health programs active in the capital. The director and senior management are political appointees, who change with each four-year mayoral term, limiting long term policy planning. With regards to our program, the Health Department had the vaccines and the healthcare professionals to deliver them, but it lacked the respect of, and close contact with, the target population. Fe´nix, on the other hand, lacked vaccines but enjoyed close links with the prostitution community. The collaboration resulted in participants who were educated and recruited by Fenix0 peer network and vaccinated using the supplies and nursing staff of the Health Department. El Refugio is a Catholic convent conveniently located on a corner that abuts three of the main streets frequented
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Initial Information Dissemination Six weeks before the first vaccination day, outreach teams composed of peer leaders and the study authors began disseminating information on hepatitis B. Peer leaders helped design pamphlets and flyers featuring strong imagery, vernacular language, and alliterative, memorable phrasing. These materials were utilized during small group workshops of one to four individuals each, usually lasting 5–10 min. The workshops, generally conducted in brothels or on street corners, focused on the prevalence of the disease, its risk factors and consequences, and vaccination as the most effective prevention method, while stressing consistent condom use. We involved each workshop participant by asking questions to generate reflection on risk, asking for feedback on the most important information, and/or inviting an individual to explain key points to newcomers. Communication techniques alternated humor, clowning, and dramatic theatricality with seriousness and evidence. This style allowed us to engage the population without minimizing the gravity and lethality of the disease. In the week preceding the first vaccination day, we added dates, times, and locations of the vaccination sessions to printed educational materials. We also intensified the frequency of street outreach.
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Primary Vaccination Days (13th and 14th of December, 2011) We offered vaccines from 10 AM to 2 PM, before the increased frequency of prostitution activities and drug use would hinder attendance. Peer leaders were among the first to receive the vaccine. We then asked them to find other potential participants to bring to the vaccination locations. We gave each person who received a vaccination an immunization card that recorded the dates of the initial and upcoming doses. We recorded extensive contact information in a database, including the following: legal name, ‘‘chapa’’ or street name, identity card number, home telephone and address, work location, cell phone, and names and phone numbers of two additional contacts (e.g., family or close friends). Each person also received a printed slip with the dates of the second and third doses. Additionally, a professional outreach worker talked to each one about the importance of receiving all three doses of the HBV vaccine to achieve maximum protection. Finally, we asked each participant to spread the word to friends and, when possible, to bring in others—a key tactic in the recruitment strategy. Promotion for Second Vaccination Days We continued street outreach by distributing educational materials in vernacular language and hosting mini-workshops. The list of names and work locations of those who had received the first dose was consulted each time, so that outreach team members could locate each participant. Additionally, a peer leader familiar with all the participants called each one the night before the vaccination session. If individuals could not be contacted using primary phone numbers, we called secondary contacts. We spoke with the majority of our participants (or a secondary contact) and reminded them to attend. We recorded calls in the database so that those who were not reached could be called again the next morning. We asked the individuals we were able to contact to bring friends, especially if they had attended the first vaccination. Second Vaccination Days (17th and 18th of January, 2012) The first vaccination days’ methods were repeated. Leaders were vaccinated and then recruited others, volunteers updated participants’ vaccination cards,
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and a volunteer or outreach worker talked to each participant about the importance of completing the entire set of vaccinations. Participants who had lost their cards were located in the database and issued a new card. Two hours into the 4-h vaccination period, we used the database to call every person in our original sample who had not yet arrived for the second dose. If individuals not included in the original program arrived through peer contacts and asked to be vaccinated, we complied unless there was strong evidence that they were not genuinely members of the target population. We recommended that they go to the nearby Hospital Samper Mendoza for subsequent doses to complete their vaccination plan. Inter-Vaccination Phase In the two months between the second and third vaccinations, we used the database to individually contact the people who had not come for their second dose. We informed them that they should go to the Hospital Samper Mendoza to obtain their vaccine. We called the phone numbers they had given us, called their additional contacts as needed, searched for them on the streets near their home and work locations, and asked other sex workers if they knew the whereabouts of those on our list. We quickly discovered that most sex workers were unwilling to go to the hospital alone. The most common explanations for resistance were the distance to the hospital, their desire not to lose clients, and their reluctance to leave the apparent security of their circumscribed territory. We therefore arranged meeting times within the prostitution zones and accompanied groups of participants to the hospital. In the weeks leading up to the final vaccination day, we applied the same protocol as that used prior to the second dose. Third Vaccination Days (13th and 14th of March, 2012) We followed the same procedure used on the previous vaccination days. The authors had individual conversations with those who received their third dose to congratulate them on their accomplishment, to encourage them to continue making positive health decisions, and to urge their peers to do the same.
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Follow-Up After the third vaccination day, we made efforts to ensure that individuals who had received only one or two doses of the HBV vaccine went to the hospital for their subsequent vaccinations. Since most would not go to the hospital alone, we hired a driver and contacted everyone who had not received the three doses. All were asked to meet the following day in a specified location. From there, we drove them to the Hospital Samper Mendoza for the next dose.
Results Altogether, 122 individuals received the primary dose of the hepatitis B vaccine on the first days of the immunization series, including some sex workers’ partners. The vaccines were delivered at two locations: El Refugio (December 13th) and La Mariposa (December 14th). Promotion for the vaccination day at El Refugio gave particular emphasis to male-tofemale transsexual prostitutes, as anal sex increases the risk of acquiring viral infections, and over onethird of participants at El Refugio were transsexual (Hadler & Margolis, 1993). ‘La Mariposa,’ officially ‘Plaza San Victorino,’ is a plaza where large numbers of street-based FSW look for clients. The sex workers in La Mariposa are predominantly younger, more recent entries into prostitution, and are less institutionalized in the sex work subculture. Some maintain other income-generating activities, and resort to prostitution only part-time or at moments of crisis. La Mariposa square is frequented by a number of young, female-to-male transgender people, but almost no male-to-female transsexuals, in contrast to the population working near El Refugio. Fe´nix has done extensive intervention work in the areas around both El Refugio and La Mariposa. The resultant trust-based relationships allowed us to recruit a large proportion of this population to the initial vaccination days. This vaccination program was not planned as a study but as a public health intervention aimed at vaccinating extremely high-risk groups against HBV. Between El Refugio and La Mariposa, the ages of participants ranged from 14 to 62, with an average age of approximately 23. Though it is possible that some of the participants between the ages of 14 and 18 had already received the vaccine at birth, there was no
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additional harm in applying a second HBV vaccination (WHO, 2009). Furthermore, exact birth years could not be determined as the participants frequently lie about their age in order to attract clients, and the authors determined that the benefits of vaccinating those interested in taking a proactive stance on their health outweighed any risk of re-vaccinating them. Aside from age, which was recorded in the nurses0 identification log for each participant vaccinated, we were not concerned with recording demographic data for people receiving any dose of the vaccine; rather, we focused on gathering information that would help recruit and maintain contact with participants. In total, 38 % of the individuals who received the first dose of the vaccine on either December 13th or 14th completed the program and received the second and third doses of the vaccine, and 67 % received at least two of the three doses. At El Refugio, 42 % of the participants who received their first dose were completely vaccinated, and 65 % received at least two of the three doses. In La Mariposa, 32 % of the participants received all three doses, while 70 % received at least two. Seventy-one people not in the original cohort came to either the second or third vaccination days to receive their first dose of vaccine. Because we were most interested in creating an intervention methodology that would elicit full program adherence, these individuals were not included in the results reported above. However, each participated in a mini-workshop explaining the importance of receiving all three doses of the vaccine in order to maximize the probability of achieving seroprotection. Each person also received a vaccination card, was asked for contact information, and received a brochure or flyer with educational material on hepatitis B along with condoms and lubricants. Finally, we gave these individuals exact instructions on how to find the local hospital, and advised them to ask for their second and third doses at this hospital on the appropriate dates. We did not have the resources to follow up with each of these people in the same manner as those enrolled in the program, and this group was less likely than the original cohort to return for subsequent doses.
Discussion The threat of HBV infection presents a major public health burden for unvaccinated populations. Mejia et al.
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(2002) reported that the HBV prevalence among commercial sex workers in Bogota´ was 7.5 %, and informal interviews (see Methods) with peer leaders of the Fe´nix Foundation indicated averages per individual of 7 sexual encounters a day and 250 days of prostitution per year. First time encounters are usually protected, but the majority of workers are willing to have unprotected sex with those who pay extra or with ‘‘special’’ clients with whom they have built a consistent relationship. Anal and oral sex are seldom protected. Hadler and Margolis (1993) suggested that there is a 1–3 % chance of HBV transmission per unprotected sexual encounter in serodiscordant partners, with women more vulnerable than men, and people in prostitution, or with other STIs, at a substantially higher risk. Furthermore, this is a public health concern for the entire population, as many clients are married or have other partners to whom they can retransmit the virus. Reducing the risk of HBV transmission by targeting high-risk groups with catch-up vaccination programs should be a public health priority. Unfortunately, the need for three separate doses of the HBV vaccine, the floating nature of sex worker populations, alcohol and drug intoxication, and the instability of prostitutes’ social links make retention for a complete vaccine course problematic in this population. Exploratory research suggests that the street-based sex worker populations of Bogota´’s city center not only engage in heavy drug use, but also in high-risk sex and frequent violence, and tend to suffer devastating socioeconomic exclusion (Mejia et al., 2009; Ritterbusch, 2011; Ross, 1992). To address these challenges, an established methodology for recruiting high-risk populations to a multidose vaccination program is necessary, but the current literature on generating adherence in similar groups is limited. Searches of Medline and LILACS, a database for research in South and Central America, returned no studies that reported adherence to an HBV vaccination program for an impoverished high-risk population engaged in drug use, sex work, or seeking care at an STD clinic in Latin America. Nonetheless, the literature that does exist illustrates the difficulty of ensuring adherence to an HBV vaccination program. To give context, a similarly sized HBV vaccination program for at-risk populations seeking care at an STD clinic, though not sex workers, recorded three-dose retention percentages as low as 2.4 % (O’Rourke et al., 2001).
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Adherence to an HBV vaccination schedule in marginalized populations is a sparsely covered but important area of research. However, the development of an effective methodology for vaccinating high-risk populations is necessary and has widespread implications, not only for the prevention of HBV, but also for similarly dangerous infectious diseases whose global prevalence can be primarily controlled through vaccination. The low cost, wide availability, and flexible schedule of the HBV vaccine make it an optimal candidate for any study seeking to develop methodologies aimed at increasing adherence to a multi-dose vaccine schedule among high-risk populations. The methods used to generate adherence in this HBV program can be applied to future HBV vaccination efforts, as well as to diseases with similar risk factors and even higher mortality rates in infected persons, notably hepatitis C (HCV) and HIV. According to the WHO, these three diseases account for almost 2.8 million deaths globally per year (WHO, 2012a, b, c). Though vaccines against HCV or HIV have thus far proved elusive, candidate vaccines for these diseases are currently in phase two (HCV) or three (HIV) testing and would feature multi-dose schedules similar to that for HBV (Gray & Michael, 2013; Houghton et al., 2013). This paper advances the field of public health by presenting a methodology for vaccinating a high-risk and hard-to-access population not only against HBV, but also against HIV and HCV if and when those vaccines come to market. Impact and Future Outlook The intended outcomes of this program were twofold: to reduce the risk of HBV infection among central Bogota´’s sex workers, and to develop a methodology for future prophylactic efforts amongst high-risk populations. By enrolling 122 members in the program, and completing a three-dose schedule for 38 % of them, a significant number of high-risk people should now have protection against HBV infection. Furthermore, Cassidy et al. (2001) showed that two doses of the hepatitis B vaccine conferred seroprotection in over 95 % of adolescents vaccinated, whereas one dose conferred seroprotection in 63.8 % of adolescents vaccinated. Thus, the public health impact of our study extends well beyond just those included in the main program, as 193 at-risk people received at
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least one dose of vaccine. This represents a substantial public health benefit for the city of Bogota´. In addition to reducing the risk of HBV infection, we hope that other organizations can use this methodology to replicate or improve upon our success in future vaccination efforts. The methods described are proposed for use by voluntary organizations, but official health institutions could also make use of these and similar techniques. Employing peer leaders to recruit hard-to-reach populations for public health programs, and combining the vaccination programs with other outreach efforts, are two potentially productive areas that could further the mission of governmental health agencies and contribute to broader health-related behavior changes in high-risk populations. In addition to applying these methods, we suggest the following improvements for generating adherence to a multi-dose vaccination program in a high-risk population. Proposals three and four are based on suggestions by participants in post-vaccination workshops. 1
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Use an accelerated vaccine schedule (i.e. 0, 10, 21 days). This schedule has been shown to generate sufficient protective antibody levels in adults who receive the three doses of the vaccine (Marchou et al., 1993; Rogers & Lubman, 2005). Prostitution in Colombia is migratory, with many individuals traveling to resorts during the high season, touring small towns during the low season, or fleeing conflicts in their home cities. Some members of the Bogota´ program were lost because of moves away from the city, travel with a client or partner, binge substance consumption, lost phones, pregnancy, or other unexpected events whose frequency could be decreased with shorter vaccination schedules. Follow up with late additions to the vaccination program. The outreach efforts of our program attracted 71 individuals who received their first dose of vaccine on either the second or third vaccination day. Because of limited resources, we were unable to follow this population as effectively, and they did not receive all the phone calls that the original 122 participants did. These individuals were therefore less likely to return for subsequent doses, and hospital records indicate that none of them went for follow-up doses on their own. In the future, participants beginning their vaccination schedule on the second or third vaccination day
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should be expected, and resources should be in place to contact them using the same system as those joining on the first vaccination day. Incorporate improved tracking of demographic information on the population receiving vaccinations. This information is essential for detecting trends in adherence to the vaccination program within subsets of the target population. We recommend recording information on the gender identity, age, housing status, alternative employment, social support structure, drug and alcohol use, mental health issues, number of clients, length of time working in prostitution, condom use patterns, history of STIs and vaccinations, and distance to the vaccination site of each participant. This information could then be used to better allocate resources and to link specific peer leaders to identified higher risk subpopulations. Provide transportation to ensure participants’ arrival at vaccination sites. Although both sites were located in or very near to the majority of the participants’ places of work, the daily schedules of these individuals are variable, and many doses were missed because participants were unable to arrive at the predetermined location on the designated day. Participants cited a number of impediments to their attendance, including tending to a client, taking care of children, working another job, or being physically incapacitated by substance abuse. If transportation were available for participants who request it during the reminder phone call, adherence might be improved. Again, we found it much easier to vaccinate on the designated days than to motivate the participants to go to the local hospital and get their doses independently, so every effort should be made to decrease attrition at these events. Vaccinate against other infectious diseases at the same time. Having a large subset of a high-risk population assembled and willing to participate in a vaccination program provides a valuable opportunity for intervention. Influenza, hepatitis A, and HPV vaccines could be useful additions to the vaccination schedule in a future study. HPV vaccines, though most effective when administered before an individual begins sexual activity, still can have prophylactic benefits due to the variety of strains against which the vaccine can protect (Adams et al., 2009; Brown et al., 2010;
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FUTURE II, 2007). Additionally, continuing to develop this methodology provides groundwork for the future inclusion of as yet undeveloped vaccines for viral diseases such as HCV. The high transmissibility of HBV and extreme vulnerability to infection from sex work, drug use, and associated risks make HBV vaccination for people in prostitution a public health priority. Successful intervention programs should assume the dual approach of Fe´nix: working with vulnerable populations to identify and address immediate risks, while generating momentum towards future changes. In addition to HBV, other STIs, violence, substance abuse, body transformations, and trauma associated with upbringing and daily environment consistently threaten the wellbeing of sex workers (Mak et al., 2003). These realities notwithstanding, qualitative research conducted in Colombia suggests that members of this population highly value their health as it is linked with the ability to work and to generate income. STIs can represent an ‘‘economic disaster’’ for sex workers that they are keen to avoid (Amaya et al., 2005, p. 70). An interest in the preservation of health by sex workers, as well as healthcare personnel, is an area in which the values of both the consumers and the suppliers of preventive care are well aligned, creating an opportunity for successful health interventions when barriers to seeking and providing care are addressed. Vaccination programs represent an ideal form of intervention in this high risk group as they serve multiple purposes: to reduce the burden of preventable infection and its social costs, to generate broader and self-sustaining changes in vulnerable groups that may reduce risk behaviors, and to create pressures on authorities to provide effective, lowcost, people-centered services. Acknowledgments The authors gratefully acknowledge the support of the Fulbright US Student Program.
References Adams, M., Jasani, B., & Fiander, A. (2009). Prophylactic HPV vaccination for women over 18 years of age. Vaccine, 27(25–26), 3391–3394. Adkins, J. C., & Wagstaff, A. J. (1998). Recombinant hepatitis B vaccine: A review of its immunogenicity and protective efficacy against hepatitis B. BioDrugs, 10(2), 137–158. Amaya, A., Canaval, G. E., & Viafara, E. (2005). Estigmatizacio´n de las trabajadoras sexuales: Influencias en la salud. Colombia Me´dica, 36(3, Supl 2), 65–74.
101 Bindel, J., & Kelly, L. (2003). A critical examination of responses to prostitution in four countries: Victoria. Australia: Child and Women Abuse Studies Unit, London Metropolitan University. Brown, B., Carcamo, C., Blas, M. M., Valderrama, M., & Halsey, N. (2010). Peruvian FSWs: Understanding HPV and barriers to vaccination. Vaccine, 28(49), 7743–7747. Camejo, M. I., Mata, G., & Dı´az, M. (2003). Prevalence of hepatitis B, hepatitis C and syphilis in female sex workers in Venezuela. Revista de Sau´de Pu´blica, 37(3), 339–344. Caprecom. (2013). Regimen Subsidiado. Retrieved from website: http://www.caprecom.gov.co/portal/index.php?tipo Doc=Regimen&idCategoria=49&idsubcat=38. Cassidy, W. M., Watson, B., Loli, V. A., Williams, K., Bird, S., & West, D. J. (2001). A randomized trial of alternative twoand three-dose hepatitis B vaccination regimens in adolescents: Antibody responses, safety, and immunologic memory. Pediatrics, 107(4), 626–631. Dror, D. M., & Jacquier, C. (1999). Micro-insurance: Extending health insurance to the excluded. International Social Security Review, 52(1), 71–97. Francis, D. P., Hadler, S. C., Thompson, S. E., Maynard, J. E., Ostrow, D. G., Altman, N., et al. (1982). The prevention of hepatitis B with vaccine: Report of the Centers for Disease Control multi-center efficacy trial among homosexual men. Annals of Internal Medicine, 97(3), 362–366. Future II Study Group. (2007). Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. New England Journal of Medicine, 356(19), 1915–1927. Gray, G. E., & Michael, N. L. (2013). Cautious optimism for HIV vaccine science. Current Opinion in HIV & AIDS, 5, 367–368. Gust, I. D. (1996). Epidemiology of hepatitis B infection in the Western Pacific and South East Asia. Gut, 38(suppl 2), S18–S23. Hadler, S. C., & Margolis, H. S. (1993). Epidemiology of hepatitis B virus infection. In R. W. Ellis (Ed.), Hepatitis B vaccines in clinical practice (pp. 141–157). New York: Marcel Dekker Inc. He´rnandez-Bernal, F., Aguilar-Betancourt, A., Aljovin, V., Arias, G., Valenzuela, C., de Alejo, K. P., et al. (2011). Comparison of four recombinant hepatitis B vaccines applied on an accelerated schedule in healthy adults. Human Vaccines & Immunotherapeutics, 7(10), 1026–1036. Houghton, M., Law, J. L., & Tyrrell, D. L. (2013). An inactivated hepatitis C virus vaccine on the horizon? Gastroenterology, 145(2), 285–288. Jeal, N., & Salisbury, C. (2004). Self-reported experiences of health services among female street-based prostitutes: A cross-sectional survey. The British Journal of General Practice, 54(504), 515. Lavanchy, F. (2004). Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. Journal of Viral Hepatitis, 11, 97–107. Mak, R., Traen, A., Claeyssens, M., Van Renterghem, L., LerouxRoels, G., & Van Damme, P. (2003). Hepatitis B vaccination for sex workers: Do outreach programmes perform better? Sexually Transmitted Infections, 79, 157–159. Marchou, B., Picot, N., Chavanet, P., Auvergnat, J. C., Armengaud, M., Devilliers, P., et al. (1993). Three-week
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102 hepatitis B vaccination provides protective immunity. Vaccine, 11(14), 1383–1385. Mast, E. E., Weinbaum, C. M., Fiores, A. E., Alter, M. J., Bell, B. O., Finelli, L., et al. (2006). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. Atlanta: Centers for Disease Control and Prevention (CDC). ´ ngel, Mayor Mora, A., Arias, A., Menjura, F. H., & Jaramillo A L. F. (2010). Cruzada interminable por la nin˜ez Colombiana. Historia del programa ampliado de inmunizaciones—PAI—en Colombia 1979–2009. Bogota´: Ministerio de la Proteccio´n Social, Organizacio´n Panamericana de la Salud. Mejia, A., Bautista, C. T., Leal, L., Ayala, C., Prieto, F., de la Hoz, F., et al. (2009). Syphilis infection among female sex workers in Colombia. Journal of Immigrant and Minority Health, 11(2), 92–98. Mejia, A.M., Montano, S.M., Vallejo, F., Prieto, F., Acosta, J., De La Hoz, F., Velandia, M.P., Sanchez, J.L., & Olson, J.G. (2002). HIV-1, syphilis and hepatitis B virus prevalence and risk factors among commercial sex workers, Bogota´, Colombia. Poster Exhibit: The XV International AIDS Conference: Abstract no. WePeC6251. O’Rourke, K. M., Redlinger, T. E., & Steege, A. M. (2001). Improving hepatitis B immunization among high-risk adolescents: A low-cost intervention on the Mexico-United States border. Revista Panamericana de Salud Pu´blica, 9, 4. Pinzo´n-Rondo´n, A. M., Ross, T. W., Botero, J. C., & BaqueroUman˜a, M. M. (2009). Prevalencia y factores asociados a enfermedades de transmisio´n sexual en menores explotados sexualmente en Bogota´, Colombia. Revista de Salud Pu´blica, 11(3), 468–479.
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J Primary Prevent (2014) 35:93–102 Ritterbusch, A. (2011). A youth vision of the city: The sociospatial lives and exclusion of street girls in Bogota´, Colombia. ProQuest ETD Collection for FIU. Paper AAI3484191. http://digitalcommons.fiu.edu/dissertations/ AAI3484191. Rogers, N., & Lubman, D. I. (2005). An accelerated hepatitis B vaccination schedule for young drug users. Australian and New Zealand Journal of Public Health, 29(4), 305–307. Ross, T. (1992). Using and dealing on Calle 19: A high risk street community in central Bogota´. International Journal of Drug Policy, 13, 45–56. Szumeness, W., Stevens, C. E., Harley, E. J., Zang, E. A., Oleszko, W. R., William, D. C., et al. (1980). Hepatitis B vaccine: Demonstration of efficacy in a controlled clinical trial in a high-risk population in the United States. New England Journal of Medicine, 303(15), 833–841. Valente, T. W., & Pumpuang, P. (2007). Identifying opinion leaders to promote behavior change. Health Education & Behavior, 34, 881. WHO. (2009). Hepatitis B vaccines: WHO position paper-recommendations. Vaccine, 28(3), 589–590. WHO. (2012a). Hepatitis B fact sheet no. 204. Retrieved from website: http://who.int/inf-fs/en/fact204.html. WHO. (2012b) Hepatitis C fact sheet no. 164. Retrieved from website: http://www.who.int/mediacentre/factsheets/fs164/ en/index.html. WHO. (2012c) HIV/AIDS fact sheet no. 360. Retrieved from website: http://www.who.int/mediacentre/factsheets/fs360/ en/index.html. Wiebel, W. (1993). The indigenous leader outreach model: Intervention manual. Rockville, MD: US Department of Health and Human Services, National Institute on Drug Abuse.
ORIGINAL PAPER
Getting the Shots: Methods to Gain Adherence to a Multi-Dose Vaccination Program for Inner City, Drug-Involved Prostitution Communities Giffin W. Daughtridge • Timothy W. Ross Paola A. Ceballos • Carmen E. Stellar
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Published online: 21 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Street-based sex-work and poly-substance drug use, coupled with low vaccination rates and limited utilization of the mainstream health care system, put the sex worker communities of Bogota´’s city center at extreme risk of infection with the hepatitis B virus (HBV). Vaccination is critical to maintaining low prevalence of the disease and low incidence of new cases, yet the floating and inconsistent nature of Bogota´’s drug-involved female and transsexual prostitution communities make it difficult to complete a
G. W. Daughtridge Perelman School of Medicine at the University of Pennsylvania, 3620 Hamilton Walk, Philadelphia, PA 19104, USA G. W. Daughtridge (&) 2400 Chestnut St. Apt. 1704, Philadelphia, PA 19103, USA e-mail: [email protected] T. W. Ross Fundacio´n Social Fe´nix, Carrera 3a, No. 21-46, Apto. 2604-A, Bogota´, Colombia e-mail: [email protected] P. A. Ceballos Universidad de La Salle, Carrera 5 N. 59A 44, Bogota´, Colombia e-mail: [email protected] C. E. Stellar Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA e-mail: [email protected]
3-dose vaccination program. Between December 2011 and March of 2012, the Fe´nix Foundation collaborated with the Bogota´ Health Department to deliver free HBV vaccines to this vulnerable population. This paper outlines methods used in the vaccination program to generate a 37.7 % adherence rate, significantly higher than that previously reported for HBV vaccination programs also targeting marginalized populations. This program’s practices are based on the Fe´nix peer leader method, and are offered as a model that can be applied to other health interventions operating in analogous contexts, with similarly high-risk populations. Keywords Hepatitis B Vaccination Prostitution Peer leaders Health intervention adherence Street communities
Introduction In Colombia, prostitution is a legally permitted activity for people over the age of 18. Sex workers are required to receive intermittent health assessments to identify and treat sexually transmitted infections (STI). However, street-based sex workers who are unaffiliated with brothels are largely unregulated, represent a highrisk population with a variety of unmet health needs, and were the primary target of an STI vaccination program. A 2009 study conducted in Bogota´, Colombia, found that 24 % of 514 female sex workers (FSW) described themselves as female street-based sex
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workers (FSSW). Relative to sex workers who worked in bars, brothels, and clubs, these women reported a greater number of clients per week, and were typically younger, more likely to use illegal drugs, less likely to use a condom during vaginal sex with clients, more likely to have a syphilis infection, and more likely to belong to a lower socio-economic stratum (Mejia et al., 2009). FSW under the age of 18, whether street-based or in clandestine brothels, are at a particularly high risk of disease (Pinzo´n-Rondo´n et al., 2009). Due to frequent engagement in high-risk activities, female and transsexual street-based sex workers are in great danger of contracting and transmitting pathogens through infected bodily fluids. High-risk behaviors endemic to this population include: unprotected sexual intercourse with multiple partners, extensive drug use resulting in bio-fluid contact, tattoos and piercings using shared instruments, and physical transformation operations performed by unlicensed amateur surgeons (Gust, 1996; Lavanchy, 2004). It is therefore especially important to target this population in vaccination campaigns aimed at controlling viral disease. The transmission of hepatitis B via infected blood or other bodily fluids is a pressing global health problem and a particular concern for individuals involved in prostitution. About 350 million people worldwide suffer from chronic hepatitis B infection, and the virus is estimated to be 50–100 times more transmissible than HIV (WHO, 2012c). As Mast et al. (2006) have noted, ‘‘Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death’’ (p. 1). The vaccine has been available since the early 1980s (Francis et al., 1982; Szumeness et al., 1980). Studies have shown that seroprotection rates— defined as an antibody to hepatitis B antigen (anti-HBs) level of C10 mIU/mL—are achieved by at least 90 % of patients receiving three doses of the vaccine (Adkins & Wagstaff, 1998; He´rnandez-Bernal et al., 2011). Colombia initiated universal neonatal vaccination against hepatitis B in 1994 (Mayor Mora et al. 2010), but because the Colombian minimum legal age for prostitution is 18, almost no adult sex workers had received the full course of the vaccine when our vaccination program was initiated in 2011. The necessity of a completed hepatitis B vaccine course for this population was demonstrated by a Venezuelan study conducted in 2003, which found that 13.8 % of
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sex workers sampled tested positive for anti-HBc serologic markers, indicating previous or ongoing infection with hepatitis B. Based on these results, the authors recommended that the Venezuelan Ministry of Health initiate programs to vaccinate sex workers against hepatitis B (Camejo et al., 2003). A similar catch-up immunization course for the sex worker population in Bogota´ is also necessary. Unfortunately, it is very difficult to successfully implement such a program due to real and perceived obstacles to accessing healthcare for marginalized populations. Colombia’s most impoverished and indigent populations are eligible for a government-subsidized form of social security, which covers emergency and preventive health services for low-income citizens, including free vaccines (Caprecom, 2013). Many street-based sex workers have difficulty navigating the enrollment process, while others possess some form of health insurance, but remain infrequent consumers of healthcare services. Mejia et al. (2009) estimated that over 60 % of female sex workers in Bogota´ have health insurance, and noted that even insured sex workers seemed to underutilize available health services. It is possible that FSSW and transsexual sex workers have lower levels of health insurance as they are more socially excluded, but further research is needed in order to determine how discrimination and self-exclusion interact to produce low levels of healthcare-seeking behavior in this particularly vulnerable population (Dror & Jacquier, 1999; Jeal & Salisbury, 2004). In addition to barriers to accessing the healthcare system, completing the hepatitis B three-dose vaccine schedule is problematic in an unstable and floating population with high rates of poly-substance abuse, weak social support structures, frequent changes in locations of work and residence, and poor capacity to project into the future and to keep appointments. Consequently, we needed to develop new contact and communication techniques to gain maximum adherence to the vaccination schedule. This paper demonstrates that principles of participatory investigation and peer led interventions (Ritterbusch, 2011; Valente & Pumpuang, 2007; Wiebel, 1993) can be used to overcome barriers to healthcare access for high-risk groups. The strategies outlined for maintaining contact can be replicated or improved in future prophylactic programs for HBV and other infections. They can also be applied to other health
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interventions such as regular pap smears and HIV testing.
Methods Informal interviews—conducted by the Fe´nix organization in September of 2011, with a convenience sample of approximately 30 people recruited by chain referral (sometimes referred to as snowball sampling)—suggested that less than ten percent of sex workers in central Bogota´ had completed HBV vaccinations. Fe´nix is a non-governmental organization with which all four authors are affiliated. It has worked with drug-involved prostitution communities since 2008 to promote enhanced healthcare-seeking behavior, self-empowerment, and opportunities for exiting prostitution. Fe´nix supports peer leaders affiliated with the organization, and as yet unaffiliated FSWs, through peer-led community outreach. Peer leaders make their own transitions from prostitution towards vocational training and professional education by first learning to act as harm reduction health educators for other FSWs and then to identify, engage, and train new peer leaders from among them. To address the low number of HBV immunized sex workers, Fe´nix requested HBV vaccines from the Bogota´ Secretary of Health and proposed a collaborative campaign for free application in two areas within key prostitution zones. In December of 2011 and January and March of 2012, a vaccination team from a local hospital administered a three-dose (20 lg/mL) course of the Bharat Biotech Revac-B ? HBV vaccine. The vaccines were applied over two days in each of these months at El Refugio and La Mariposa square. They were also offered daily in a local hospital for those not attending the vaccination days. Participants in the three-dose vaccination campaign were recruited through peer network contacts and chain referrals. Contact details of all who attended one of the two vaccination days in December were listed, and their compliance with subsequent doses was tracked by means of a comprehensive database. Peer Leader Methodology Existing peer networks within the sex work community are central to Fe´nix0 outreach methods and to the
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recruitment and retention of participants in this vaccination program. Core peer leaders are engaged through the generation of mutual relationships, which encourage the personal development of peer leaders, as well as their involvement in advocacy for their street-based social groups (e.g. distribution of condoms or invitations to healthcare activities). The work of peer leaders has a dual purpose: to help reduce risks and to generate motion towards positive decision-making. The relationships between Fe´nix and street populations are built up through the work of four kinds of peer leaders: 1
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3
4
‘Embedded’ Peer Leaders are still enmeshed in prostitution but act as key informants and information diffusers. ‘Transitional’ Peer Leaders are trying to reduce involvement in prostitution, take Fe´nix-run training classes, and function as models for others. ‘Exited’ Peer Leaders have left prostitution, found other sources of income, and are usually completing their education. They act as educators, gatekeepers, mentors, and models. ‘Congruent’ Peer Leaders study health and social care professions, but come from similar backgrounds of poverty, neglect, dysfunctional or absent families, social exclusion, and sometimes sexual abuse or exploitation, giving them the ability to identify with and mentor street youth.
Embedded peer leaders are initially identified through ‘‘staff selection,’’ by which potential leaders are recognized through community observation, and ‘‘judge’s ratings,’’ whereby community members themselves identify individuals they believe to be leaders (Valente & Pumpuang, 2007). Selected leaders may attend any number of 60–80 min workshops, which cover topics ranging from the prevention, detection, and treatment of STIs, to opportunities for education and job training. Peer leaders who demonstrate interest are invited to attend workshops focused on outreach intervention methods, and may also be offered psychotherapeutic support through the Fe´nix network of clinicians. As self-efficacy and capacity for positive action advance, the peer leaders in turn begin to teach their friends and propose new candidates for leadership work. Natural diffusion of information on opportunities for change and possibilities for exiting prostitution encourage still others to volunteer for leadership roles.
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Throughout the course of the vaccination program, one ‘transitional’ and one ‘congruent’ peer leader, who were both closely affiliated with the organization, worked directly with the study’s authors. The effectiveness of this nuclear team was enhanced by ten ‘embedded’ and ‘transitional’ peer leaders who were very supportive of the program’s goals and motivated to assist with the recruitment and retention of participants. Members were able to exploit their existing peer networks to further circulate the message of health maintenance and disease prevention. In one case, an approximately 35-year-old ‘embedded’ peer leader received a dose on the first vaccination day and was then asked to look for friends to relay what she had learned about hepatitis B. She returned shortly with another FSW and was delighted to be congratulated. During the day, she arrived three more times with one to three others, explained the procedure, shepherded them into the vaccination tent, and introduced them to the coordinator.
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by sex workers in Bogota´, especially male-to-female transsexual sex workers. They regularly offer their facilities for HIV testing, pap smears, meetings, and other services. Due to the overlapping missions of the Fe´nix organization and El Refugio, the two frequently partner on outreach activities. Fe´nix provides the peer leader network, which facilitates access to the populations on the street. El Refugio offers its ideal location and reputation as a comfortable center for free healthcare, psychological support, and—especially important in a Catholic country—spiritual comfort. The participation of nuns in action with marginalized groups helps reduce their sense of exclusion and appears to provide important support and acceptance in a country where Catholic social values can contribute to stigmatization (Bindel & Kelly, 2003). This religious order, along with two others, provides a range of services that includes schooling, vocational training, and employment, and forms part of a network of organizations defending prostitution communities. This has led to conflicts with the Catholic hierarchy, particularly over condom advocacy.
Collaboration with Other Organizations Fe´nix has a strong peer leader network, but lacks several necessary components for carrying out an effective vaccination program. The three most critical are the following: vaccines, healthcare professionals, and a safe and comfortable space near the participants’ work place in which to deliver the vaccinations. The authors identified these needs prior to the onset of the program, and were able to address all three through meetings with the Bogota´ Health Department and El Refugio convent. The Bogota´ Secretary of Health coordinates, controls, and funds all public hospitals and health programs active in the capital. The director and senior management are political appointees, who change with each four-year mayoral term, limiting long term policy planning. With regards to our program, the Health Department had the vaccines and the healthcare professionals to deliver them, but it lacked the respect of, and close contact with, the target population. Fe´nix, on the other hand, lacked vaccines but enjoyed close links with the prostitution community. The collaboration resulted in participants who were educated and recruited by Fenix0 peer network and vaccinated using the supplies and nursing staff of the Health Department. El Refugio is a Catholic convent conveniently located on a corner that abuts three of the main streets frequented
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Initial Information Dissemination Six weeks before the first vaccination day, outreach teams composed of peer leaders and the study authors began disseminating information on hepatitis B. Peer leaders helped design pamphlets and flyers featuring strong imagery, vernacular language, and alliterative, memorable phrasing. These materials were utilized during small group workshops of one to four individuals each, usually lasting 5–10 min. The workshops, generally conducted in brothels or on street corners, focused on the prevalence of the disease, its risk factors and consequences, and vaccination as the most effective prevention method, while stressing consistent condom use. We involved each workshop participant by asking questions to generate reflection on risk, asking for feedback on the most important information, and/or inviting an individual to explain key points to newcomers. Communication techniques alternated humor, clowning, and dramatic theatricality with seriousness and evidence. This style allowed us to engage the population without minimizing the gravity and lethality of the disease. In the week preceding the first vaccination day, we added dates, times, and locations of the vaccination sessions to printed educational materials. We also intensified the frequency of street outreach.
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Primary Vaccination Days (13th and 14th of December, 2011) We offered vaccines from 10 AM to 2 PM, before the increased frequency of prostitution activities and drug use would hinder attendance. Peer leaders were among the first to receive the vaccine. We then asked them to find other potential participants to bring to the vaccination locations. We gave each person who received a vaccination an immunization card that recorded the dates of the initial and upcoming doses. We recorded extensive contact information in a database, including the following: legal name, ‘‘chapa’’ or street name, identity card number, home telephone and address, work location, cell phone, and names and phone numbers of two additional contacts (e.g., family or close friends). Each person also received a printed slip with the dates of the second and third doses. Additionally, a professional outreach worker talked to each one about the importance of receiving all three doses of the HBV vaccine to achieve maximum protection. Finally, we asked each participant to spread the word to friends and, when possible, to bring in others—a key tactic in the recruitment strategy. Promotion for Second Vaccination Days We continued street outreach by distributing educational materials in vernacular language and hosting mini-workshops. The list of names and work locations of those who had received the first dose was consulted each time, so that outreach team members could locate each participant. Additionally, a peer leader familiar with all the participants called each one the night before the vaccination session. If individuals could not be contacted using primary phone numbers, we called secondary contacts. We spoke with the majority of our participants (or a secondary contact) and reminded them to attend. We recorded calls in the database so that those who were not reached could be called again the next morning. We asked the individuals we were able to contact to bring friends, especially if they had attended the first vaccination. Second Vaccination Days (17th and 18th of January, 2012) The first vaccination days’ methods were repeated. Leaders were vaccinated and then recruited others, volunteers updated participants’ vaccination cards,
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and a volunteer or outreach worker talked to each participant about the importance of completing the entire set of vaccinations. Participants who had lost their cards were located in the database and issued a new card. Two hours into the 4-h vaccination period, we used the database to call every person in our original sample who had not yet arrived for the second dose. If individuals not included in the original program arrived through peer contacts and asked to be vaccinated, we complied unless there was strong evidence that they were not genuinely members of the target population. We recommended that they go to the nearby Hospital Samper Mendoza for subsequent doses to complete their vaccination plan. Inter-Vaccination Phase In the two months between the second and third vaccinations, we used the database to individually contact the people who had not come for their second dose. We informed them that they should go to the Hospital Samper Mendoza to obtain their vaccine. We called the phone numbers they had given us, called their additional contacts as needed, searched for them on the streets near their home and work locations, and asked other sex workers if they knew the whereabouts of those on our list. We quickly discovered that most sex workers were unwilling to go to the hospital alone. The most common explanations for resistance were the distance to the hospital, their desire not to lose clients, and their reluctance to leave the apparent security of their circumscribed territory. We therefore arranged meeting times within the prostitution zones and accompanied groups of participants to the hospital. In the weeks leading up to the final vaccination day, we applied the same protocol as that used prior to the second dose. Third Vaccination Days (13th and 14th of March, 2012) We followed the same procedure used on the previous vaccination days. The authors had individual conversations with those who received their third dose to congratulate them on their accomplishment, to encourage them to continue making positive health decisions, and to urge their peers to do the same.
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Follow-Up After the third vaccination day, we made efforts to ensure that individuals who had received only one or two doses of the HBV vaccine went to the hospital for their subsequent vaccinations. Since most would not go to the hospital alone, we hired a driver and contacted everyone who had not received the three doses. All were asked to meet the following day in a specified location. From there, we drove them to the Hospital Samper Mendoza for the next dose.
Results Altogether, 122 individuals received the primary dose of the hepatitis B vaccine on the first days of the immunization series, including some sex workers’ partners. The vaccines were delivered at two locations: El Refugio (December 13th) and La Mariposa (December 14th). Promotion for the vaccination day at El Refugio gave particular emphasis to male-tofemale transsexual prostitutes, as anal sex increases the risk of acquiring viral infections, and over onethird of participants at El Refugio were transsexual (Hadler & Margolis, 1993). ‘La Mariposa,’ officially ‘Plaza San Victorino,’ is a plaza where large numbers of street-based FSW look for clients. The sex workers in La Mariposa are predominantly younger, more recent entries into prostitution, and are less institutionalized in the sex work subculture. Some maintain other income-generating activities, and resort to prostitution only part-time or at moments of crisis. La Mariposa square is frequented by a number of young, female-to-male transgender people, but almost no male-to-female transsexuals, in contrast to the population working near El Refugio. Fe´nix has done extensive intervention work in the areas around both El Refugio and La Mariposa. The resultant trust-based relationships allowed us to recruit a large proportion of this population to the initial vaccination days. This vaccination program was not planned as a study but as a public health intervention aimed at vaccinating extremely high-risk groups against HBV. Between El Refugio and La Mariposa, the ages of participants ranged from 14 to 62, with an average age of approximately 23. Though it is possible that some of the participants between the ages of 14 and 18 had already received the vaccine at birth, there was no
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additional harm in applying a second HBV vaccination (WHO, 2009). Furthermore, exact birth years could not be determined as the participants frequently lie about their age in order to attract clients, and the authors determined that the benefits of vaccinating those interested in taking a proactive stance on their health outweighed any risk of re-vaccinating them. Aside from age, which was recorded in the nurses0 identification log for each participant vaccinated, we were not concerned with recording demographic data for people receiving any dose of the vaccine; rather, we focused on gathering information that would help recruit and maintain contact with participants. In total, 38 % of the individuals who received the first dose of the vaccine on either December 13th or 14th completed the program and received the second and third doses of the vaccine, and 67 % received at least two of the three doses. At El Refugio, 42 % of the participants who received their first dose were completely vaccinated, and 65 % received at least two of the three doses. In La Mariposa, 32 % of the participants received all three doses, while 70 % received at least two. Seventy-one people not in the original cohort came to either the second or third vaccination days to receive their first dose of vaccine. Because we were most interested in creating an intervention methodology that would elicit full program adherence, these individuals were not included in the results reported above. However, each participated in a mini-workshop explaining the importance of receiving all three doses of the vaccine in order to maximize the probability of achieving seroprotection. Each person also received a vaccination card, was asked for contact information, and received a brochure or flyer with educational material on hepatitis B along with condoms and lubricants. Finally, we gave these individuals exact instructions on how to find the local hospital, and advised them to ask for their second and third doses at this hospital on the appropriate dates. We did not have the resources to follow up with each of these people in the same manner as those enrolled in the program, and this group was less likely than the original cohort to return for subsequent doses.
Discussion The threat of HBV infection presents a major public health burden for unvaccinated populations. Mejia et al.
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(2002) reported that the HBV prevalence among commercial sex workers in Bogota´ was 7.5 %, and informal interviews (see Methods) with peer leaders of the Fe´nix Foundation indicated averages per individual of 7 sexual encounters a day and 250 days of prostitution per year. First time encounters are usually protected, but the majority of workers are willing to have unprotected sex with those who pay extra or with ‘‘special’’ clients with whom they have built a consistent relationship. Anal and oral sex are seldom protected. Hadler and Margolis (1993) suggested that there is a 1–3 % chance of HBV transmission per unprotected sexual encounter in serodiscordant partners, with women more vulnerable than men, and people in prostitution, or with other STIs, at a substantially higher risk. Furthermore, this is a public health concern for the entire population, as many clients are married or have other partners to whom they can retransmit the virus. Reducing the risk of HBV transmission by targeting high-risk groups with catch-up vaccination programs should be a public health priority. Unfortunately, the need for three separate doses of the HBV vaccine, the floating nature of sex worker populations, alcohol and drug intoxication, and the instability of prostitutes’ social links make retention for a complete vaccine course problematic in this population. Exploratory research suggests that the street-based sex worker populations of Bogota´’s city center not only engage in heavy drug use, but also in high-risk sex and frequent violence, and tend to suffer devastating socioeconomic exclusion (Mejia et al., 2009; Ritterbusch, 2011; Ross, 1992). To address these challenges, an established methodology for recruiting high-risk populations to a multidose vaccination program is necessary, but the current literature on generating adherence in similar groups is limited. Searches of Medline and LILACS, a database for research in South and Central America, returned no studies that reported adherence to an HBV vaccination program for an impoverished high-risk population engaged in drug use, sex work, or seeking care at an STD clinic in Latin America. Nonetheless, the literature that does exist illustrates the difficulty of ensuring adherence to an HBV vaccination program. To give context, a similarly sized HBV vaccination program for at-risk populations seeking care at an STD clinic, though not sex workers, recorded three-dose retention percentages as low as 2.4 % (O’Rourke et al., 2001).
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Adherence to an HBV vaccination schedule in marginalized populations is a sparsely covered but important area of research. However, the development of an effective methodology for vaccinating high-risk populations is necessary and has widespread implications, not only for the prevention of HBV, but also for similarly dangerous infectious diseases whose global prevalence can be primarily controlled through vaccination. The low cost, wide availability, and flexible schedule of the HBV vaccine make it an optimal candidate for any study seeking to develop methodologies aimed at increasing adherence to a multi-dose vaccine schedule among high-risk populations. The methods used to generate adherence in this HBV program can be applied to future HBV vaccination efforts, as well as to diseases with similar risk factors and even higher mortality rates in infected persons, notably hepatitis C (HCV) and HIV. According to the WHO, these three diseases account for almost 2.8 million deaths globally per year (WHO, 2012a, b, c). Though vaccines against HCV or HIV have thus far proved elusive, candidate vaccines for these diseases are currently in phase two (HCV) or three (HIV) testing and would feature multi-dose schedules similar to that for HBV (Gray & Michael, 2013; Houghton et al., 2013). This paper advances the field of public health by presenting a methodology for vaccinating a high-risk and hard-to-access population not only against HBV, but also against HIV and HCV if and when those vaccines come to market. Impact and Future Outlook The intended outcomes of this program were twofold: to reduce the risk of HBV infection among central Bogota´’s sex workers, and to develop a methodology for future prophylactic efforts amongst high-risk populations. By enrolling 122 members in the program, and completing a three-dose schedule for 38 % of them, a significant number of high-risk people should now have protection against HBV infection. Furthermore, Cassidy et al. (2001) showed that two doses of the hepatitis B vaccine conferred seroprotection in over 95 % of adolescents vaccinated, whereas one dose conferred seroprotection in 63.8 % of adolescents vaccinated. Thus, the public health impact of our study extends well beyond just those included in the main program, as 193 at-risk people received at
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least one dose of vaccine. This represents a substantial public health benefit for the city of Bogota´. In addition to reducing the risk of HBV infection, we hope that other organizations can use this methodology to replicate or improve upon our success in future vaccination efforts. The methods described are proposed for use by voluntary organizations, but official health institutions could also make use of these and similar techniques. Employing peer leaders to recruit hard-to-reach populations for public health programs, and combining the vaccination programs with other outreach efforts, are two potentially productive areas that could further the mission of governmental health agencies and contribute to broader health-related behavior changes in high-risk populations. In addition to applying these methods, we suggest the following improvements for generating adherence to a multi-dose vaccination program in a high-risk population. Proposals three and four are based on suggestions by participants in post-vaccination workshops. 1
2
Use an accelerated vaccine schedule (i.e. 0, 10, 21 days). This schedule has been shown to generate sufficient protective antibody levels in adults who receive the three doses of the vaccine (Marchou et al., 1993; Rogers & Lubman, 2005). Prostitution in Colombia is migratory, with many individuals traveling to resorts during the high season, touring small towns during the low season, or fleeing conflicts in their home cities. Some members of the Bogota´ program were lost because of moves away from the city, travel with a client or partner, binge substance consumption, lost phones, pregnancy, or other unexpected events whose frequency could be decreased with shorter vaccination schedules. Follow up with late additions to the vaccination program. The outreach efforts of our program attracted 71 individuals who received their first dose of vaccine on either the second or third vaccination day. Because of limited resources, we were unable to follow this population as effectively, and they did not receive all the phone calls that the original 122 participants did. These individuals were therefore less likely to return for subsequent doses, and hospital records indicate that none of them went for follow-up doses on their own. In the future, participants beginning their vaccination schedule on the second or third vaccination day
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3
4
5
should be expected, and resources should be in place to contact them using the same system as those joining on the first vaccination day. Incorporate improved tracking of demographic information on the population receiving vaccinations. This information is essential for detecting trends in adherence to the vaccination program within subsets of the target population. We recommend recording information on the gender identity, age, housing status, alternative employment, social support structure, drug and alcohol use, mental health issues, number of clients, length of time working in prostitution, condom use patterns, history of STIs and vaccinations, and distance to the vaccination site of each participant. This information could then be used to better allocate resources and to link specific peer leaders to identified higher risk subpopulations. Provide transportation to ensure participants’ arrival at vaccination sites. Although both sites were located in or very near to the majority of the participants’ places of work, the daily schedules of these individuals are variable, and many doses were missed because participants were unable to arrive at the predetermined location on the designated day. Participants cited a number of impediments to their attendance, including tending to a client, taking care of children, working another job, or being physically incapacitated by substance abuse. If transportation were available for participants who request it during the reminder phone call, adherence might be improved. Again, we found it much easier to vaccinate on the designated days than to motivate the participants to go to the local hospital and get their doses independently, so every effort should be made to decrease attrition at these events. Vaccinate against other infectious diseases at the same time. Having a large subset of a high-risk population assembled and willing to participate in a vaccination program provides a valuable opportunity for intervention. Influenza, hepatitis A, and HPV vaccines could be useful additions to the vaccination schedule in a future study. HPV vaccines, though most effective when administered before an individual begins sexual activity, still can have prophylactic benefits due to the variety of strains against which the vaccine can protect (Adams et al., 2009; Brown et al., 2010;
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FUTURE II, 2007). Additionally, continuing to develop this methodology provides groundwork for the future inclusion of as yet undeveloped vaccines for viral diseases such as HCV. The high transmissibility of HBV and extreme vulnerability to infection from sex work, drug use, and associated risks make HBV vaccination for people in prostitution a public health priority. Successful intervention programs should assume the dual approach of Fe´nix: working with vulnerable populations to identify and address immediate risks, while generating momentum towards future changes. In addition to HBV, other STIs, violence, substance abuse, body transformations, and trauma associated with upbringing and daily environment consistently threaten the wellbeing of sex workers (Mak et al., 2003). These realities notwithstanding, qualitative research conducted in Colombia suggests that members of this population highly value their health as it is linked with the ability to work and to generate income. STIs can represent an ‘‘economic disaster’’ for sex workers that they are keen to avoid (Amaya et al., 2005, p. 70). An interest in the preservation of health by sex workers, as well as healthcare personnel, is an area in which the values of both the consumers and the suppliers of preventive care are well aligned, creating an opportunity for successful health interventions when barriers to seeking and providing care are addressed. Vaccination programs represent an ideal form of intervention in this high risk group as they serve multiple purposes: to reduce the burden of preventable infection and its social costs, to generate broader and self-sustaining changes in vulnerable groups that may reduce risk behaviors, and to create pressures on authorities to provide effective, lowcost, people-centered services. Acknowledgments The authors gratefully acknowledge the support of the Fulbright US Student Program.
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