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Original Article
 Condom Use and Prevalence of Genital Chlamydia trachomatis Among the Korean Female Sex Workers
Joongyub Lee1, Sun-Young Jung2, Dong Seok Kwon3, Minsoo Jung4, Byung-Joo Park2
Epidemiol Health 2010;32:e2010008.
DOI: https://doi.org/10.4178/epih/e2010008
Published online: August 13, 2010

1Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea.

2Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea.

3Korea Federation for HIV/AIDS Prevention, Seoul, Korea.

4Department of Health Policy and Management, School of Public Health, Seoul National University, Seoul, Korea.

Correspondence: Byung-Joo Park, MD. MPH. PhD. Department of Preventive Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Jongro-gu, Seoul 110-799, Korea. Tel: +82-2-740-8325, Fax: +82-2-747-4830, bjpark@snu.ac.kr
• Received: May 24, 2010   • Accepted: July 7, 2010

Copyright © 2010 Korean Society of Epidemiology

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • OBJECTIVES
    Since 2004, availability of resources for preventing sexually transmitted diseases in Korean female sex workers (FSWs) has decreased because of strict application of a law against prostitution. This study is to evaluate the condom use and prevalence of Chlamydia trachomatis among FSWs in Korea.
  • METHODS
    We performed a cross-sectional study of FSWs from 15 major sex work sites in Korea from June to November 2008, using convenience sampling. Self-administered questionnaires and urine samples were collected after all participants' written informed consent. Urine samples were analyzed with PCR at a single central laboratory.
  • RESULTS
    Among 1,086 FSWs who consented to study participation, data from 999 FSWs were appropriate for analysis. C. trachomatis prevalence was 12.8% (95% CI: 10.7-14.9%). Younger age increased risk for C. trachomatis. Whereas majority of FSWs (71.0%) answered high self confidence in condom negotiation, the proportion of FSWs who always used condoms last month was only 23.7%. However, practicing regular condom use showed significant protection against chlamydia infection, not self confidence in condom negotiation.
  • CONCLUSION
    In Korea, FSWs were not practicing enough self-protection at work with a high prevalence of C. trachomatis. Education for constant practice of protection against sexually transmitted diseases is needed, especially for younger FSWs.
  • Keywords: Chlamydia trachomatis, Condom use, Sex worker
Chlamydia trachomatis is the most common pathogen of human genitourinary system infection, annual number of new cases was estimated as 92 million [1]; a large proportion of the patients are asymptomatic and stay untreated. However, untreated C. trachomatis infection can cause chronic inflammation in the genital organs, which results in serious health problems like pelvic inflammatory disease (PID) and infertility [2].
It is not feasible to approach a study on female sex workers (FSWs) academically and produce reliable statistics, for that reason epidemiologic data are very limited regarding the prevalence of sexually transmitted diseases (STDs) among FSWs in developing countries, especially in those where the prostitution is illegal like Korea. In September 2004, the Act on the Prevention of Sexual Traffic and Protection, etc. of Victims Thereof became effective, and the police clamped down on traditional sex work venues. The budget for the healthcare of FSWs was cut, and it became more difficult for non-governmental organizations (NGOs) to provide services for FSWs. Therefore, individual FSW have been in decreased supply of condoms and contraceptives after 2004 which would induce an increased risk of STDs for FSWs. Thus we urgently needed to evaluate the current status of condom use and STD control among FSWs.
We performed a cross-sectional study to evaluate the condom use and C. trachomatis prevalence in FSWs.
We conducted a cross-sectional study from June to November 2008 with the collaboration of an NGO, the Korea Federation for HIV/AIDS Prevention. The NGO contacted every representative business owners of 39 sex work venues identified in a nationwide economic survey of the sex industry in 2003. Total 24 out of 39 representatives responded positively to our request to participate. We excluded 9 small venues considering efficiency, convenience of sampling by site. Sample size calculation was done assuming that the size of the target population would be 6,009, which was an estimation from the Korean Ministry of Gender Equality report of 2003. Assuming that estimate, the calculated sample size was 1,063 with a C. trachomatis prevalence of 30% and a precision of 2.5% [3]. Questionnaire was developed through cultural adaptation of previously validated questionnaires for sexual behavior including condom use [4].
After the informed consent, a self-administered questionnaire on sexual behavior, and random urine samples were obtained. On completion of the survey, a card was given in which the telephone number of an information center and a 10-digit individual code were printed to assure participants' access to their test results. We provided those who had positive results with a sincere recommendation for receiving prompt and adequate treatment.
After the manual review of questionnaires, data were input via double entry. Urine samples were analyzed at a central laboratory with a commercial PCR kit (BDProbTecET, BD Diagnostic Systems).
Condom use, general characteristics were presented with proportion of each characteristic, and prevalence of C. trachomatis was calculated with 95% confidence interval.
Univariate logistic regression was performed to evaluate the relationship between general characteristics, condom use and C. trachomatis prevalence. Variables with a p-value<0.2 were selected as covariates for the multiple logistic regression model to calculate the adjusted prevalence odds ratios (PORs) and 95% confidence intervals (CIs). SPSS version 17.0 (SPSS INc., Chicago, IL, USA) was used for analysis.
The Institutional Review Board of Seoul National University Hospital and the Seoul National University College of Medicine reviewed and approved the study protocol.
We obtained written consent from 1,083 FSWs. However, 18 FSWs refused to provide questionnaires or samples during the survey. After exclusion of the 22 incomplete or low quality questionnaires and 44 inappropriate samples, we used the data from 999 FSW for statistical analysis.
We found that 128 samples were positive for C. trachomatis out of 999 samples; the proportion with a positive test was 12.8% (95% CI: 10.7-14.9%). Distribution of general characteristics was described in Table 1. Older age (p<0.01), smoking more than 1 pack/day (p=0.14), previous STD history (p=0.06), anxiety for STDs (p=0.10) and low educational level (p=0.18) were included in the multiple logistic regression model.
When asked about the frequency of condom use, only 23.7% of participants answered 100% condom use during last month, and 36.0% reported 100% use of condom on the day before the survey. However 71.0% of participants answered that they have high self confidence in condom negotiation (Table 2). The higher the inconsistency of the condom use, the higher the prevalence of C. trachomatis (p for trend<0.01). This tendency appeared in both condom use at last night and during last month, and remained significant after adjustment of potential confounding variables. However, increasing level of self confidence in condom negotiation did not show decreasing trend of C. trachomatis prevalence (Table 2).
In this study results, not self confidence, but consistent condom use practice was strongly associated with low prevalence of C. trachomatis. Condom use has been shown to have protective effect against STDs including C. trachomatis [5, 6], which was reproduced in our study, but proportion of participant who always used condom was smaller than previous studies which had been conducted in Cambodia by Wong et al. [7] and in China by Pingmin et al. [8] Wong et al. interviewed 140 direct FSWs and reported that 78% of FSWs used condom always with client [7]. Pingmin et al. reported 58.8% of 'every time' condom use during 1 month period before the survey [8]. What we found during the literature review brought about a hypothesis that the minor difference in the questionnaire item for condom use frequency could bring about a difficulty in direct comparison of the result except for the 100% use. A survey of 7 major venues that a congress member's bill was based on reported that 60.5% out of 1,000 FSWs 'always' used condom at work in 2006 [9]. Although no other published Korean data from comparable population before the law was available, our study results suggested decreased prevalence of consistent condom use.
Several interpretations can be raised for increase of inconsistent condom use. Selection of low utilization group by the emigration is one of them; The sex industry in South Korea, like other Asian developing countries, had been reorienting itself from direct prostitution to indirect prostitution [10], and this change was anticipated to be accelerated by the law. Moreover, it was believed that this law had brought the so-called 'balloon effect' causing the change in structure and visibility of prostitution, and migration of FSWs to neighboring countries or indirect sex work via informal regional linkages in the sex industry. During this process if the most adaptive FSWs to this environment were selected, selection bias can be a possible explanation to our findings.
Confidence in condom negotiation was not related to the C. trachomatis prevalence. However, all the participants of this study were direct FSW. Even though some of participants have high condom negotiation skill, they were at high risk of C. trachomatis infection when they use condom less than 90% of coitus.
We included 5 variables (age, education, smoking, STD history, and anxiety for STD) as potential confounders, but only age was significant after the adjustment in the final model, which was consistent with previous reports that younger age was a risk factor for C. trachomatis infection [11]. Although the peak prevalent age range of STD (16-19 years old) was not covered in this study, linear trend for the risk increase along age was significant (p for trend<0.01).
A C. trachomatis prevalence of 12.8% (95% CI: 10.7-14.9%) seems higher than those observed in studies for the general population of Korea. The Korean Center for Disease Control and Prevention (KCDC) reported a 4.7% C. trachomatis prevalence in 959 females from 4 major cities in 2007 [12], and Lee et al. reported 3.1% in 420 female college students from the Seoul metropolitan area [13]. In addition, we could find studies with similar prevalence among FSW in Bangladesh and Cambodia [14, 15], while recent FSW studies conducted in Spain and San Francisco showed relatively smaller values in prevalence than our study [16, 17]. However, without standardization for the age structure of the population, a simple comparison may not be appropriate.
A large study population, which was obtained by covering most of the major sex work sites in Korea, is merit of this study. But limited availability of information on the size and distribution of FSWs made it impossible for us to perform probability sampling, which may put limitation on external validity. We found that FSWs were not practicing enough self-protection at work with a high prevalence of C. trachomatis. Education for constant practice of protection against STDs is needed, especially for younger FSWs.
This study was funded by the Korean Center for Disease Control and Prevention, in a project titled 'Prevalence of sexually transmitted diseases in high risk population of Korea' (Project ID: 2007-E00049-00).

The authors have no conflict of interest to declare on this study.

This article is available from: http://e-epih.org/

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Table 1
Characteristics of study participants and prevalence odds ratio (POR) of C. trachomatis
Characteristics n* C. trachomatis positivity (%) p-value POR 95% CI
Age <25 199 39 (19.6) <0.01 1.00
25-34 679 74 (10.9) 0.50 0.33 - 0.75
≥35 120 12 (10.0) 0.44 0.22 - 0.88
Age of sexual debut <19 504 64 (12.7) 0.90 1.00
≥19 500 57 (12.4) 0.98 0.68 - 1.42
Education level ≥ High school 811 96 (11.8) 0.18 1.00
<High school 174 27 (15.5) 1.41 0.90 - 2.21
Number of people with regular social contact 0-4 Family 712 94 (13.2) 0.27 1.00
≥5 Family 247 26 (10.5) 0.80 0.52 - 1.22
0-4 Friend 599 76 (12.7) 0.88 1.00
≥5 Friend 364 45 (12.4) 0.94 0.65 - 1.37
Smoking ≥ 1 packs No 890 115 (12.9) 0.14 1.00
Yes 102 8 (7.8) 0.57 0.27 - 1.21
Alcohol use Almost everyday 112 15 (13.4) 0.96 1.00
Occasional 557 69 (12.4) 0.84 0.47 - 1.50
Never 326 41 (12.6) 0.91 0.49 - 1.69
Drunken state during coitus Almost everyday 34 6 (17.6) 0.67 1.00
Occasional 212 27 (12.7) 0.76 0.29 - 1.98
Never 739 92 (12.4) 0.72 0.29 - 1.77
Suicidal ideation No 711 86 (12.1) 0.44 1.00
Yes 283 39 (13.8) 1.14 0.76 - 1.69
Level of self-measured health Good 411 49 (11.9) 0.47 1.00
Intermediate 474 65 (13.7) 1.10 0.75 - 1.62
Bad 112 11 (9.8) 0.74 0.37 - 1.46
Previous STD History No 691 78 (11.3) 0.06 1.00
Yes 258 41 (15.9) 1.49 0.98 - 2.23
Anxiety for STDs Yes 536 60 (11.2) 0.10 1.00
Neutral 375 57 (15.2) 1.42 0.96 - 2.10
No 83 7 (8.4) 0.73 0.32 - 1.66
Regular screening during last year No 551 76 (13.8) 0.22 1.00
Yes 439 49 (11.2) 0.82 0.57 - 1.20
Number of customers per week 1-14 318 43 (13.5) 0.66 1.00
15-28 264 35 (13.3) 1.15 0.70 - 1.89
≥ 29 313 43 (13.7) 1.11 0.70 - 1.78

*Numbers may not add up because of missing values in each variable.

STD, sexually transmitted disease; CI, confidence interval.

Table 2
Characteristics of condom use and impact of condom use on the prevalence of C. trachomatis in 930 participants by adjusted prevalence odds ratio and p for trend
Characteristics n (%) C.trachomatis positivity (%) p-value cPOR 95% CI aPOR* 95% CI p for trend
Condom use last night All 335 (36.0) 8.7 0.06 Ref Ref <0.01
Most 544 (58.5) 13.4 0.03 1.64 1.04 - 2.57 1.64 1.03 - 2.62
Some 51 (5.5) 23.5 <0.01 3.25 1.53 - 6.88 3.39 1.54 -7.46
Self confidence in condom negotiation High 660 (71.0) 11.8 0.80 Ref Ref 0.52
Moderate 253 (27.2) 13.4 0.50 1.16 0.75 - 1.78 1.07 0.69 -1.66
Low 17 (1.8) 11.8 0.99 0.99 0.22 - 4.43 0.87 0.19 -4.00
Condom use during the last month 100% 220 (23.7) 7.7 0.04 Ref Ref <0.01
90-100% 275 (29.6) 11.3 0.19 1.52 0.82 - 2.82 1.39 0.74 - 2.62
50-90% 376 (40.4) 14.6 0.01 2.05 1.16 - 3.62 1.92 1.06 - 3.47
<50% 59 (6.3) 18.6 0.02 2.74 1.20 - 6.22 2.91 1.25 -6.81
Age Output
Prevalence (100,000)
 Incidence (100,000)
 Case fatality (100,000)
 Duration (yr)
 Age of onset (yr)
Male Female Male Female Male Female Male Female Male Female
0-4 0.873 0.485 0.065 0.058 0.012 0.007 63.514 68.560 2.496 2.504
5-9 1.196 0.779 0.063 0.061 0.012 0.007 58.613 63.582 7.468 7.546
10-14 1.490 1.116 0.053 0.077 0.012 0.007 53.721 58.523 12.403 12.642
15-19 1.736 1.592 0.048 0.117 0.608 0.499 48.654 53.520 17.546 17.689
20-24 2.037 2.436 0.082 0.246 32.038 25.409 43.538 48.470 22.812 22.847
25-29 2.645 4.156 0.174 0.421 155.442 116.999 38.897 43.999 27.760 27.552
30-34 3.731 6.090 0.264 0.340 381.433 286.767 34.715 39.709 32.540 32.316
35-39 4.844 7.324 0.202 0.220 612.093 511.466 30.906 35.518 37.260 37.351
40-44 5.439 8.019 0.126 0.161 829.406 730.133 27.077 31.643 42.402 42.399
45-49 5.730 8.362 0.093 0.117 1,023.053 1,018.765 23.682 28.135 47.320 47.326
50-54 5.768 8.321 0.055 0.071 1,269.681 1,387.967 20.433 24.942 52.298 52.296
55-59 5.578 7.974 0.036 0.045 1,642.101 1,685.364 17.415 21.984 57.327 57.333
60-64 5.232 7.466 0.021 0.030 1,945.372 1,875.199 14.685 19.196 62.278 62.334
65-69 4.801 6.909 0.014 0.018 2,147.840 1,853.795 12.057 16.446 67.392 67.294
70-74 4.356 6.388 0.012 0.013 2,272.387 1,725.053 9.635 13.557 72.564 72.478
75-79 3.970 5.969 0.027 0.019 2,242.941 1,424.477 7.450 10.833 77.917 77.743
80-84 3.770 5.729 0.050 0.028 1,806.896 1,066.389 5.885 8.784 82.600 82.578
85-89 3.769 5.588 0.054 0.030 1,066.266 1,002.421 4.697 7.865 87.4894 87.501
90≤ 11.864 16.067 0.165 0.091 2,473.864 2,997.072 8.879 22.783 292.163 297.142
Total 3.676 5.304 0.103 0.150 933.467 942.503 35.087 40.679 33.240 32.195

*Adjusted for age, education, previous sexually transmitted disease history, anxiety for the sexually transmitted disease, smoking more than 1 pack/day.

cPOR, crude prevalence odds ratio; CI, confidence interval; aPOR, adjusted prevalence odds ratio.

Figure & Data

References

    Citations

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    Condom Use and Prevalence of Genital Chlamydia trachomatis Among the Korean Female Sex Workers
    Condom Use and Prevalence of Genital Chlamydia trachomatis Among the Korean Female Sex Workers
    Characteristics n* C. trachomatis positivity (%) p-value POR 95% CI
    Age <25 199 39 (19.6) <0.01 1.00
    25-34 679 74 (10.9) 0.50 0.33 - 0.75
    ≥35 120 12 (10.0) 0.44 0.22 - 0.88
    Age of sexual debut <19 504 64 (12.7) 0.90 1.00
    ≥19 500 57 (12.4) 0.98 0.68 - 1.42
    Education level ≥ High school 811 96 (11.8) 0.18 1.00
    <High school 174 27 (15.5) 1.41 0.90 - 2.21
    Number of people with regular social contact 0-4 Family 712 94 (13.2) 0.27 1.00
    ≥5 Family 247 26 (10.5) 0.80 0.52 - 1.22
    0-4 Friend 599 76 (12.7) 0.88 1.00
    ≥5 Friend 364 45 (12.4) 0.94 0.65 - 1.37
    Smoking ≥ 1 packs No 890 115 (12.9) 0.14 1.00
    Yes 102 8 (7.8) 0.57 0.27 - 1.21
    Alcohol use Almost everyday 112 15 (13.4) 0.96 1.00
    Occasional 557 69 (12.4) 0.84 0.47 - 1.50
    Never 326 41 (12.6) 0.91 0.49 - 1.69
    Drunken state during coitus Almost everyday 34 6 (17.6) 0.67 1.00
    Occasional 212 27 (12.7) 0.76 0.29 - 1.98
    Never 739 92 (12.4) 0.72 0.29 - 1.77
    Suicidal ideation No 711 86 (12.1) 0.44 1.00
    Yes 283 39 (13.8) 1.14 0.76 - 1.69
    Level of self-measured health Good 411 49 (11.9) 0.47 1.00
    Intermediate 474 65 (13.7) 1.10 0.75 - 1.62
    Bad 112 11 (9.8) 0.74 0.37 - 1.46
    Previous STD History No 691 78 (11.3) 0.06 1.00
    Yes 258 41 (15.9) 1.49 0.98 - 2.23
    Anxiety for STDs Yes 536 60 (11.2) 0.10 1.00
    Neutral 375 57 (15.2) 1.42 0.96 - 2.10
    No 83 7 (8.4) 0.73 0.32 - 1.66
    Regular screening during last year No 551 76 (13.8) 0.22 1.00
    Yes 439 49 (11.2) 0.82 0.57 - 1.20
    Number of customers per week 1-14 318 43 (13.5) 0.66 1.00
    15-28 264 35 (13.3) 1.15 0.70 - 1.89
    ≥ 29 313 43 (13.7) 1.11 0.70 - 1.78
    Characteristics n (%) C.trachomatis positivity (%) p-value cPOR 95% CI aPOR* 95% CI p for trend
    Condom use last night All 335 (36.0) 8.7 0.06 Ref Ref <0.01
    Most 544 (58.5) 13.4 0.03 1.64 1.04 - 2.57 1.64 1.03 - 2.62
    Some 51 (5.5) 23.5 <0.01 3.25 1.53 - 6.88 3.39 1.54 -7.46
    Self confidence in condom negotiation High 660 (71.0) 11.8 0.80 Ref Ref 0.52
    Moderate 253 (27.2) 13.4 0.50 1.16 0.75 - 1.78 1.07 0.69 -1.66
    Low 17 (1.8) 11.8 0.99 0.99 0.22 - 4.43 0.87 0.19 -4.00
    Condom use during the last month 100% 220 (23.7) 7.7 0.04 Ref Ref <0.01
    90-100% 275 (29.6) 11.3 0.19 1.52 0.82 - 2.82 1.39 0.74 - 2.62
    50-90% 376 (40.4) 14.6 0.01 2.05 1.16 - 3.62 1.92 1.06 - 3.47
    <50% 59 (6.3) 18.6 0.02 2.74 1.20 - 6.22 2.91 1.25 -6.81
    Age Output
    Prevalence (100,000)
    		 Incidence (100,000)
    		 Case fatality (100,000)
    		 Duration (yr)
    		 Age of onset (yr)
    Male Female Male Female Male Female Male Female Male Female
    0-4 0.873 0.485 0.065 0.058 0.012 0.007 63.514 68.560 2.496 2.504
    5-9 1.196 0.779 0.063 0.061 0.012 0.007 58.613 63.582 7.468 7.546
    10-14 1.490 1.116 0.053 0.077 0.012 0.007 53.721 58.523 12.403 12.642
    15-19 1.736 1.592 0.048 0.117 0.608 0.499 48.654 53.520 17.546 17.689
    20-24 2.037 2.436 0.082 0.246 32.038 25.409 43.538 48.470 22.812 22.847
    25-29 2.645 4.156 0.174 0.421 155.442 116.999 38.897 43.999 27.760 27.552
    30-34 3.731 6.090 0.264 0.340 381.433 286.767 34.715 39.709 32.540 32.316
    35-39 4.844 7.324 0.202 0.220 612.093 511.466 30.906 35.518 37.260 37.351
    40-44 5.439 8.019 0.126 0.161 829.406 730.133 27.077 31.643 42.402 42.399
    45-49 5.730 8.362 0.093 0.117 1,023.053 1,018.765 23.682 28.135 47.320 47.326
    50-54 5.768 8.321 0.055 0.071 1,269.681 1,387.967 20.433 24.942 52.298 52.296
    55-59 5.578 7.974 0.036 0.045 1,642.101 1,685.364 17.415 21.984 57.327 57.333
    60-64 5.232 7.466 0.021 0.030 1,945.372 1,875.199 14.685 19.196 62.278 62.334
    65-69 4.801 6.909 0.014 0.018 2,147.840 1,853.795 12.057 16.446 67.392 67.294
    70-74 4.356 6.388 0.012 0.013 2,272.387 1,725.053 9.635 13.557 72.564 72.478
    75-79 3.970 5.969 0.027 0.019 2,242.941 1,424.477 7.450 10.833 77.917 77.743
    80-84 3.770 5.729 0.050 0.028 1,806.896 1,066.389 5.885 8.784 82.600 82.578
    85-89 3.769 5.588 0.054 0.030 1,066.266 1,002.421 4.697 7.865 87.4894 87.501
    90≤ 11.864 16.067 0.165 0.091 2,473.864 2,997.072 8.879 22.783 292.163 297.142
    Total 3.676 5.304 0.103 0.150 933.467 942.503 35.087 40.679 33.240 32.195
    Table 1 Characteristics of study participants and prevalence odds ratio (POR) of C. trachomatis

    *Numbers may not add up because of missing values in each variable.

    STD, sexually transmitted disease; CI, confidence interval.

    Table 2 Characteristics of condom use and impact of condom use on the prevalence of C. trachomatis in 930 participants by adjusted prevalence odds ratio and p for trend

    *Adjusted for age, education, previous sexually transmitted disease history, anxiety for the sexually transmitted disease, smoking more than 1 pack/day.

    cPOR, crude prevalence odds ratio; CI, confidence interval; aPOR, adjusted prevalence odds ratio.

    Table 1

    Table 2

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