Mplex interactions that will occur over time within the multiple levels

Only then can we begin to understand the role of the multiple influences upon behavior and begin to translate this evidence into future healthenhancing interventions. A complex web of sexual health practices and a0022827 industry-level RRx-001 biological activity factors journal.pone.0077579 place female sex workers (FSW) in China at increased risk for Torin 1 cost acquiring HIV/AIDS and other sexually transmitted diseases [1?]. Although illegal, stigmatized and constantly under attack from police, prostitution remains a full-time job for many Chinese women. Interventions to improve sexual health practices among FSW in China tend to assume that women engage in?Springer Science+Business Media New York 2013 Correspondence to: Zhang Youchun, youchun_zhang@126.com.Youchun et al.Pagehigh-risk behaviors because of low knowledge about correct condom use and HIV/STI transmission, and thus focus on education and condom-use skills training [1]. Previous research has shown, however, that while some FSW may continue to rely on ineffective prevention methods such as washing with salt water or disinfectants, douching, and selfmedicating with antibiotics [5], others are better informed about reproductive health and more skilled in condom use than women outside the sex trade [6]. Yet knowledge does not necessarily translate into safer sexual behaviors even among well-informed FSW [7, 8]. Instead, a variety of factors influence FSWs' choice or ability to practice safer sexual behaviors, including--but not limited to--economic hardship, concerns about fertility, client refusal/coercion, relationship status, and working conditions [8?3]. The relative importance of each of these factors for HIV/STI acquisition may also vary as they operate through the unique characteristics of different settings within the sex work industry [2, 5, 7, 13, 14]. The Chinese Ministry of Health considers FSW a priority population for HIV/STI disease surveillance and prevention activities [15]. However, according to previous ethnographic research [13, 16], at least seven categories of Chinese sex workers exist, differing by workplace, types of services offered, income levels, and demographic characteristics. Recent epidemiologic surveillance data suggests that these differences may play a role in HIV/STI risk among FSW [4]. For example, in a study of 816 FSW, women recruited from streets and rented houses had a syphilis prevalence of 40.7 compared to 11.1 among women recruited from hair salons, saunas and massage shops [2]. Although national estimates of HIV prevalence among FSW remain relatively low (