100% Condom Use Programme: Experience from China (2001-2004)

The 100% condom use programme (CUP) was a collaborative programme between local authorities (health services, police, public security, and local governor or government office) and sex entertainment establishments (owners, managers, and sex workers) that aimed to reduce the sexual transmission of HIV and sexually transmitted infections (STIs) by assuring high condom use among sex workers and clients. The main characteristic of the programme was the empowerment of sex workers to be able to practice ''No condom - No sex'' in sex work everywhere.

From 2001-2004 the World Health Organization (WHO) assisted the government of China in implementing 100% CUP in Hubei, Jiangsu, Hunan, Hainan, and Guangxi provinces. This document provides a review of the experiences at the five 100% CUP pilot sites in order to:

• identify progress made and impact achieved;
• identify problems confronted and strategies employed to overcome them;
• evaluate commonalities and differences in the experiences of pilot sites; and
• provide best practices and suggestions to assist others in meeting the challenges of designing and implementing a 100% CUP in their jurisdiction.

The goals of 100% CUP was to assure that condoms are used at 100% of the entertainment establishments in a large geographic area, 100% of the time by 100% of the people involved in high-risk sexual relations. Key communication strategies are present in the core components of the programme:

• Thorough mapping of sex establishments over a wide area to increase participation and decrease risk of clients seeking non-100% CUP establishments (outreach to owners to gain commitment is key);
• Awareness raising among sex establishment owners (and commitment from them), sex workers,  and clients;
• Consensus building between AIDS groups, authorities, and sex establishments (owners and workers);
• Logistical support (condoms, water-soluble lubricants, STI services, and educational materials)
• Programme monitoring and evaluation.

Lessons learned include the following:

• The China pilot project showed that a 100% CUP could be successfully implemented and adapted successfully to specific localities and different socioeconomic and demographic settings.
• The specific needs of different types of sex establishments may vary, and programmes must adapt to these needs in order to maximise effectiveness.
• The effectiveness of increasing condom use dictates that prevention efforts must also strongly promote condom use with non-commercial partners for both clients and sex workers.
• The political commitment should translate into funding for public education and a consistent supply of good quality condoms for distribution free of charge to sex establishments.
• Political leadership is critical in all aspects from public education to funding to programme management. 
• A successful 100% CUP may result in other public health benefits.
• Experience-sharing on the 100% CUP can expedite the process in new sites.
• Media and public relations are outlets for generating public support and understanding the necessity of the 100% CUP.
• Use of public health and public security regulations are critical.
• The 100% CUP promotes condom use and monitoring and encourages cooperation of entertainment establishments using a "carrot and stick" strategy to gain voluntary collaboration and sanction those who do not.

Future challenges for the 100% CUP at the time of this report included mainstreaming the strategy and building a strong policy environment to ensure compliance and enforcement in rural and urban China. STI clinics should be brought into the loop of monitoring condom use. Condom quality must be high and consistent.