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Ann Behav Med. 2017 Jun;51(3):470-476. doi: 10.1007/s12160-016-9861-1.

Fidelity Moderates the Association Between Negative Condom Attitudes and Outcome Behavior in an Evidence-Based Sexual Risk Reduction Intervention for Female Sex Workers.

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Division of Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
Evaluation and Research Department, Mexican Foundation for Family Planning (MexFam), Mexico City, DF, Mexico.
Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA), Mexico City, Mexico.
Universidad Autonoma de Ciudad Juarez, Ciudad Juarez, Chihuahua, Mexico.
Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.



Intervention fidelity and participant-level variables, such as negative attitudes towards condoms, are important variables to consider in the successful implementation of evidence-based HIV prevention interventions. Mujer Segura is an intervention that has been shown to be efficacious at reducing condomless sex for female sex workers (FSWs) in Mexico [1].


We examined main effects of fidelity, negative condom attitudes, and their interaction on the effectiveness of the Mujer Segura intervention at reducing condomless sex at intervention follow-up.


Of the FSWs recruited from 13 cities across Mexico, 528 participated in the Mujer Segura intervention. We measured negative condom attitudes at baseline (comprising of beliefs and outcome evaluations) and condomless sex with clients at baseline and 6-month follow-up. Fidelity was measured by a fidelity checklist completed by independent raters; the sum of potentially 43 total elements completed by the counselor constituted fidelity.


Complete fidelity was found in only 15.1% (n = 73) of sessions. There was no significant main effect of intervention fidelity on condomless sex with clients at follow-up. There was a significant and positive main effect of negative condom attitudes and a significant two-way interaction. At lower levels of fidelity, negative condom attitudes predicted greater condomless sex acts, whereas at higher levels of fidelity, the effect of condom attitudes became weaker. The results also indicated that the interaction between negative condom attitudes and fidelity were driven primarily by negative condom beliefs, as opposed to negative condom outcome evaluations.


Ensuring treatment fidelity in an HIV prevention intervention is particularly important when participants have negative attitudes towards condoms.

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