Reviewer ’s report  
 
Title:  Short -term Acceptability of female condom use among low -fee female sex workers in 
China: a follow -up study  
 
Version: 0 Date: 13 Aug 2018 
 
Reviewer:  Joanna  Busza  
 
Reviewer’s report:  
 
This is a well -written paper that identifies some of the characteristics of sex workers in 3 cities in 
China who might benefit from proactive targeting of the female condom for STI and  HIV 
prevention. After initial international enthusiasm for the female condom, few studies now 
examine its acceptability to sex workers and other vulnerable populations so this is a welcome 
addition to the literature.  
 
The paper would benefit from a few ad ditions, notably in the Background/Introduction section 
(to improve readers' understanding of the local context) and Discussion (which currently 
contains some notable omissions and contradictions). My comments are as follows:  
 
(1) It would be helpful to gi ve a bit more detail on "low fee" sex work, and how it compares to 
other forms of sex work in China. The paper gives two different fee structures by which to 
characterise "low fee" - in one place this is defined as charging less than 80 RMB, while in the 
survey the variable is divided in <30, 30 -50, >50 RMB. I suggest making this consistent, and 
explaining what average or "high fee" sex workers might charge, so that the extent of inequity 
can be assessed. The authors also do not provide adequate details abo ut low -fee sex workers' 
vulnerability. For example, their HIV prevalence is compared to the general population's in 
China rather than other sex worker populations. In one place it is stated that low -fee sex workers 
are vulnerable partly because they work i n venues "without gatekeepers", yet later (page 5, line 
42) the existence of their "gatekeepers" is referred to. Unless readers have pre -existing 
knowledge of sex work conditions and typologies in China, it will be difficult for them to really 
understand t he justification for focusing on this group and how they differ from others.  
 
(2) In Methods, it is stated that outreach workers conducted both the intervention (handing out 
female condoms and explaining their use) and the survey. Were these outreach workers known to 
the sex workers already? Did they work for a recognised service pr ovider or sex work 
organisation? If not, how did they identify and reach the sex workers? On the other hand, if they 
were already known to the recruited sample it may be worth mentioning that responses by sex 
workers could be influenced by some form of cou rtesy or social desirability bias.  
 
(3) The analysis differentiates use of "0 -2" and "more than 2" female condoms within 30 days. Is 
data available for the average number (or range) of clients sex workers might have during this 
period so readers can judge what proportion of sexual transactions the female condoms covered? 
Also, is there any data on uptake of female condoms by "higher fee" sex workers in China or 
neighbouring countries? The paper seems to imply that low -fee sex workers are particularly 
likely  to adopt female condom use, without providing any comparison data for other socio -
economic groups.  
 
(4) The Discussion would benefit from a bit more depth. For example, it is both stated that the 
fact that sex workers who report consistent condom use with  regular clients are more likely to 
use the female condom may signify that they are better able to negotiate with regular clients than 
new clients (which may well be true). However, it is also stated that they may use female 
condoms because their regular c lients tend to be older and there may be difficulties with male 
condom use due to erectile dysfunction. But if the women using the female condoms were most 
like to report male condom use as well, the argument about compensating for erectile 
dysfunction by using the female condom seems unlikely. It may be that those sex workers who 
are better negotiators in general, or who have better relationships with their regular clients, are 
successfully introducing BOTH male and female condoms with their clients. It mi ght be worth 
mentioning that this group may be less vulnerable than the others who do NOT use male 
condoms consistently, but that they may be early adopters with relevant skills that they could 
share with their peers through a process of "diffusion of inno vations."  
 
(5) Related to the above, inclusion of more theory -driven constructs would strengthen the 
Discussion, perhaps drawing on frameworks such as Diffusion of Innovations or other more 
conceptual literature. The high prevalence of migration among thi s group of sex workers is also 
notable, and could be mentioned as another determinant of vulnerability.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the  work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
Acceptable  
 
Declaration of competing interests  
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