Condom use and prevalence of syphilis and HIV among female sex workers in Andhra Pradesh, India - following a large-scale HIV prevention intervention.

BACKGROUND: Avahan, the India AIDS initiative began HIV prevention interventions in 2003 in Andhra Pradesh (AP) among high-risk groups including female sex workers (FSWs), to help contain the HIV epidemic. This manuscript describes an assessment of this intervention using the published Avahan evaluation framework and assesses the coverage, outcomes and changes in STI and HIV prevalence among FSWs. METHODOLOGY: Multiple data sources were utilized including Avahan routine program monitoring data, two rounds of cross-sectional survey data (in 2006 and 2009) and STI clinical quality monitoring assessments. Bi-variate and multivariate analyses, Wald Chi-square tests and multivariate logistic regressions were used to measure changes in behavioural and biological outcomes over time and their association. RESULTS: Avahan scaled up in conjunction with the Government program to operate in all districts in AP by March 2009. By March 2009, 80% of the FSWs were being contacted monthly and 21% were coming to STI services monthly. Survey data confirmed an increase in peer educator contacts with the mean number increasing from 2.9 in 2006 to 5.3 in 2009. By 2008 free and Avahan-supported socially marketed condoms were adequate to cover the estimated number of commercial sex acts, at 45 condoms/FSW/month. Consistent condom use was reported to increase with regular (63.6% to 83.4%; AOR=2.98; p<0.001) and occasional clients (70.8% to 83.7%; AOR=2.20; p<0.001). The prevalence of lifetime syphilis decreased (10.8% to 6.1%; AOR=0.39; p<0.001) and HIV prevalence decreased in all districts combined (17.7% to 13.2%; AOR 0.68; p<0.01). Prevalence of HIV among younger FSWs (aged 18 to 20 years) decreased (17.7% to 8.2%, p=0.008). A significant increase in condom use at last sex with occasional and regular clients and consistent condom use with occasional clients was observed among FSWs exposed to the Avahan program. There was no association between exposure and HIV or STIs, although numbers were small. CONCLUSIONS: The absence of control groups is a limitation of this study and does not allow attribution of changes in outcomes and declines in HIV and STI to the Avahan program. However, the large scale implementation, high coverage, intermediate outcomes and association of these outcomes to the Avahan program provide plausible evidence that the declines were likely associated with Avahan. Declining HIV prevalence among the general population in Andhra Pradesh points towards a combined impact of Avahan and government interventions.

Programme coverage, condom use and STI treatment among FSWs in a large-scale HIV prevention programme: results from cross-sectional surveys in 22 districts in southern India.

OBJECTIVE: This paper evaluates Avahan programme's coverage of female sex workers (FSWs), focus on high-risk FSWs and intermediate outcomes. METHODS: First round of cross-sectional survey data, Integrated Behavioral and Biological Assessments (IBBA), conducted in 22 districts, were aggregated into district categories: Solo, where Avahan was the sole service provider covering all FSWs and Major or Minor where Avahan was not the sole provider, but intended coverage was >50% or or=15 clients in the past week had a higher chance of being exposed to core services (AOR=1.56; 95% CI 1.03 to 2.35). Exposure to the three services in Solo Avahan districts was significantly associated with correct knowledge on condom use (AOR=1.36; 95% CI 1.05 to 1.78), consistent condom use with occasional clients (AOR=3.17; 95% CI 2.17 to 4.63) and regular clients (AOR=2.47; 95% CI 1.86 to 3.28) and STI treatment-seeking behaviour (AOR=3.00; 95% CI 1.94 to 4.65). CONCLUSIONS: Higher coverage of FSWs was achieved in districts where Avahan was the only intervention compared with districts having multiple and longstanding non-Avahan programmes. Exposure in Solo districts was associated with intermediate outcomes; this need to be further evaluated in comparison with non Avahan areas and substantiated through data from next IBBA.

Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India.

OBJECTIVE: To describe the sociodemographic characteristics, prevalence of high-risk sexual behaviours, HIV, sexually transmitted infections (STI), and perception of risk in self-identified men who have sex with men (MSM) in four south Indian states. METHODS: A cross-sectional probability-based survey of 4597 self-identified MSM in selected districts from four states in south India was undertaken. Self-defined sexual identity, sexual behaviour, and STI/HIV knowledge were assessed using a structured questionnaire. Blood and urine samples were tested for HIV and STI. Recruitment criteria differed slightly across states. RESULTS: When grouped by self-identity, the HIV prevalence was: hijra (transgender) 18.1%; bisexuals 15.9%; kothis (anal-receptive) 13.5%; double-deckers (both anal-insertive/anal-receptive) 10.5%; and panthis (anal-insertive) 7.6%. Reported condom use with last paid male partner was over 80% in all states and categories. Consistent condom use was overall low among self-identified MSM, with less than 29% with non-commercial non-regular male partners and less than 49% with regular male partners. The percentage of self-identified MSM with regular female partners was 4-43% and with commercial female partners was 14-36% across states, and consistent condom use differed by self-identity. Syphilis prevalence was high among kothis and hijras (15.8 and 13.6%, respectively). Urethral gonorrhoea prevalence was less than 1% and chlamydia prevalence ranged from 0.4 to 4.0%. CONCLUSION: HIV prevalence and risk behaviour within these self-identified MSM communities in south India is high. Moreover, a significant proportion of them had female partners, both regular and commercial. The national programme's focus on HIV prevention services for these high-risk MSM is justified.

HIV, sexually transmitted infections and sexual behaviour of male clients of female sex workers in Andhra Pradesh, Tamil Nadu and Maharashtra, India: results of a cross-sectional survey.

OBJECTIVE: To characterize and describe patterns of HIV, sexually transmitted infections (STI) and sexual behaviour of male clients of female sex workers (FSW). METHODS: A cross-sectional study was conducted among 4821 clients of FSW from 12 districts in three states in India: Andhra Pradesh, Maharashtra and Tamil Nadu. A structured questionnaire was administered to elicit demographic characteristics and sexual behavioural patterns. Blood and urine samples were tested for HIV, syphilis and herpes simplex type 2 serology, gonococcal and chlamydial infection. RESULTS: The median age of clients surveyed was 30 years; 57% were married and 64% had a steady sexual partner; 61% had sex with more than one FSW and 39% had four or more sexual encounters in the past month. The prevalence of HIV ranged from 2.0% to 10.9%, syphilis ranged from 3.1% to 10.1%; gonorrhoea and chlamydia ranged between 0% and 4.5%. Clients older than 30 years [odds ratio (OR) 1.65; 95% confidence interval (CI) 1.33-2.05] and having a different mix of commercial and non-commercial partners (OR 1.56; 95% CI 1.25-1.96) had a higher volume of sex acts with FSW. Inconsistent condom use with FSW was significantly associated with older clients (OR 4.2; 95% CI 3.33-5.29), illiteracy (OR 1.39; 95% CI 1.14-1.69), age <18 years at first paid sex (OR 1.83; 95% CI 1.24-2.70) and having different FSW partners in the past month (OR 1.64; 95% CI 1.23-2.18). CONCLUSION: Clients of FSW studied here constitute a significant bridge group for HIV and other STI, because of their high volume of different sexual partners and very low consistent condom use. HIV prevention programmes need to address male clients.