P Narayanan

Large-scale STI services in Avahan improve utilization and treatment seeking behaviour amongst high-risk groups in India: an analysis of clinical records from six states.

BackgroundAvahan, the India AIDS Initiative, implemented a large HIV prevention programme across six high HIV prevalence states amongst high risk groups consisting of female sex workers, high risk men who have sex with men, transgenders and injecting drug users in India. Utilization of the clinical services, health seeking behaviour and trends in syndromic diagnosis of sexually transmitted infections amongst these populations were measured using the individual tracking data.MethodsThe Avahan clinical monitoring system included individual tracking data pertaining to clinical services amongst high risk groups. All clinic visits were recorded in the routine clinical monitoring system using unique identification numbers at the NGO-level. Visits by individual clinic attendees were tracked from January 2005 to December 2009. An analysis examining the limited variables over time, stratified by risk group, was performed.ResultsA total of 431,434 individuals including 331,533 female sex workers, 10,280 injecting drug users, 82,293 men who have sex with men, and 7,328 transgenders visited the clinics with a total of 2,700,192 visits. Individuals made an average of 6.2 visits to the clinics during the study period. The number of visits per person increased annually from 1.2 in 2005 to 8.3 in 2009. The proportion of attendees visiting clinics more than four times a year increased from 4% in 2005 to 26% in 2009 (p<0.001). The proportion of STI syndromes diagnosed amongst female sex workers decreased from 39% in 2005 to 11% in 2009 (p<0.001) while the proportion of STI syndromes diagnosed amongst high risk men who have sex with men decreased from 12% to 3 % (p<0.001). The proportion of attendees seeking regular STI check-ups increased from 12% to 48% (p<0.001). The proportion of high risk groups accessing clinics within two days of onset of STI-related symptoms and acceptability of speculum and proctoscope examination increased significantly during the programme implementation period.ConclusionsThe programme demonstrated that acceptable and accessible services with marginalised and often difficult–to-reach populations can be brought to a very large scale using standardized approaches. Utilization of these services can dramatically improve health seeking behaviour and reduce STI prevalence.

High rates of reinfection and incidence of bacterial sexually transmitted infections in a cohort of female sex workers from two Indian cities: need for different STI control strategies?

Background Female sex workers (FSWs) in India are provided a standardised package of clinical interventions for management of sexually transmitted infections (STIs). A study was conducted among FSWs at known high STI prevalence sites to determine the effectiveness of the service package. Methods A cohort of FSW clinic attendees in two cities, Hyderabad and Mumbai, were enrolled and followed up from October 2008 to November 2009. At each visit, behavioural and clinical data were obtained and vaginal swabs collected for laboratory testing of cervical infections (gonorrhoea and chlamydia). Results 417 participants were enrolled, of whom 360 attended at least a follow-up visit. Prevalence of cervical infections did not change between the baseline and final visits (27.7% and 21.3% respectively, p=0.08) in spite of presumptive treatment at baseline and syndromic management at all visits. The proportion of asymptomatic cervical infections increased from 36% at baseline to 77% at the final visit. Incidence rate of cervical infections was high (85.6/100 person years) and associated with a prevalent cervical infection at baseline (HR=2.7, p<0.001) and inconsistent condom use with non-commercial partners (HR=2.5, p=0.014). Conclusions High rates of STIs persisted despite the interventions due to poor condom use, minimal partner treatment, and high prevalence and incidence of STIs with a large proportion of asymptomatic infections. High-prevalence FSW sites in India need to design more effective partner treatment strategies and consider increasing the frequency of presumptive treatment as a temporary measure for quickly reducing STI prevalence, with renewed emphasis on consistent condom use with all partners.

An exploration of elevated HIV and STI risk among male sex workers from India

BackgroundMen who have sex with men (MSM) who also report transactional sex (male sex workers or MSWs) are known to be at higher risk for HIV and sexually transmitted infections (STIs). The study aimed to profile socio-demographic characteristics and risk factors associated with high HIV prevalence among MSWs.MethodsA cross-sectional study was conducted in 2008–9 among 483 high-risk MSM who attended STI clinics at Mumbai and Hyderabad, two large cities in India.ResultsAbout 70% of the MSM reported transactional sex. As compared to other MSM, MSWs had more male partners (8.9 versus 2.5, p < 0.001) and higher rates of receptive anal sex (96% versus 72%, p < 0.001). HIV prevalence among MSWs and other MSM was 43.6% and 18.1% respectively. HIV prevalence among MSWs was associated with the place of residence (MSWs from Hyderabad were 7.3 times more likely to be infected), positive syphilis serology (3.8 times) and duration of sex work (increased by 8% for every additional year).ConclusionThe study showed that MSWs are at high risk for HIV acquisition/transmission, which highlights the need for intensified interventions for personalized risk-reduction counselling and STI screening. Newer biomedical interventions such as pre-exposure prophylaxis and treatment as prevention could also be considered.

Genital ulcer disease in India: etiologies and performance of current syndrome guidelines.

Background In India, genital ulcer disease (GUD) syndrome is clinically classified as herpetic or nonherpetic and managed accordingly; laboratory support is unavailable at most health facilities. We undertook a study to determine the etiology of GUDs in men presenting to sexually transmitted infection (STI) clinics and assess the performance of the national algorithm for syndromic management of herpetic and nonherpetic GUDs in India. Method A cross-sectional study was conducted among men with complaints of genital ulcers attending 8 STI clinics in 4 states. Ulcer swabs were collected and tested by the multiplex polymerase chain reaction method to determine the etiology of GUD. Results Of the 194 men recruited, etiology was confirmed in 121 GUD cases (62%). Herpes simplex virus (48%) was the most common etiological agent identified, followed by Treponema pallidum (23%) and mixed infections (9%). One case of Haemophilus ducreyi was confirmed in this series. The overall sensitivity and specificity of the national syndromic management algorithm for GUD were 68% and 52%, respectively. Using the national algorithm, 52 (42%) cases clinically misclassified as either herpetic (18 cases) or nonherpetic (34 cases) GUD resulting in incorrect treatment. Conclusions Our findings suggest a revision of existing national STI treatment guidelines in India to include treatment of syphilis infections of all GUD patients. Periodic studies are required to monitor changing spectrum of GUD etiologies in India.

Self-Identity, Sexual Practices and Sexually Transmitted Infections among High-Risk Men who Have Sex with Men Attending Clinics in Urban India

Journal of AIDS & Clinical Research aims to provide the most complete and true source of information about “on-going” developments in the field. The journal covers studies and research on experimental; clinical; therapeutic; pathogenesis; vaccines; drug resistance; diagnosis and virology on AIDS. The Journal of AIDS & Clinical Research will comprehend all aspects of basic and clinical science that have impact on slaking the spread of AIDS. It is a multidisciplinary journal that aims to keep scientists, clinicians, and researchers with updated knowledge.

O1-S10.05 Cohort study to determine sexually transmitted rectal infections among high-risk men who have sex with men in India

Background There are few studies on sexually transmitted infections (STIs) among men who have sex with men (MSM) in India to inform the development of appropriate strategies for STI control. This cohort study aimed to determine the prevalence and incidence of rectal gonorrhoea and chlamydia among high-risk MSM in response to standardised interventions in Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation. High-risk MSM are self-identified MSM who have large numbers of sex partners and sell sex or practice receptive anal sex. Methods A cohort of 512 high-risk MSM attending STI clinics in two high HIV prevalence cities of India was recruited in 2008 and followed for four visits over a year. During each visit, rectal swabs were collected during proctoscopic examination and tested for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) by Roche Amplicor PCR. Participants were provided risk reduction counselling and those with ano-rectal discharge syndrome received treatment as per the national guidelines. In addition, all participants received presumptive treatment for gonorrhoea and chlamydia at the baseline visit. Results At baseline, rectal GC and/or CT prevalence was 14% and remained consistent over the visits. Of those with laboratory confirmed infections, only 8.2% were clinically diagnosed with ano-rectal discharge syndrome, while the majority (91.8%) did not have relevant symptoms or signs. Participants were followed for a total of 139.3 person years (median—0.25 years, max—1.07 years) during which 1562 visits were made. During the study period, 127 incident infections of rectal GC and CT were found giving an incidence rate of 91.2 per 100 person years. The incidence rate was highest when consecutive visits were within 30 days (241.8 per 100 person years, HR 0.83, p=0.00). There were no significant associations of incidence of rectal gonorrhoea and chlamydia with demographic and behavioural characteristics (Abstract O1-S10.05 table 1). Abstract O1-S10.05 Table 1 Correlates of GC/CT incidence S. No. Characteristic HR p Value 1 Age (up to 25 years) 0.9 0.76 2 Self-reported sexual identity of Panthi (insertive in anal sex) compared to Kothi (receptive in anal sex) 1.6 0.18 3 Self-reported sexual identity of double decker (both insertive and receptive) compared to Kothi 0.9 0.63 4 Self-reported sexual identity of Panthi compared to double decker 1.6 0.14 5 Engaged in commercial sex 0.9 0.70 6 Sex work as main source of income 1.0 0.90 7 New to commercial sex (<1 year) 0.7 0.21 8 Self-reported condom use with male in last encounter 2.3 0.06 9 Do not have regular partner 1.0 0.96 Conclusions A high prevalence of asymptomatic rectal gonorrhoea and chlamydia was observed along with a high incidence rate of these infections among high-risk MSM in India. The persistence of high prevalence of asymptomatic infections remaining even after presumptive treatment at the first visit calls for a review of the periodicity of presumptive treatment in similar clusters of MSM. Consistent condom use and partner treatment need to be re-emphasised.

P6.038 Technical Support For Clinical Services of a Large Scale HIV Prevention Programme For Key Populations in India

Background Avahan was a focused HIV prevention programme implemented across six states in India by seven lead agencies through 129 local NGOs, providing services to 321,000 individuals from key populations. Clinical services for STIs were an important component of Avahan’s intervention package. Methods Technical support was provided by a centralised agency to lead agencies’ STI staff who directly supervised NGO clinical services. The approach during the first phase (2005–2009) of ‘build and operate’ included developing standardised guidelines, training, quality assurance and quality improvement, and using monitoring data to improve the programme. During the final phase (2009–2013) of transitioning to government support, the strategy was to ensure that services were restructured to align with national guidelines, generate and provide evidence towards advocacy for improvement of the national programme. Results In 2005–2009, 431,434 individuals made 2.7 million clinic visits. The annual average number of clinic visits by individuals increased from 1.6 to 3.5, and the proportion of visits for STI syndromes decreased from 52.5% to 11.8%. Verbal screening for tuberculosis (TB) identified 6,879 TB suspects of whom 1,565 were diagnosed with active TB. The quality monitoring of Avahan clinics showed an increased score from 2.21 to 3.82 (on a scale of 0–5). The introduction of a point of care test for syphilis doubled the proportion of clinic attendees screened from 2007 to 2009. In the transition phase, revised operational guidelines were developed to align with national guidelines and a nurses’ training was conducted to address ‘task shifting’. The national programme adapted the Avahan guidelines for STI management among key populations. Conclusion A centralised technical support agency has a pivotal role in ensuring standardised and high quality services. Large scale and national programmes would benefit from collaborating with independent technical units to outsource some of the work of implementation.

P3-S1.20 Aetiology of urethral discharge syndrome and its association with sexual practices among males attending STI clinics in India

Background Studies to validate the aetiology of urethral discharge (UD) syndrome are limited in India. The objectives of the study were to determine etiological agents of UD syndrome among males attending STI clinics and associated risk factors. Methods We conducted a cross-sectional study among males presenting with complaints of dysuria and/or urethral discharge at eight government and non-governmental organization STI clinics in four Indian states from 2008 to 2009. A behavioural questionnaire was administered, clinical examination performed and urine was collected to test for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) by Gen-Probe-APTIMA Combo II. In cases where a urethral discharge was elicited, urethral swabs were collected and tested for Mycoplasma genitalium (MG), Ureaplasma urealyticum (UU) and Trichomonas vaginalis (TV) by using PCR method. Data were analysed using STATA V10. Results 246 clients diagnosed with UD syndrome as per the national algorithm were enrolled in the study. 29% of the participants had at least one of the infections. The overall prevalence of GC was 14% and CT was 4%. Among the 86 participants from whom urethral swabs were collected, prevalence of MG and UU was 33% and 34% respectively while TV was not detected. In this sub-group of 86 participants, the prevalence of GC and CT was higher at 24% and 7% respectively while 64% individuals had at least one infection. Factors such as younger age (<25 years), illiteracy, paid sex in last 2 weeks and penetrative anal sex in last 3 months were found to be significantly associated with having any infection (see Abstract P3-S1.20 table 1). Abstract P3-S1.20 Table 1 Correlates of infections (gonococcal and/or non-gonococcal) S. No. Characteristic OR (95% CI) p Value 1 Age up to 25 years 1.7 (0.9 to 3.1) 0.06 2 Inability to read or write 2.2 (0.9 to 5.1) 0.05 3 Paid sex in last 2 weeks 2.1 (1.1 to 4.2) 0.02 4 Penetrative anal sex in past 3 months 2.1 (0.9 to 4.8) 0.05 5 Vaginal sex in past 3 months 2.8 (0.6 to 26.4) 0.16 6 No condom use at last sexual act 1.4 (0.7 to 2.7) 0.32 Conclusion The current practice of diagnosing UD syndrome based on the history of dysuria and/or discharge is leading to over-diagnosis. A detailed sexual history for determining risk factors and demonstration of urethral discharge on clinical examination will help to improve the diagnosis.

P2-S2.07 Improving sexually transmitted infections (STI) prevention strategies: factors associated with STIs among female sex workers in India

Background Studies among high-risk groups (HRGs) have shown that the presence of STIs is associated with certain demographic and behavioural characteristics as well as exposure to HIV/STI prevention interventions. The objective of this study was to understand the correlates of STIs in female sex workers (FSWs) in India in order to improve STI programming for HRGs. Methods During 2008–2009, 417 female sex workers were recruited from three STI clinics in two cities of India as part of an operations research to evaluate the effectiveness of STI prevention service package for sex workers under Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation. Behavioural and clinical information along with biological samples were collected. Bivariate analysis of demographic and behavioural characteristics associated with the prevalence of common bacterial STIs- Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum and Trichomonas vaginalis from the baseline data is presented in this paper. Results At baseline 49.2% of the participants had a laboratory confirmed diagnosis for at least one of the four bacterial STIs. The significant factors associated with STI prevalence among FSWs were: inability to read or write (OR=2.2, p=0.002); not staying with a sexual partner (OR=1.5, p=0.036); typology of sex work: home-/hotel-based (OR=2.5, p=0.038) vs brothel-based and street-based (OR=3.1, p=0.004) vs brothel-based; regular or occasional consumption of alcohol (OR=1.9, p=0.002); poor knowledge of STI symptoms (OR=1.6, p=0.017); low self-risk perception for acquiring STIs (OR=1.6, p=0.031); less than 2 years in sex work (OR=1.8, p=0.008); no prior exposure to HIV/STI interventions (OR=2.0, p=0.001); and no STI check-ups in the past 6 months (OR=1.5, p=0.029) see Abstract P2-S2.07 Table 1. Abstract P2-S2.07 Table 1 Factors associated with sexually transmitted infections among female sex workers in India Factors OR 95% CI p value Illiterate (can not read or write) 2.2 (1.3 to 3.7) 0.002 Not staying with a sexual partner 1.5 (1.0 to 2.4) 0.036 Typology  Brothel-based Reference  Home/hotel-based 2.5 (1.0 to 6.7) 0.038  Street-based 3.1 (1.3 to 7.7) 0.004 Consume alcohol (regularly or occasionally) 1.9 (1.2 to 2.8) 0.002 Poor knowledge of STI symptoms 1.6 (1.1 to 2.4) 0.017 Low self-risk perception for acquiring STIs 1.6 (1.0 to 2.5) 0.031 New to sex work (less than 2 years) 1.8 (1.1 to 2.8) 0.008 No prior exposure to STI/HIV interventions 2.0(1.3 to 3.0) 0.001 No STI check-ups in past 6 months 1.5 (1.0 to 2.3) 0.029 Conclusions HIV/STI prevention programs for FSWs in India need to prioritise services for HRGs who have characteristics associated with STI prevalence. Additionally, awareness activities should promote the importance of regular STI check-ups, recognition and early treatment for STI symptoms.

P1-S2.54 Repeat Gonococcal and chalymadial infections in a cohort of men who have sex with men in India

Background Men who have sex with men (MSM) are found to be at increased risk for many sexually transmitted infections (STI). Among the STIs, most common are bacterial STIs such as Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT). In the present study we analysed determinants of repeat gonococcal and chlymadial infections among the cohort of high-risk MSM. Methods Between 2008 to 2009, 512 MSM attending STI clinics in four clinics of two cities (Mumbai and Hyderabad) of India were recruited and followed for 3 months. First catch urine, rectal swabs, Pharyngeal swabs were collected in all visits and tested for NG and CT by Gen-Probe APTIMA Combo II assay and Roche PCR (Pharyngeal swabs positive by Roche Amplicor and 16s RNA NG PCR were considered). Presumptive treatment for gonorrhoea and chlamydia at the baseline visit and syndromic STI management at all subsequent visits was provided during the study period. Re-infection was defined as a positive test result occurring after 30 days and above after an initial positive result until the last follow-up. Results Of 417 MSMs recruited during 2008−2009, 454 made at least on fallow-up visit. Three hundred and fifteen were NG infected and 138 were CT infected. 41 (9%) NG and 7 (1.5%) CT re-infections were observed during the follow-up visits see Abstract P1-S2.54 Table 1. Past history of STI (as reported by the participants) (OR=2.82, p=0.00) and diagnosis of any STI by Physician (OR=2.24, p=0.05) were significantly associated factors with re-infection. Conclusions Cumulative incidence of repeat gonococcal infections among MSMs highlight the need of a routine STI screening, prevention counselling, promoting use of consistent condom, laboratory screening and prompt treatment of patients at high risk. These efforts maximally help in avoiding recurrent NG/CT re-infection among high risk MSMs and there partners. Abstract P1-S2.54 Table 1 Re-infection frequency among cohort of men having sex with men in India Visits Visit 1 Visit 2 Visit 3 Visit 4 Total NG-Re-infection  No re-infection/ Negatives 512 435 342 232 1521  Re-infected (31 to 292 days) 0 19 13 9 41  Total 512 454 355 241 1562 CT-Re-infection  No re-infection/Negatives 512 451 352 240 1555  Re-infected (31 to 291 days) 0 3 3 1 7  Total 512 454 355 241 1562