Reynold Washington

Declines in risk behaviour and sexually transmitted infection prevalence following a community-led HIV preventive intervention among female sex workers in Mysore India.

Objective:To investigate the impact on sexual behaviour and sexually transmitted infections (STI) of a comprehensive community-led intervention programme for reducing sexual risk among female sex workers (FSW) in Mysore, India. The key programme components were: community mobilization and peer-mediated outreach; increasing access to and utilization of sexual health services; and enhancing the enabling environment to support programme activities. Methods:Two cross-sectional surveys among random samples of FSW were conducted 30 months apart, in 2004 and 2006. Results:Of over 1000 women who sell sex in Mysore city, 429 participated in the survey at baseline and 425 at follow-up. The median age was 30 years, median duration in sex work 4 years, and the majority were street based (88%). Striking increases in condom use were seen between baseline and follow-up surveys: condom use at last sex with occasional clients was 65% versus 90%, P < 0001; with repeat clients 53% versus 66%, P < 0.001; and with regular partners 7% versus 30%, P < 0.001. STI prevalence declined from baseline to follow-up: syphilis 25% versus 12%, P < 0.001; trichomonas infection 33% versus 14%, P < 0.001; chlamydial infection 11% versus 5%, P = 0.001; gonorrhoea 5% versus 2%, P = 0.03. HIV prevalence remained stable (26% versus 24%), and detuned assay testing suggested a decline in recent HIV infections. Conclusion:This comprehensive HIV preventive intervention empowering FSW has resulted in striking increases in reported condom use and a concomitant reduction in the prevalence of curable STI. This model should be replicated in similar urban settings across India.

Determinants of HIV prevalence among female sex workers in four south Indian states: analysis of cross-sectional surveys in twenty-three districts

Objective:In four states in southern India we explored the determinants of HIV prevalence among female sex workers (FSW), as well as factors associated with district-level variations in HIV prevalence among FSW. Methods:Data from cross-sectional surveys in 23 districts were analysed, with HIV prevalence as the outcome variable, and sociodemographic and sex work characteristics as predictor variables. Multilevel logistic regression was applied to identify factors that could explain variations in HIV prevalence among districts. Results:HIV prevalence among the 10 096 FSW surveyed was 14.5% (95% confidence interval 14.0–15.4), with a large interdistrict variation, ranging from 2% to 38%. Current marital status and the usual place of solicitation emerged as important factors that determine individual probability of being HIV positive, as well as the HIV prevalence within districts. In multivariate analysis, compared with home-based FSW, the odds of being HIV positive was greater for brothel-based FSW [adjusted odds ratio (AOR) 2.17, P ≤ 0.001] and for public place-based FSW (AOR 1.32, P = 0.005). Unmarried FSW and those who were widowed/divorced/separated, or from the devadasi tradition, had higher odds of being HIV positive (AOR 1.79, P ≤ 0.001 and 1.98, P < 0.001, respectively), than those currently married. The estimated district level variance in HIV prevalence was lowest (0.152) for brothel-based unmarried FSW, followed by brothel-based widowed/divorced/separated or devadasi FSW (0.192). Conclusion:Heterogeneity in the organization and structure of sex work is an important determinant of variations in HIV prevalence among FSW across districts in India, much more so than the districts themselves. This understanding should help to improve the design of HIV preventive interventions.

Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India

Objectives To examine the impact of a large-scale HIV prevention programme for female sex workers (FSW) in Karnataka state, south India, on the prevalence of HIV/sexually transmitted infections (STI), condom use and programme coverage. Methods Baseline and follow-up integrated biological and behavioural surveys were conducted on random samples of FSW in five districts in Karnataka between 2004 and 2009. Results 4712 FSW participated in the study (baseline 2312; follow-up 2400), with follow-up surveys conducted 28–37 months after baseline. By follow-up, over 85% of FSW reported contact by a peer educator and having visited a project STI clinic. Compared with baseline, there were reductions in the prevalence of HIV (19.6% vs 16.4%, adjusted odds ratio (AOR) 0.81, 95% CI 0.67 to 0.99, p=0.04); high-titre syphilis (5.9% vs 3.4%, AOR 0.53, 95% CI 0.37 to 0.77, p=0.001); and chlamydia and/or gonorrhoea (8.9% vs 7.0%, AOR 0.72, 95% CI 0.54 to 0.94, p=0.02). Reported condom use at last sex increased significantly for repeat clients (66.1% vs 84.1%, AOR 1.98, 95% CI 1.58 to 2.48, p<0.001) and marginally for occasional clients (82.9% vs 88.0%, AOR 1.22, 95% CI 0.89 to 1.66, p=0.2), but remained stable for regular partners (32%). Compared with street and home-based FSW, brothel-based FSW were at highest risk of HIV and STI, despite high levels of reported condom use. Conclusions This large-scale HIV prevention programme for FSW achieved reductions in HIV and STI prevalence, high rates of condom use with clients and high rates of programme coverage. Improved strategies to increase condom use with regular partners and reduce the vulnerability of brothel-based FSW to HIV are required.

An integrated structural intervention to reduce vulnerability to HIV and sexually transmitted infections among female sex workers in Karnataka state, south India

BackgroundStructural factors are known to affect individual risk and vulnerability to HIV. In the context of an HIV prevention programme for over 60,000 female sex workers (FSWs) in south India, we developed structural interventions involving policy makers, secondary stakeholders (police, government officials, lawyers, media) and primary stakeholders (FSWs themselves). The purpose of the interventions was to address context-specific factors (social inequity, violence and harassment, and stigma and discrimination) contributing to HIV vulnerability. We advocated with government authorities for HIV/AIDS as an economic, social and developmental issue, and solicited political leadership to embed HIV/AIDS issues throughout governmental programmes. We mobilised FSWs and appraised them of their legal rights, and worked with FSWs and people with HIV/AIDS to implement sensitization and awareness training for more than 175 government officials, 13,500 police and 950 journalists.MethodsStandardised, routine programme monitoring indicators on service provision, service uptake, and community activities were collected monthly from 18 districts in Karnataka between 2007 and 2009. Daily tracking of news articles concerning HIV/AIDS and FSWs was undertaken manually in selected districts between 2005 and 2008.ResultsThe HIV prevention programme is now operating at scale, with over 60,000 FSWs regularly contacted by peer educators, and over 17,000 FSWs accessing project services for sexually transmitted infections monthly. FSW membership in community-based organisations has increased from 8,000 to 37,000, and over 46,000 FSWs have now been referred for government-sponsored social entitlements. FSWs were supported to redress > 90% of the 4,600 reported incidents of violence and harassment reported between 2007-2009, and monitoring of news stories has shown a 50% increase in the number of positive media reports on HIV/AIDS and FSWs.ConclusionsStigma, discrimination, violence, harassment and social equity issues are critical concerns of FSWs. This report demonstrates that it is possible to address these broader structural factors as part of large-scale HIV prevention programming. Although assessing the impact of the various components of a structural intervention on reducing HIV vulnerability is difficult, addressing the broader structural factors contributing to FSW vulnerability is critical to enable these vulnerable women to become sufficiently empowered to adopt the safer sexual behaviours which are required to respond effectively to the HIV epidemic.

Condom use within non-commercial partnerships of female sex workers in southern India

BackgroundAlthough female sex workers (FSWs) report high levels of condom use with commercial sex clients, particularly after targeted HIV preventive interventions have been implemented, condom use is often low with non-commercial partners. There is limited understanding regarding the factors that influence condom use with FSWs’ non-commercial partners, and of how programs can be designed to increase condom use with these partners. The main objectives of this study were therefore to describe FSWs’ self-reported non-commercial partners, along with interpersonal factors characterizing their non-commercial partnerships, and to examine the factors associated with consistent condom use (CCU) within non-commercial partnerships.MethodsThis study used data collected from cross-sectional questionnaires administered to 988 FSWs in four districts in Karnataka state in 2006-07. We used bivariate and multivariable logistic regression analysis to examine the relationship between CCU (i.e., ‘always’ compared to ‘never’, ‘sometimes’ or ‘frequently’) with non-commercial partners of FSWs (including the respondents’ husband or main cohabiting partner [if not married] and their most recent non-paying partner [who is neither a husband nor the main cohabiting partner, and with whom the FSW had sex within the previous year]) and interpersonal factors describing these partnerships, as well as social and environmental factors. Weighting and survey methods were used to account for the cluster sampling design.ResultsOverall, 511 (51.8%) FSWs reported having a husband or cohabiting partner and 247 (23.7%) reported having a non-paying partner. CCU with these partners was low (22.6% and 40.3% respectively). In multivariable analysis, the odds of CCU with FSWs’ husband or cohabiting partner were 1.8-fold higher for FSWs whose partner knew she was a sex worker (adjusted odds ratio [AOR]: 1.84, 95% confidence intervals[CI]: 1.02-3.32) and almost 6-fold higher if the FSW was unmarried (AOR: 5.73, 95%CI: 2.79-11.76]. CCU with FSWs’ non-paying partner decreased by 18% for each one-year increase in the duration of the relationship (AOR: 0.82, 95%CI: 0.68-0.97).ConclusionsThis study revealed important patterns and interpersonal determinants of condom use within non-commercial partnerships of FSWs. Integrated structural and community-driven HIV/STI prevention programs that focus on gender and reduce sex work stigma should be investigated to increase condom use in non-commercial partnerships.

A dose-response relationship between exposure to a large-scale HIV preventive intervention and consistent condom use with different sexual partners of female sex workers in southern India

BackgroundThe Avahan Initiative, a large-scale HIV preventive intervention targeted to high-risk populations including female sex workers (FSWs), was initiated in 2003 in six high-prevalence states in India, including Karnataka. This study assessed if intervention exposure was associated with condom use with FSWs’ sexual partners, including a dose-response relationship.MethodsData were from a cross-sectional study (2006-07) of 775 FSWs in three districts in Karnataka. Survey methods accounted for the complex cluster sampling design. Bivariate and multivariable logistic regression was used to separately model the relationships between each of five intervention exposure variables and five outcomes for consistent condom use (CCU= always versus frequently/sometimes/never) with different sex partners, including with: all clients; occasional clients; most recent repeat client; most recent non-paying partner; and the husband or cohabiting partner. Linear tests for trends were conducted for three continuous intervention exposure variables.ResultsFSWs reported highest CCU with all clients (81.7%); CCU was lowest with FSWs’ husband or cohabiting partner (9.6%). In multivariable analysis, the odds of CCU with all clients and with occasional clients were 6.3-fold [95% confidence intervals, CIs: 2.8-14.5] and 2.3-fold [95% CIs: 1.4-4.1] higher among FSWs contacted by intervention staff and 4.9-fold [95% CIs: 2.6-9.3] and 2.3-fold [95% CIs: 1.3-4.1] higher among those who ever observed a condom demonstration by staff, respectively, compared to those who had not. A significant dose-response relationship existed between each of these CCU outcomes and increased duration since first contacted by staff (P=0.001; P=0.006) and numbers of condom demonstrations witnessed (P=0.004; P=0.026); a dose-response relationship was also observed between condom use with all clients and number of times contacted by staff (P=0.047). Intervention exposure was not associated with higher odds of CCU with the most recent repeat client, most recent non-paying partner or with the husband or cohabiting partner.ConclusionStudy findings suggest that exposure to a large-scale HIV intervention for FSWs was associated with increased CCU with commercial clients. Moreover, there were dose-response relationships between CCU with clients and increased duration since first contacted by staff, times contacted by staff and number of condom demonstrations. Additional program effort is required to increase condom use with non-commercial partners.

Evaluating large-scale HIV prevention interventions: study design for an integrated mathematical modelling approach

Background: There is an urgent need to evaluate HIV prevention interventions, thereby improving our understanding of what works, under what circumstances and what is cost effective. Objectives: To describe an integrated mathematical evaluation framework designed to assess the population-level impact of large-scale HIV interventions and applied in the context of Avahan, the Indian AIDS Initiative, in southern India. The Avahan Initiative is a large-scale HIV prevention intervention, funded by the Bill & Melinda Gates Foundation, which targets high-risk groups in selected districts of the six states most affected by the HIV/AIDS epidemic (Maharashtra, Karnataka, Tamil Nadu, Andhra Pradesh, Nagaland and Manipur) and along the national highways. Methods: One important component of the monitoring and evaluation of Avahan relies on an integrated mathematical framework that combines empirical biological and behavioural data from different subpopulations in the intervention areas, with the use of tailor-made transmission dynamics models embedded within a Bayesian framework. Results: An overview of the Avahan Initiative and the objectives of the monitoring and evaluation of the intervention is given. The rationale for choosing this evaluation design compared with other possible designs is presented, and the different components of the evaluation framework are described and its advantages and challenges are discussed, with illustrated examples. Conclusions: This is the first time such an approach has been applied on such a large scale. Lessons learnt from the CHARME project could help in the design of future evaluations of large-scale interventions in other settings, whereas the results of the evaluation will be of programmatic and public health relevance.

Prevalence and determinants of HIV infection in South India : a heterogeneous, rural epidemic

Objectives: To assess the prevalence and determinants of HIV infection in the general population in Bagalkot district, a largely rural district in the southern Indian state of Karnataka. Methods: Approximately 6700 individuals aged 15–49 years were randomly sampled from 10 villages and six towns, from three of Bagalkots six sub-districts. Each consenting respondent was administered a questionnaire, followed by blood collection and testing for HIV, syphilis, and herpes simplex virus type 2 (HSV-2) on a 25% sub-sample. Results: HIV prevalence was 2.9% overall, 2.4% in urban areas and 3.6% in rural areas [odds ratio (OR), 0.65; 95% confidence interval (CI), 0.45–0.95]. Significant differences in HIV prevalence were seen between the three sub-districts, with prevalences of 1.1, 3.0 and 6.4% (P < 0.05), and HIV prevalence in the 10 villages ranged from 0 to 8.2%. Reported multiple sexual partners, receiving money for sex and a history of medical injections were significantly associated with HIV infection, as were older age, being widowed, divorced, separated or deserted, lower education levels and being a woman of a lower caste. There was a strong association between HSV-2 and HIV infection (OR, 5.2; 95% CI, 2.3–11.5). Conclusions: The rural nature of this epidemic has important implications for prevention and care programs. The striking differentials observed in HIV prevalence between sub-districts and even villages suggest that risk and vulnerability for HIV are highly heterogeneous. Further research is required to understand the individual and community-level factors behind these differentials, so that preventive interventions can be directed to where they are most needed.

Devising a female sex work typology using data from Karnataka, India

BACKGROUND We examine the extent to which an existing sex work typology captures human immunodeficiency virus (HIV) risk in Karnataka and propose a systematic approach for devising evidence-based typologies. METHODS The proposed approach has four stages: (i) identifying main places of solicitation and places of sex; (ii) constructing possible typologies based on either or both of these criteria; (iii) analysing variations in indicators of risk, such as HIV/sexually transmitted infection (STI) prevalence and client volume, across the categories of the typologies; and (iv) identifying the simplest typology that captures the risk variation experienced by female sex workers (FSWs) across different settings. Analysis is based on data from 2312 participants in integrated biological and behavioural assessments of FSWs conducted in Karnataka, India. Logistic regression was used to predict HIV/STI status (high-titre syphilis, gonorrhea or chlamydia) and linear regression to predict client volume. RESULTS Our analysis suggests that the most appropriate typology in Karnataka consists of the following categories: brothel to brothel (i.e. solicit and have sex in brothels) (11% of sampled FSWs); home to home (32%), street to home (11%), street to rented room (9%), street to lodge (22%), street to street (9%) and other FSWs (8%). Street to lodge FSWs had high HIV (30%) and STI prevalence (27%), followed by brothel to brothel FSWs (34 and 13%, respectively). CONCLUSIONS The proposed typology identifies street to lodge FSWs as being at particularly high risk, which was obscured by the existing typology that distinguishes between FSWs based on place of solicitation alone.

Variability in the sexual structure in a rural Indian setting: implications for HIV prevention strategies

Objectives: To describe the sexual structure, including numbers and distribution of female sex workers (FSWs) and male sexual behaviours in the Bagalkot district of the state of Karnataka in south India. Methods: Village health workers and peer educators enumerated FSWs in each village by interviewing key informants and FSWs. Urban FSW populations were estimated using systematic interviews with key informants to identify sex work sites and then validating FSW populations at each sex work site. Male sexual behaviours were measured through confidential polling booth surveys in randomly selected villages. HIV prevalence was estimated through a community-based survey using randomised cluster sampling. Lorenz curves and Gini coefficients were used to describe the degree of clustering of FSW populations. Results: Of an estimated 7280 FSWs in Bagalkot district (17.1/1000 adult males), 87% live and work in rural areas. The relative size of the FSW population varies from 9.6 to 30.5/1000 adult males in the six subdistrict administrative areas (talukas). The FSW population was highest in the three talukas with more irrigated land and fewer and larger villages. FSW populations are highly clustered; 93 (15%) of the villages accounted for 54% of all rural FSWs. There is a high degree of FSW clustering in all talukas, and talukas with fewer and larger villages have larger clusters and more FSWs overall. General population HIV prevalence is highest in the taluka with the highest relative FSW population. Conclusions: Prevention programmes in India should be scaled up to reach FSWs in rural areas. These programmes should be focused on those districts and subdistrict areas with large concentrations of FSWs. More research is required to determine the distribution of FSWs in rural areas in other regions of India.