Sonali Wayal

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

OBJECTIVES We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India. METHODS Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants. RESULTS Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child. CONCLUSIONS Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. Indias widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.

Self-taken pharyngeal and rectal swabs are appropriate for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in asymptomatic men who have sex with men

Introduction: Self-taken specimens from men who have sex with men (MSM) could be important in reducing high levels of demand on sexual health services. The performance of self-taken specimens for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) from both pharyngeal and rectal sites in asymptomatic MSM was assessed. Methods: MSM were examined according to clinic protocol: a rectal and pharyngeal swab for GC culture and a rectal swab for the CT strand displacement assay. An extra set of nurse-taken and self-taken pharyngeal and rectal specimens were also requested and were tested using the Aptima Combo 2 assay and the result compared with the routine clinic result, which was considered the gold standard. Results: A total of 272 MSM was recruited and the sensitivity and specificity of nurse-taken and patient-taken swabs, respectively, was as follows: rectal GC: 94.9% and 90.1% (nurse); 92.3% and 87.9% (patient); pharyngeal GC: 88.2% and 91.8% (nurse); 100% and 87.8% (patient); rectal CT: 80.0% and 99.6% (nurse); 91.4% and 98.2% (patient). No significant difference in sensitivity or specificity was observed between the nurse-taken and the patient-taken rectal swabs for either GC or CT. For the detection of GC from the pharynx, comparable sensitivities were achieved between nurse-taken and patient-taken swabs (p = 0.5); however, a significant difference in specificity was observed (p = 0.006). This was due to a higher number of false GC-positive self-taken pharyngeal swabs from patients with high rates (90.9%; 10/11) of confirmed concurrent GC infection in different anatomical sites. Conclusions: MSM are able to collect self-taken rectal and pharyngeal swabs that are comparable to those taken by clinicians.

The burden and determinants of HIV and sexually transmitted infections in a population based sample of female sex workers in Goa, India

Background: Interventions targeting sex workers are central to the National AIDS Control programme of India’s third 5-year plan. Understanding the way in which societal and individual factors interact to shape sex workers’ vulnerability would better inform interventions. Methods: 326 female sex workers, recruited throughout Goa using respondent-driven sampling, completed interviewer-administered questionnaires. Biological samples were tested for Trichomonas vaginalis, Neisseria gonorrhoea, Chlamydia trachomatis and antibodies to herpes simplex virus type 2 (HSV-2) and HIV. Multivariate analysis was used to define the determinants of HIV infection and any bacterial sexually transmitted infection (STI). Results: Infections were common, with 25.7% prevalence of HIV and 22.5% prevalence of bacterial STI; chlamydia 7.3%, gonorrhoea 8.9% and trichomonas 9.4%. Antibodies to HSV-2 were detected in 57.2% of women. STI were independently associated with factors reflecting gender disadvantage and disempowerment, namely young age, lack of schooling, no financial autonomy, deliberate self-harm, sexual abuse and sex work-related factors, such as having regular customers and working on the streets. Other factors associated with STI were Goan ethnicity, not having an intimate partner and being asymptomatic. Having knowledge about HIV and access to free STI services were associated with a lower likelihood of STI. HIV was independently associated with being Hindu, recent migration to Goa, lodge or brothel-based sex work and dysuria. Conclusion: Sex workers working in medium prevalence states of India are highly vulnerable to HIV and STI and need to be rapidly incorporated into existing interventions. Structural and gender-based determinants of HIV and STI are integral to HIV prevention strategies.

Contraceptive practices, sexual and reproductive health needs of HIV-positive and negative female sex workers in Goa, India

Objectives In India, female sex workers (FSWs), suffer from high HIV prevalence and abortions. Contraceptive use among general population women is well understood. However, FSWs contraceptives practices and reproductive health needs are under-researched. We investigated contraceptive practices among HIV-positive and negative FSWs in Goa, India and explored its association with socio-demographic and sex work related factors. Methods Cross-sectional study using respondent driven sampling recruited 326 FSWs. They completed an interviewer-administered questionnaire and were screened for STI/HIV. Multivariable logistic regression was used to explore factors associated with sterilisation relative to no contraception. Results HIV prevalence was high (26%). Of the 59 FSWs planning pregnancy, 33% were HIV-positive and 5–7% had Gonorrhoea, Chlamydia and Trichomonas. 25% and 65% of FSWs screened-positive for Syphilis and Herpes simplex virus type 2 antibodies respectively. Among the 260 FSWs analysed for contraceptive use, 39% did not use contraceptives, and 26% had experienced abortion. Half the FSWs had undergone sterilisation, and only 5% used condoms for contraception. Among HIV-positive FSWs, 45% did not use contraceptives. Sterilisation was independently associated with older age, illiteracy, having an intimate non-paying male partner, having children and financial autonomy. Exposure to National AIDS Control Organisations HIV-prevention interventions was reported by 34% FSWs and was not significantly associated with contraceptive use (adjusted odds ratio 1.4, 95% CI 0.7 to 2.9). Conclusion HIV-prevention interventions should promote contraception, especially among young and HIV-positive FSWs. Integrating HIV treatment and care services with HIV-prevention interventions is vital to avert HIV-positive births.

Self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections: acceptability among men who have sex with men

Objectives: To explore the feasibility and acceptability of self-sampling for oropharyngeal and rectal specimens to screen for sexually transmitted infections (STIs) among men who have sex with men (MSM). Participant’s willingness to self-sample at home was also explored. Methods: Participants of a study to evaluate the sensitivity and specificity of self versus nurse taken oropharyngeal and rectal specimens were surveyed to assess the feasibility and acceptability of self-sampling using specimen collection methods (gargle, OraSure mouth pad to collect oropharyngeal specimens and APTIMA unisex swabs to collect rectal and pharyngeal specimens). Acceptability was measured using a five-point Likert-type response scale (for example, 1 =  strongly disagree; 5 =  strongly agree). Open-ended questions explored participants’ experiences of self-sampling. Results: Of 334 eligible MSM, 301 (90%) participated in the study. Altogether, 301 participants self-sampled using gargle and rectal and pharyngeal swabs and 288 using mouth pad. Complete questionnaire data from 274 participants showed that feasibility and acceptability of self-sampling using gargle and mouth pad was higher (92%) than pharyngeal swabs (76%). Rectal swabs were acceptable to 82% participants. Despite some discomfort and difficulty in using swabs, 76% were willing to use all four methods for self-sampling in the future. Home sampling was acceptable (84%) as it was perceived to be less intrusive and more convenient than a clinic visit and likely to reduce genitourinary medicine (GUM) waiting time. Conclusions: Self-sampling for rectal and oropharyngeal specimens is feasible and acceptable to MSM. Self-sampling can be offered as an alternative to clinic-based testing and has the potential to improve choice, access and uptake of screening for STIs.

Minimal Cognitive Impairment in UK HIV Positive Men Who Have Sex with Men: Effect of Case Definitions, and Comparison with the General Population and HIV Negative Men.

Background:To determine the prevalence of neurocognitive impairment (NCI) in UK HIV-positive and HIV-negative men who have sex with men (MSM). Methods:HIV-positive and HIV-negative participants were recruited to a cross-sectional study from 2 London clinics and completed computer-assisted neuropsychological tests and questionnaires of depression, anxiety, and activities of daily living. Published definitions of HIV-associated neurocognitive disorders (HAND) and global deficit scores were used. Age- and education-adjusted neuropsychological test scores were directly compared with reference population data. Results:A total of 248 HIV-positive and 45 HIV-negative MSM participated. In the HIV-positive group, median time since diagnosis was 9.4 years, median CD4+ count was 550 cells per cubic millimeter, and 88% were on antiretroviral therapy. Prevalence of HAND was 21.0% in HIV-positive MSM (13.7% asymptomatic neurocognitive impairment, 6.5% mild neurocognitive disorder, and 0.8% HIV-associated dementia). Using a global deficit score threshold of 0.5, the prevalence of NCI was 31.5% (when averaged over 5 neuropsychological domains) and 40.3% (over 10 neuropsychological test scores). These results were not significantly different from the HIV-negative study sample. No consistent pattern of impairment was seen in HIV-positive patients relative to general male population data (n = 380). Conclusions:We found a prevalence of HAND and degree of impairment on neuropsychological testing of HIV-positive MSM that could represent a normal population distribution. These findings suggest that NCI may be overestimated in HIV-positive MSM, and that the attribution of NCI to HIV infection implied by the term HAND requires revision.

Targeting commercial sex-workers in Goa, India: time for a strategic rethink?

At 0700 h June 14 2004 bulldozers shattered our dream of an evidence-based participatory intervention for HIV prevention with sex-workers in Goa India. Under the pretext of a High Court order to rehabilitate commercial sexworkers (CSWs) the government of Goa demolished the red-light area of Baina. The demolition occurred during the monsoon rains and the government provided no rehabilitation or relief for the thousands of people it rendered homeless. A day’s work demolished a decade of HIV prevention and made the newly homeless destitute women even more vulnerable to HIV. After a decade of HIV prevention efforts by non-governmental organisations (NGOs) CSWs regularly turned to peer educators and NGOs for condoms and treatment of sexually transmitted infections (STIs). The CSWs’ active participation invigorated the HIV prevention programme. (excerpt)

Men who have sex with men in Great Britain: comparing methods and estimates from probability and convenience sample surveys

Objective To examine sociodemographic and behavioural differences between men who have sex with men (MSM) participating in recent UK convenience surveys and a national probability sample survey. Methods We compared 148 MSM aged 18–64 years interviewed for Britains third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) undertaken in 2010–2012, with men in the same age range participating in contemporaneous convenience surveys of MSM: 15 500 British resident men in the European MSM Internet Survey (EMIS); 797 in the London Gay Mens Sexual Health Survey; and 1234 in Scotlands Gay Mens Sexual Health Survey. Analyses compared men reporting at least one male sexual partner (past year) on similarly worded questions and multivariable analyses accounted for sociodemographic differences between the surveys. Results MSM in convenience surveys were younger and better educated than MSM in Natsal-3, and a larger proportion identified as gay (85%–95% vs 62%). Partner numbers were higher and same-sex anal sex more common in convenience surveys. Unprotected anal intercourse was more commonly reported in EMIS. Compared with Natsal-3, MSM in convenience surveys were more likely to report gonorrhoea diagnoses and HIV testing (both past year). Differences between the samples were reduced when restricting analysis to gay-identifying MSM. Conclusions National probability surveys better reflect the population of MSM but are limited by their smaller samples of MSM. Convenience surveys recruit larger samples of MSM but tend to over-represent MSM identifying as gay and reporting more sexual risk behaviours. Because both sampling strategies have strengths and weaknesses, methods are needed to triangulate data from probability and convenience surveys.

A Study Comparing Sexually Transmitted Infections and Hiv Among Ex-red-light District and Non-red-light District Sex Workers After the Demolition of Baina Red-light District

Objectives:In June 2004, the red-light area of Goa was demolished. We compare HIV and sexually transmitted infections (STIs) between sex workers who had been based in Baina red-light district (ex-RLD-SWs) with sex workers who had never worked in Baina (non-RLD-SWs). Methods:Three hundred twenty-six sex workers recruited using respondent-driven sampling, completed interviewer-administered questionnaires, and were tested for Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, and antibodies to HIV. The association between ever working in Baina red-light area and HIV and STIs was examined using multivariate analysis. Results:Non-RLD-SWs made up 55.3% (n = 201) of the sample, 48% of whom had entered sex work since the demolition. Non-RLD-SWs more likely to be less than 20 years old, Goan, have experienced sexual and intimate partner violence, to work part time, from home or the streets, and to have fewer clients. Ex-RLD-SWs were less likely to have curable STIs adjusted odds ratio of 0.27 (95% confidence interval: 0.10 to 0.73) and were more likely to have been exposed to HIV prevention and report consistent condom use with clients. Conclusions:Non-RLD-SWs were more likely to be engaged in high-risk sexual activity. Although partly explained by lack of exposure to HIV prevention and inconsistent condom use, social and professional isolation and greater experience of intimate partner and sexual violence may play a role.

Home sampling for sexually transmitted infections and HIV in men who have sex with men: a prospective observational study

To determine uptake of home sampling kit (HSK) for STI/HIV compared to clinic-based testing, whether the availability of HSK would increase STI testing rates amongst HIV infected MSM, and those attending a community-based HIV testing clinic compared to historical control. Prospective observational study in three facilities providing STI/HIV testing services in Brighton, UK was conducted. Adult MSM attending/contacting a GUM clinic requesting an STI screen (group 1), HIV infected MSM attending routine outpatient clinic (group 2), and MSM attending a community-based rapid HIV testing service (group 3) were eligible. Participants were required to have no symptomatology consistent with STI and known to be immune to hepatitis A and B (group 1). Eligible men were offered a HSK to obtain self-collected specimens as an alternative to routine testing. HSK uptake compared to conventional clinic-based STI/HIV testing in group 1, increase in STI testing rates due to availability of HSK compared to historical controls in group 2 and 3, and HSK return rates in all settings were calculated. Among the 128 eligible men in group 1, HSK acceptance was higher (62.5% (95% CI: 53.5–70.9)) compared to GUM clinic-based testing (37.5% (95% CI: 29.1–46.5)), (p = 0.0004). Two thirds of eligible MSM offered an HSK in all three groups accepted it, but HSK return rates varied (highest in group 1, 77.5%, lowest in group 3, 16%). HSK for HIV testing was acceptable to 81% of men in group 1. Compared to historical controls, availability of HSK increased the proportion of MSM testing for STIs in group 2 but not in group 3. HSK for STI/HIV offers an alternative to conventional clinic-based testing for MSM seeking STI screening. It significantly increases STI testing uptake in HIV infected MSM. HSK could be considered as an adjunct to clinic-based services to further improve STI/HIV testing in MSM.