Getting to the First 90: Incentivized Peer Mobilizers Promote HIV Testing Services to Men Who Have Sex With Men Using Social Media in Mumbai, India.

Recent studies of Indian men who have sex with men (MSM) have shown widespread use of social media for seeking sex partners. We piloted a peer mobilization approach to explore the feasibility of engaging previously unreached MSM online to link them to HIV testing services (HTS). MSM were encouraged to seek HTS through messages posted on a popular dating website. Those who visited the designated HTS site and tested for HIV were recruited as peer mobilizers and given coupons with unique identifying codes to distribute to other men in their virtual networks. If a network member presented at the site with a coupon and tested for HIV, the peer mobilizer was given a small monetary incentive. Network members presenting at the testing site were also recruited as peer mobilizers and given coupons. In a 6-month period, 247 MSM were recruited and tested for HIV and syphilis, of whom 244 (99%) were first-time testers. Two-thirds were less than 25 years old and about half reported inconsistent or no condom use during the last 10 anal sex acts. Eight individuals (3.2%) tested positive for HIV, and 22 (8.9%) had a high titer for syphilis; all were referred to tertiary hospitals for treatment. Our approach was modestly successful in reaching and providing HTS to previously unreached MSM, but challenges included lower-than-expected recruitment, individuals not returning for posttest counseling, and loss to follow-up of individuals with HIV. The next phase of peer mobilization will aim to scale up these services through government-supported targeted interventions for this subpopulation of primarily young, unreached MSM at high risk. The challenges will be addressed by targeting more dating sites, increasing access to testing using rapid HIV tests at several community-based facilities, and offering peer navigation support for people living with HIV.

A surveillance model for sexually transmitted infections in India.

The strategy for prevention and control of sexually transmitted infections (STIs) in India is based on syndromic case management delivered through designated STI/reproductive tract infection (RTI) centers (DSRCs) situated in medical colleges, district hospitals, and STI-clinics of targeted interventions programs. Laboratory tests for enhanced syndromic management are available at some sites. To ensure country-level planning and effective local implementation of STI services, reliable and consistent epidemiologic information is required on the distribution of STI cases, rate and trends of newly acquired infections, and STI prevalence in specific population groups. The present STI management information system is inadequate to meet these requirements because it is based on syndromic data and limited laboratory investigations on STIs reported passively by DSRCs and laboratories. Geographically representative information on the etiology of STI syndromes and antimicrobial susceptibility of STI pathogens although essential for optimizing available treatment options, is deficient. Surveillance must provide high quality information on: (a) prevalence of STIs such as syphilis, trichomoniasis, gonorrhea, and chlamydia among high-risk groups; syphilis in the general population and pregnant antenatal women; (b) demographic characteristics such as age, sex, new/recurrent episode, and type of syndromically diagnosed STI cases; (c) proportion of acute infections such as urethral discharge (UD) in men and nonherpetic genital ulcer disease (GUD) in men and women; (d) etiology of STI syndromes; and (e) gonococcal antimicrobial susceptibility. We describe here a framework for an STI sentinel surveillance system in India, building on the existing STI reporting systems and infrastructure, an overview of the components of the proposed surveillance system, and operational challenges in its implementation.

Rolling out new biomedical HIV prevention tools: what can be learned from Avahan, the India AIDS initiative?

More than 30 years after HIV was first identified as a disease, with disastrous consequences for many subpopulations in most countries and for entire populations in some African countries, it continues to occupy centre stage among the world's many global health challenges. Prevention still remains the primary long-term focus. New biomedical tools such as pre-exposure propyhlaxis (PrEP) and treatment hold great promise for select groups such as key populations (KPs) who are critical to transmission dynamics, and serodiscordant couples. Programs delivering these new tools will need to layer them over existing services, with potential modifications for increased and sustained engagement between health services and beneficiaries owing to the nature of the interventions. Avahan, an HIV prevention intervention for KPs in six states in India, achieved population-level impact with conventional prevention programming, which, however, required high program-beneficiary engagement. Avahan's implementation strategy included articulating clear service definitions and denominator-based targets; establishing routine data systems with regular, multilevel supervision that allowed for cross-learning across the program; and developing a cadre of frontline workers through KP peer outreach workers who addressed structural issues and provided viable and sustainable mechanisms for sustained interaction between health services and KPs. This basic prevention implementation infrastructure was used to expand clinical services over time. Many of the lessons from programs such as Avahan can be applied to KP programs that are expanding service scope, including PrEP and treatment.

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

BACKGROUND: Men 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. METHODS: A 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. RESULTS: About 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). CONCLUSION: The 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.

Integrating syphilis screening in a large-scale HIV prevention program for key populations: the Avahan experience from India.

INTRODUCTION: Documented experiences from India on the implementation of syphilis screening in large-scale HIV prevention programs for "key populations at higher risk" (KPs) are limited. Avahan is a large-scale HIV prevention program providing services to more than 300,000 KPs in six high HIV prevalence states of India since 2004. Avahan clinics provide a sexually transmitted infection service package which includes bi-annual syphilis screening. The trends in the coverage of syphilis screening among Avahan clinic attendees were studied retrospectively. METHODOLOGY: Screening was performed using either the Rapid Plasma Reagin (RPR) test or point-of-care immunochromatographic strip test (ICST). Clinic records from 2005 to 2009 were collated in an individual tracking database and analyzed with STATA-10. RESULTS: Initially the coverage of syphilis screening (2.6% in 2005) was constrained by the availability and operational complexity of the RPR test. After its introduction in 2007, the use of ICST for screening increased from 7.4% to 77.0% and the proportion of clinic attendees screened increased from 9.0% to 21.6% during 2007-2009. The RPR reactivity rates declined from 6.6% (2006) to 4.4% (2009). CONCLUSION: The data showed improved rates of screening of clinic attendees and declining trends in sero-reactivity over time. The introduction of point-of-care syphilis tests may have contributed to the improved coverage of syphilis screening. The ICST may be considered for initial syphilis screening at other resource-constrained primary care sites in India such as ante-natal clinics and other KP interventions.

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.

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.

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.

BACKGROUND: Avahan, 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. METHODS: The 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. RESULTS: A 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. CONCLUSIONS: The 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.

Quality assurance and quality improvement using supportive supervision in a large-scale STI intervention with sex workers, men who have sex with men/transgenders and injecting-drug users in India.

BACKGROUND: Documentation of the long-term impact of supportive supervision using a monitoring tool in STI intervention with sex workers, men who have sex with men and injection-drug users is limited. The authors report methods and results of continued quality monitoring in a large-scale STI services provided as a part of a broader HIV-prevention package in six Indian states under Avahan, the India AIDS Initiative. METHODOLOGY: Guidelines and standards for STI services, and a supportive supervisory tool to monitor the quality were developed for providing technical support to STI component of large-scale HIV-prevention intervention through 372 project-supported STI clinics. The tool contained 80 questions to track the quality of STI services provided on a five-point scoring scale in five performance areas: coverage, quality of clinic and services, referral networks, community involvement and technical support. RESULTS: The tool was applied to different STI clinics during supportive supervision visits conducted once in every 3 months to assess quality, give immediate feedback and develop a quality score. A total of 292 clinics managed by seven lead implementing partners in six Indian states were covered in 15 quarters over 45 months. Overall quality indicators for the five performance areas showed a three- to sevenfold improvement over the period. CONCLUSION: It was possible to improve quality over the long-term in STI interventions for sex workers, men who have sex with men and injection-drug users using an interactive and comprehensive supportive supervision tool which gives on-the-spot feedback. However, such an effort is time-consuming and resource-intensive, and needs a structured approach.