Pandemic within a pandemic! Policy Implications of community-based Interventions to mitigate violence against women during COVID-19 in Urban Slums of Lucknow, India.

Background: The COVID-19 pandemic has brought an unprecedented adverse impact on women's health. Evidence from the literature suggests that violence against women has increased multifold. Gender-based violence in urban slums has worsened due to a lack of water and sanitation services, overcrowding, deteriorating conditions and a lack of institutional frameworks to address gender inequities. Methods: The SAMBHAV (Synchronized Action for Marginalized to Improve Behaviors and Vulnerabilities) initiative was launched between June 2020 to December 2020 by collaborating with the Uttar Pradesh state government, UNICEF and UNDP. The program intended to reach 6000 families in 30 UPS (Urban Poor settlements) of 13 city wards. These 30 UPS were divided into 5 clusters. The survey was conducted in 760 households, 397 taken from randomly selected 15 interventions and 363 households from 15 control UPS. This paper utilized data from a baseline assessment of gender and decision-making from a household survey conducted in the selected UPS during July 03-15, 2020. A sample size of 360 completed interviews was calculated for intervention and control areas to measure changes attributable to the SAMBHAV intervention in the behaviours and service utilization (pre- and post-intervention). Results: The data analysis showed a significant difference (p-value < 0.001) between respondents regarding women's freedom to move alone in the control and intervention area. It also reflected a significant difference between control and intervention areas as the respondents in the intervention area chose to work for the cause of gender-based violence. Conclusion: The SAMBHAV initiative brought an intersectional lens to gender issues. The community volunteers were trained to approach issues based on gender-based violence with the local public, and various conferences and meetings were organized to sensitize the community. The initiative's overall impact was that it built momentum around the issue of applying the concept of intersectionality for gender issues and building resilience in the community. There is still a need to bring multi-layered and more aggressive approaches to reduce the prevalence of gender-based violence in the community.

Modelling and estimation of HIV prevalence and number of people living with HIV in India, 2010-2011.

This paper provides HIV estimation methodology used in India and key HIV estimates for 2010-2011. We used a modified version of the Spectrum tool that included an Estimation and Projection Package as part of its AIDS Impact Module. Inputs related to population size, age-specific pattern of fertility, gender-ratio at birth, age and gender-specific pattern of mortality, and volume and age-gender distribution of net migration were derived from census records, the Sample Registration System and large-scale demographic health surveys. Epidemiological and programmatic data were derived from HIV sentinel surveillance, large-scale epidemiological surveys and the programme management information system. Estimated adult HIV prevalence retained a declining trend in India, following its peak in 2002 at a level of 0.41% (within bounds 0.35-0.47%). By 2010 and 2011, it levelled at estimates of 0.28% (0.24-0.34%) and 0.27% (0.22-0.33%), respectively. The estimated number of people living with HIV (PLHIV) reduced by 8% between 2007 and 2011. While children accounted for approximately 6.3% of total HIV infections in 2007, this proportion increased to about 7% in 2011. With changing priorities and epidemic patterns, the programme has to customise its strategies to effectively address the emerging vulnerabilities and adapt them to suit the requirements of different geographical regions.

Community collectivization and its association with consistent condom use and STI treatment-seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India.

We examine community collectivization among female sex workers (FSWs) and high-risk men who have sex with men and transgenders (HR-MSM) following several years of HIV prevention programming with these populations, and its association with selected outcome indicators measuring individual behaviors (condom use with different partners and sexually transmitted infection [STI] treatment-seeking from government health facilities). Data for this study were collected from a large-scale cross-sectional survey conducted in 2010-2011 among FSWs (sample size: 3557) and HR-MSM (sample size: 2399) in Andhra Pradesh, India. We measured collectivization among FSWs in terms of three binary (low, high) indices of collective efficacy, collective agency, and collective action. Collectivization among HR-MSM was measured by participation in a public event (no, yes), and a binary (low, high) index of collective efficacy. Adjusted odds ratios (adjusted OR) and their 95% confidence intervals (CI) were computed to assess the relationships between collectivization and outcome indicators directly and through mediation of variables such as self-efficacy for condom use and utilization of government health facilities. Results show that among FSWs, high levels of collective efficacy (adjusted OR: 1.3, 95% CI: 1.1-1.7) and collective action (adjusted OR:1.3, 95% CI: 1.1-1.8) were associated with consistent condom use (CCU) with regular clients. Among HR-MSM, participation in a public event (adjusted OR: 2.7, 95% CI: 2.0-3.6) and collective efficacy (adjusted OR: 1.9, 95% CI: 1.5-2.3) were correlated with condom use with paying partners. The association between collectivization and outcome indicators continued to be significant in most cases even after adjusting for the potential mediators. Indicators of collectivization exhibited significant positive association with self-efficacy for condom use and service utilization from government health facilities among both FSWs and HR-MSM. The association of high levels of collectivization with CCU, STI treatment-seeking from government health facilities, ability to negotiate for condom use, and self-efficacy in utilizing government health facilities is relevant to effort to improve the effectiveness and sustainability of HIV prevention programs in India and beyond.

The Association between Noncommercial Partnerships and Risk of HIV among Female Sex Workers: Evidences from a Cross-Sectional Behavioral and Biological Survey in Southern India.

This paper examines the association between female sex workers' (FSWs) noncommercial partnerships with risk of HIV in Andhra Pradesh, India. Data were drawn from a cross-sectional behavioral and biological survey conducted in 2009 among 3225 FSWs from Andhra Pradesh. Participants were asked about their sexual partnerships, condom use, and vulnerability factors and tested for HIV and sexually transmitted infections. The key independent variables considered were presence of a noncommercial sexual partner (no, yes) and the nature of such partnerships (regular, nonregular). FSWs who reported husband as noncommercial partner were considered to have a regular partner, while the rest were defined as having nonregular partners. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated to measure the associations between variables of interest. Almost three-fourths (74.8%) of FSWs reported having noncommercial partners (regular: 55.6%; nonregular: 19.3%). FSWs in nonregular partnerships were more likely to be HIV positive (13.1% versus 10.9%, adjusted OR: 1.4, 95% CI: 1.1-1.8), have syphilis (10.3% versus 4.2%, adjusted OR: 2.3, 95% CI: 1.6-3.3), use condoms inconsistently with occasional clients (21.0% versus 16.5%, adjusted OR: 1.5, 95% CI: 1.2-1.9), and report forced sex (25.1% versus 14.1%, adjusted OR: 1.9, 95% CI: 1.5-2.4) as compared to those in regular partnerships. HIV prevention programs need to emphasize safe sex behaviors, particularly among FSWs who have nonregular partners.

Impact of an HIV prevention intervention on condom use among long distance truckers in India.

This paper examines the impact of three components of an HIV prevention program (mid-media, interpersonal communication, and project-run clinics) on consistent condom use by long distance truckers with paid and non-paid female partners in India. Data from 2,723 long distance truckers were analyzed using the propensity score matching approach. Based on utilization of services, the following categories of intervention exposure were derived: no exposure, exposure only to mid-media, exposure only to mid-media and interpersonal communication, exposure only to mid-media and project-run clinics, and exposure to all three intervention components. Compared to those who were not exposed to any intervention, exposure to mid-media alone increased consistent condom use with paid female partners by about ten percent. Exposure to mid-media and visits to project-run clinics increased consistent condom use with non-paid female partners by 26 %. These findings suggest that mid-media events and clinics were the most effective package of services to increase consistent condom use among the long distance truckers.

The association between adolescent entry into the trucking industry and risk of HIV among long-distance truck drivers in India.

This study examines the relationship between entry into the trucking industry during adolescence and both sexually transmitted infections (STIs) and infection by the human immunodeficiency virus (HIV) among long-distance truck drivers in India. Data were sourced from a cross-sectional survey (sample size: 2066) undertaken in 2007 among long-distance truck drivers. The survey spread across major transshipment locations covering the bulk of India's transport volume along four routes. Participants were interviewed about sexual behaviors and were tested for HIV and STIs. The present authors constructed two synthetic cohorts based on the participants' duration of employment in the trucking industry: (1) low (duration ≤ 6 years) and (2) high experience (duration ≥ 7 years). Based on age at entry into the trucking industry, participants were termed as either adolescent (age at entry < 18 complete years) or adult entrants (age at entry ≥ 18 complete years). In the low-experience cohort, the adolescent entrants were more likely than the adult entrants to have sex with paid female partners (42.6% versus 27.2%, respectively; adjusted odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.3-2.9) and to practice inconsistent condom use with such partners (69.1% versus 26.8%, respectively; adjusted OR: 5.3; 95% CI: 2.4-11.6). However, no significant differences were found in STI and HIV prevalence between the adolescent and the adult entrants in this cohort. In the high-experience cohort, the adolescent entrants were about two times more likely than the adult entrants to practice inconsistent condom use with paid female partners (38.5% versus 26.7%, respectively; adjusted OR: 1.7; 95% CI: 1.1-2.8) and to test positive for HIV (7.4% versus 4.0%, respectively; adjusted OR: 1.9; 95% CI: 1.2-3.1) and syphilis (5.7% versus 3.5%, respectively; adjusted OR: 1.8; 95% CI: 1.1-3.1). These results suggest the need for focused behavioral change programs in HIV prevention interventions for adolescent truckers in India and elsewhere.

Relationship between mobility, violence and HIV/STI among female sex workers in Andhra Pradesh, India.

BACKGROUND: Violence and mobility have been identified as critical factors contributing to the spread of HIV worldwide. This study aimed to assess the independent and combined associations of mobility and violence with sexual risk behaviors and HIV, STI prevalence among female sex workers (FSWs) in India. METHODS: Data were drawn from a cross-sectional, bio-behavioral survey conducted among 2042 FSWs across five districts of southern India in 2005-06. Regression models were used to estimate odds ratios and 95% confidence intervals (CIs) for sexual risk behaviors and HIV infection based on experience of violence and mobility after adjusting for socio-demographic and sex work related characteristics. RESULTS: One-fifth of FSWs (19%) reported experiencing violence; 68% reported travelling outside their current place of residence at least once in the past year and practicing sex work during their visit. Mobile FSWs were more likely to report violence compared to their counterparts (23% vs. 10%, p < 0.001). Approximately 1 in 5 tested positive for HIV. In adjusted models, FSWs reporting both mobility and violence as compared to their counterparts were more likely to be infected with HIV (Adjusted odds ratio (adjusted OR): 2.07, 95% CI: 1.42-3.03) and to report unprotected sex with occasional (adjusted OR: 2.86, 95% CI: 1.76-4.65) and regular clients (adjusted OR: 2.07, 95% CI: 1.40-3.06). CONCLUSIONS: The findings indicate that mobility and violence were independently associated with HIV infection. Notably, the combined effect of mobility and violence posed greater HIV risk than their independent effect. These results point to the need for the provision of an enabling environment and safe spaces for FSWs who are mobile, to augment existing efforts to reduce the spread of HIV/AIDS.

Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model.

BACKGROUND: Mumbai is one of the most populous and high HIV prevalence cities in India. It has witnessed substantial changes in HIV-risk behaviors and a decline in HIV prevalence among high-risk groups during the past decade. AIM: To examine the changing pattern in the number of new HIV infections by transmission routes in Mumbai during 2000-2017. METHODS: We used the Asian Epidemic Model by dividing the adult population (aged 15 and above) into seven subgroups: brothel-based and non-brothel based female sex workers (FSWs), heterosexual clients of FSWs, men who have sex with men/transgendered people (MSM), injecting drug users (IDUs), general women and general men. The MSM subgroup included homosexual and bisexual men. RESULTS: New HIV infections among adults reduced by 86% during 2000-2010. The highest decline was among FSWs and their heterosexual clients (95%-98%), followed by MSM (82%), general women (77%), IDUs (51%) and general men (42%). Most new HIV infections during 2011-2017 are expected to occur among general women (1666) and general men (977) followed by MSM (715). Bisexual men were estimated to contribute about 14% of the new HIV infections among general women in 2010 and this proportion was estimated to increase to 19% in 2017. DISCUSSION: HIV prevention programs for MSM and the general population need to be strengthened. Ensuring early detection of HIV, and higher levels of consistent condom use by HIV-infected men and women are essential to prevent new HIV infections in future.

Alcohol Use and STI among Men in India: Evidences from a National Household Survey.

BACKGROUND: Alcohol use has been found to correlate with risky sexual behavior as well as with sexually transmitted infections (STI) among populations with high-risk behavior in India. OBJECTIVE: To examine the correlates of alcohol use and its association with STI among adult men in India. MATERIALS AND METHODS: Data from a national representative large-scale household sample survey in the country were used. It included information on sociodemographic characteristics and alcohol use as a part of substance use. Clinical as well laboratory testing was done to ascertain the STI. RESULTS: The overall STI prevalence among adult males was found to be 2.5% (95% confidence interval (CI): 1.9-3.1). Over 26% adult men were found to have been using alcohol in the study population. It was higher among men who were illiterate and unskilled industrial workers/drivers. The men who consumed alcohol had higher prevalence of STI (3.6%; 95% CI: 2.9-5.1) than those who did not consume alcohol (2.1%; 95% CI: 1.5-2.6). The degree of association between alcoholism and STI was slightly reduced after adjusting for various sociodemographic characteristics (adjusted odds ratio: 1.5; 95% CI: 0.9-2.3; P=0.06). CONCLUSIONS: The findings of present study suggest integrating alcohol risk reduction into STI/HIV prevention programmes.

Mobilising community collectivisation among female sex workers to promote STI service utilisation from the government healthcare system in Andhra Pradesh, India.

BACKGROUND: To assess the association between female sex workers' (FSWs) degree of community collectivisation and self-efficacy, utilisation of sexually transmitted infection (STI) services from government-run health centres in Andhra Pradesh, India. METHODS: Cross-sectional analyses of 1986 FSWs recruited using a probability-based sampling from five districts of Andhra Pradesh during 2010-2011. Multiple logistic regression models were constructed to assess associations. The independent variables included-collective efficacy, collective agency and collective action-measured using a series of items that assessed the grouping of the community on issues that concern most sex workers. An additional independent variable included FSWs belonging to an area where there was a project partnership with government health centres to provide STI treatment services to FSWs. The outcome indicators included self-efficacy for service utilisation from government health facilities and the treatment for STIs from government health facilities at least once in the past year experience of STI symptoms. RESULTS: Of the 1986 FSWs, nearly two-fifths (39.5%) reported a high level of overall collectivisation (collective efficacy: 89%, collective agency: 50.7%; collective action: 12.7%). Sex workers with a high degree compared with low degree of overall collectivisation were significantly more likely to report high self-efficacy to use government health facilities (75.0% vs 57.3%, adjusted OR 2.5, 95% CI 2.0 to 3.1) and to use government health centres for STI treatment in past 1 year (78.1% vs 63.2%, adjusted OR 2.1, 95% CI 1.6 to 2.8), irrespective of project partnership with government centres. CONCLUSION: The current research findings reinforce the need for stronger community mobilisation for better utilisation of government health facilities for STI and HIV prevention interventions.

Community advocacy groups as a means to address the social environment of female sex workers: a case study in Andhra Pradesh, India.

BACKGROUND: To examine the association between the presence of community advocacy groups (CAGs) and female sex workers' (FSWs) access to social entitlements and outcomes of police advocacy. METHODS: Data were used from a cross-sectional survey conducted in 2010-2011 among 1986 FSWs and 104 NGO outreach workers from five districts of Andhra Pradesh. FSWs were recruited using a probability-based sampling from 104 primary sampling units (PSUs). A PSU is a geographical area covered by one outreach worker and is expected to have an active CAG as per community mobilisation efforts. The presence of active CAGs was defined as the presence of an active committee or advocacy group in the area (PSU). Outcome indicators included acquisition of different social entitlements and measures of police response as reported by FSWs. Multivariate linear and logistic regression analyses were used to examine the associations. RESULTS: Areas with active CAGs compared with their counterparts had a significantly higher mean number of FSWs linked to ration cards (12.8 vs 6.8; p<0.01), bank accounts (9.3 vs 5.9; p=0.05) and health insurance (13.1 vs 7.0; p=0.02). A significantly higher percentage of FSWs from areas with active CAGs as compared with others reported that the police treat them more fairly now than a year before (79.7% vs 70.3%; p<0.05) and the police explained the reasons for arrest when arrested the last time (95.7% vs 87%; p<0.05). CONCLUSION: FSWs from areas with active CAGs were more likely to access certain social entitlements and to receive a fair response from the police, highlighting the contributions of CAGs in community mobilisation.

Heading towards the Safer Highways: an assessment of the Avahan prevention programme among long distance truck drivers in India.

BACKGROUND: Using data from two rounds of a cross-sectional, national-level survey of long-distance truck drivers, this paper examines the extent and trend of sexual risk behavior, prevalence of STI/HIV, and the linkage between exposure to HIV prevention programs and safe sex behavior. METHODS: Following the time location cluster sampling approach, major transshipment locations covering the bulk of India's transport volume along four routes, North-East (NE), North-South (NS), North-West (NW) and South-East (SE) were surveyed. First round of the survey was conducted in 2007 (sample size 2066) whereas the second round was undertaken in 2009-2010 (sample size 2085). Long distance truck drivers were interviewed about their sexual behaviors, condom use practices, exposure to different HIV prevention interventions, and tested for HIV, reactive syphilis serology, Neiserria gonorrhoeae and Chlamydia trachomatis. The key variable of this evaluation study - exposure to HIV prevention interventions was divided into three categories - no exposure, less intensive exposure and intensive exposure. Data were analyzed using multiple logistic regression methods to understand the relationship between risk behavior and exposure to intervention and between program exposure and condom use. RESULTS: The proportion of truckers exposed to HIV prevention interventions has increased over time with much significant increase in the intensive exposure across all the four routes (NE: from 14.9% to 28%, P < 0.01; NS: from 20.9% to 38.1%; NW: 11.5% to 39.5%, P < 0.01; SE: 4.7% to 9.7%, P <0.05). Overall, the consistent condom use in sex with non-regular female partners too has increased over the time (paid female partners: from 67.1% to 73.2%, P <0.05; non-paid female partners: from 17.9% to 37.1%, P <0.05). At the aggregate level, the proportion tested HIV positive has declined from 3.2% to 2.5% in (p<0.10) and proportion tested positive for Syphilis too has reduced from 3.2% to 1.7% (p<0.05). Truckers who had sex with paid female partners (men at risk) were significantly more likely to get exposed to intensive program (aOR: 2.6, 95%CI 1.9-3.4) as compared to those who did not have sex with paid partners. Truckers who had sex with paid partners and exposed to intervention program were more likely to use condoms consistently (aOR: 2.1, 95% CI 1.2-3.7). The consistent condom use among respondents who travel through states with targeted interventions towards female sex workers was higher than those who travel through states with less intensive program among FSWs. CONCLUSIONS: These evaluation study results highlight the ability of intensive program to reach truckers who have sex outside marriage with HIV prevention interventions and promote safe sex behaviors among them. Truckers who practice safe sex behaviors with an exposure to intensive program are less likely to suffer from STIs and HIV, which has implications for HIV prevention program with truckers' population in India and elsewhere. The simultaneous targeted interventions among female sex workers appeared to have contributed to safe sexual practices among truckers.