Acceptability of HIV oral self-test among truck drivers and youths: a qualitative investigation from Pune, Maharashtra.

BACKGROUND: Ending AIDS by 2030 is a global target, to which India is a signatory. HIV-self-test (HIVST) coupled with counselling and AIDS-care, including antiretroviral therapy, has the potential to achieve this. However, national programs are at varying stages of acceptance of HIVST, as discussions around its introduction spark controversy and debates. HIV-self-test, as yet, is not part of the AIDS control program in India. Against this backdrop, we explored acceptability of an HIV oral self-test (HIVOST) among truckers and young men and women. METHODS: A qualitative investigation with 41 in-depth-interviews and 15 group discussions were conducted in the district of Pune, in the western state of Maharashtra, India. These interactions were built around a prototype HIVOST kit, helped in taking the discussions forward. The software N-vivo (version 11.0) was used to manage the volumes of data generated through the aforementioned process. The study was conducted during June through December, 2019. RESULTS: While the truckers belonged to the age bracket 21-67 year, the youths were in the age group 18-24 year. 'Ease of doing HIVOST' and 'fear of needle pricks' were the reasons behind acceptance around HIVOST by both the study groups. Truckers felt that HIVOST would encourage one to know one's HIV status and seek help as appropriate. Accuracy of HIVOST result and disposal of the kits following use were concerns of a few. Most of the participants preferred saliva over blood as the specimen of choice. Instructions in local language reportedly would enable test-use by self. The truck drivers preferred undertaking HIVOST at the truckers-friendly 'Khushi clinics' or in the vehicle, while youths preferred the privacy of home. Some of the young men mis-perceived the utility of HIVOST by referring to doing a test on a partner immediately prior to sexual encounter. On the other hand, a few truckers had wrong information on HIV cure. CONCLUSIONS: Overall, the study communities expressed their acceptance towards HIV-self-test. The National AIDS Control Program, India would benefit by drawing upon the findings of the current investigation. Existing myths and misconceptions around HIV test and treatment require program attention.

Socio-demographic factors associated with HIV prevalence among pregnant women attending antenatal clinics in six Southern States of India: Evidences from the latest round of HIV sentinel surveillance.

BACKGROUND: HIV/AIDS is a global public health issue and its transmission in a defined geographic region is influenced by the interplay of sociodemographic and behavioral factors. Better understanding of sociodemographic characteristics of HIV-positive individuals is required to prevent the spread of HIV among the general population. OBJECTIVES: The objective of the study was to find the association between HIV prevalence and sociodemographic characteristics of pregnant women aged 15-49 years attending the antenatal clinics (ANCs) in six Southern states of India. METHODS: The data from the latest round of HIV sentinel surveillance, a cross-sectional study, conducted during January-March 2017 among ANC attendees were considered for this analysis. Blood samples along with other relevant information were collected from 98,634 pregnant women from 248 sites across the states. The association between HIV prevalence and sociodemographic variables was examined using multivariable logistic regression. RESULTS: The highest HIV prevalence was reported in Karnataka (0.38%) and Andhra Pradesh (0.38%), followed by Telangana (0.33%), Odisha (0.28%), Tamil Nadu (0.27%), and Kerala (0.05%). In all states, the prevalence was highest among illiterate pregnant women exception being Kerala, wherein the prevalence was highest in pregnant women with schooling up to primary education. A significant association was found between HIV prevalence and spouse occupation in Karnataka and Odisha and spouse migration in Andhra Pradesh and Karnataka. CONCLUSIONS: Need for improvising the interventions for the young, illiterates, having a migrant spouse, and spouse occupation as truckers/hotel staff is recommended to the stakeholders involved in HIV management of the six southern states of India.

Size Estimation of high-risk groups for hiv infection in india based on data from national integrated bio-behavioral surveillance and targeted interventions.

BACKGROUND: Targeted interventions (TIs) are one of the most effective strategies to control HIV/AIDS transmission, especially among the high-risk groups (HRGs). Implementation of HIV/AIDS control strategies relies heavily on estimation of the size of HRG population. Size estimation for key populations such as female sex workers (FSWs), men who have sex with men (MSM), and injecting drug users (IDUs) is a crucial component of national HIV strategic planning. OBJECTIVE: The objective of this study was to estimate the size of FSWs, MSM, and IDUs in various states of India. METHODS: The program multiplier method was used to estimate the size of FSWs, MSM, and IDUs across the country using two distinct but overlapping data sources - Integrated Bio-Behavioral Surveillance and TI program from the same geographical area at the same time period. RESULTS: In India, as on 2018-2019, there were nearly 18.2 lakhs estimated FSWs accounting to 0.53% among female population aged 15-49 years, with a highest in West Bengal (4.5 lakhs); 5.7 lakhs estimated MSM accounting to 0.16% among male population aged 15-49 years, with a highest in Gujarat (0.7 lakh); and 3.9 lakhs estimated IDUs accounting to 0.11% among male population aged 15-49 years, with a highest in Uttar Pradesh (0.5 lakh). CONCLUSIONS: The current size estimates on HRGs will support the development of projections and estimations of the HIV epidemic at national and state levels. These estimates also help in framing national guidelines such as HIV strategic planning, program design, allocation of resources, prioritizing the interventions, and monitoring and evaluation.

HIV Risk profile and its socio-demographic correlates among long-distance truckers in West Bengal, India: Evidence from national HIV sentinel surveillance 2017.

BACKGROUND: Long-distance truckers (LDTs) belong to a special sentinel group with potentially high risk of acquisition of HIV owing to their high mobility, sociodemographic vulnerability, and high-risk behaviors. OBJECTIVE: The objective is to estimate the prevalence of HIV and identifies its sociodemographic correlates among a representative population of LDTs in West Bengal, India. METHODS: Between May and July 2017, HIV Sentinel Surveillance (HSS) was conducted in West Bengal by the National AIDS Control Organization. A total of 749 LDTs were recruited for the study, were interviewed, and tested for HIV. Descriptive and logistic regression analysis of socio-demographics, sexual risk behavior, and HIV serostatus were performed using SAS 9.3.2. RESULTS: The prevalence of HIV among LDT was 1.2% (95% confidence interval [CI] = 0.4-2.0). Mean age was 32.8 years (standard deviation 8.5), 77.1% were currently married, 89.9% were literate, 85.7% visited HSS site for collecting condoms or seeking medical care and treatment, 53.1% were rural residents, 86.7% had sex at least once with a female partner other than wife in the past 6 months, 2.7% had sex with a male partner and 1.7% injected drugs for recreational purpose. Higher age (odds ratio [OR] = 1.1 [95% CI = 1.0-1.1]), literate (OR = 0.3 [95% CI = 0.1-0.9]), visiting HSS sites for collecting condoms or seeking medical care and treatment (adjusted OR [AOR] = 0.2 [95% CI = 0.1-0.6]), rural residence (OR = 0.2 [95% CI = 0.1-0.3]) and duration of stay in home (AOR = 1.3 [95% CI = 1.1-1.5]) were found to be significant predictors of having sex with a female partner other than wife. CONCLUSION: High HIV burden calls for urgency in the implementation of targeted intervention to minimize HIV risk among LDTs in West Bengal to fight against HIV/AIDS.

Building the evidence base on the HIV programme in India: an integrated approach to document programmatic learnings.

BACKGROUND: The Knowledge Network project was launched in 2010 to build evidence on the HIV epidemic by using the data generated by HIV programme implementing organisations in India. This paper describes the implementation of the programme and the strategies adopted to enhance the capacity of individuals to document and publish HIV prevention programme learnings. Further, it discusses the outcomes of the initiative. METHODS: A multipronged approach was adopted, where a group of experts were brought together to collaborate with programme implementing organisations, review available data, develop research questions and guide peer-reviewed publications. Further, scientific writing courses were conducted to support individuals from HIV programme implementing organisations as well as educational and government organisations (mentees) to build the documentation capacity of individuals leading programme implementation and current and future researchers. The impact and quality of evidence generated was measured by examining the number of papers published, the number of citations, and the number of papers with at least 10 citations. Additionally, course participants' responses to open-ended questions in the anonymous course evaluation questionnaires are presented as verbatim quotes. RESULTS: Overall, 99 papers on HIV programmatic learnings from India were finalised under the programme, of which 95 have been published. In all, 67 papers were co-authored by mentees. Most papers were published in high-impact factor (1 or more) journals and 72% were cited at least once in the literature. The main themes documented include key populations' HIV risk, HIV risk of general population groups, HIV/STI service delivery models and community mobilisation interventions. CONCLUSION: The study demonstrates that an integrated approach, involving partnership, capacity-building and mentorship, can maximise the use of available data and build the evidence base on HIV programmatic learnings. The capacity-building model adopted in the programme can be used to build scientific writing and documentation capacity in other public health programmes that are implemented at scale.

An analysis of respondent-driven sampling with injecting drug users in a high HIV prevalent state of India.

BACKGROUND: Personal networks are significant social spaces to spread of HIV or other blood-borne infections among hard-to-reach population, viz., injecting drug users, female sex workers, etc. Sharing of infected needles or syringes among drug users is one of the major routes of HIV transmission in Manipur, a high HIV prevalence state in India. This study was carried out to describe the network characteristics and recruitment patterns of injecting drug users and to assess the association of personal network with injecting risky behaviors in Manipur. METHODS: A total of 821 injecting drug users were recruited into the study using respondent-driven sampling (RDS) from Bishnupur and Churachandpur districts of Manipur; data on demographic characteristics, HIV risk behaviors, and network size were collected from them. Transition probability matrices and homophily indices were used to describe the network characteristics, and recruitment patterns of injecting drug users. Univariate and multivariate binary logistic regression models were performed to analyze the association between the personal networks and sharing of needles or syringes. RESULTS: The average network size was similar in both the districts. Recruitment analysis indicates injecting drug users were mostly engaged in mixed age group setting for injecting practice. Ever married and new injectors showed lack of in-group ties. Younger injecting drug users had mainly recruited older injecting drug users from their personal network. In logistic regression analysis, higher personal network was found to be significantly associated with increased likelihood of injecting risky behaviors. CONCLUSION: Because of mixed personal network of new injectors and higher network density associated with HIV exposure, older injecting drug users may act as a link for HIV transmission or other blood-borne infections to new injectors and also to their sexual partners. The information from this study may be useful to understanding the network pattern of injecting drug users for enriching the HIV prevention in this region.

HIV Prevalence and Risk Behaviors Among Female Sex Workers in Botswana: Results from the 2012 HIV/STI Bio-Behavioral Study.

To evaluate HIV/STI prevalence among female sex workers (FSWs) in Botswana, and assess HIV-related risk behaviors. Cross-sectional study using time-location sampling in three districts of Botswana. Adjusted HIV prevalence at district level ranged from 53.5 to 68.5 %. Syphilis prevalence ranged from 3.7 to 14.5 %; chlamydia prevalence ranged from 4.8 to 16.3 %; and gonorrhoea prevalence ranged from 8.3 to 11.7 %. FSWs had been practicing sex work for a mean of 4.7 years, and had a mean of 7.6 sex partners in the week before the survey. While 67.1 % of FSWs surveyed reported always using condoms with clients in the past month. 59.5 % reported one or more of the following: being paid more not to use a condom, having a condom break, or being forced not to use a condom by clients. Predictors of HIV infection in the multivariate analysis included: age (over 30 years), perceiving oneself to be at high risk of HIV, selling sex for 2 or more years, and having a mean of 11 or more partners in the last week. High HIV prevalence, high rates of partner exchange, a sizable population, and Inconsistent condom use combine together help fuel the country's hyper epidemic. HIV prevention interventions need to take into account the important influence of clients and boyfriends on condom use behavior.

Increase in condom use and decline in prevalence of sexually transmitted infections among high-risk men who have sex with men and transgender persons in Maharashtra, India: Avahan, the India AIDS Initiative.

BACKGROUND: The present study assessed coverage, changes in condom use, and prevalence of HIV and other STIs among high-risk men who have sex with men (HR-MSM; highly visible, recruited from cruising sites/sex venues) and transgender (TG; male-to-female transgender persons, also called hijras) in the Indian state of Maharashtra. METHODS: Data from Avahan's computerized management information system; two rounds of integrated behavioral and biological assessment (IBBA) surveys (Round 1 with 653 HR-MSM/TG and Round 2 with 652 HR-MSM/TG); and project-supported condom social marketing was used for the present analysis. Logistic regression models were used to assess changes in key indicators over these two rounds and to explore the association between exposure to Avahan interventions and condom use and STI prevalence in HR-MSM/TG. RESULTS: By December 2007, Avahan had reached about 90% of the estimated HR-MSM/TG population, and 83% of the estimated total population had visited STI clinics by March 2009. Free direct condom distribution by Avahan program NGOs and social marketing outlets in Maharashtra increased from about 2.7 million condoms in 2004 to 15.4 million in 2008. HR-MSM/TG were more likely to report higher consistent condom use (adjusted odds ratio [AOR]: 1.90; 95% confidence interval [CI] 1.01-3.58) with regular male partners (spouse/lover/boyfriend) in Round 2 of IBBA, compared to Round 1. HR-MSM/TG exposed to Avahan interventions were more likely to report consistent condom use with regular male partners (AOR: 2.46; CI 1.34-4.52) than those who were unexposed. Prevalence of reactive syphilis serology declined significantly from 8.8% in Round 1 to 1.1% in Round 2 (p = 0.001), while the observed change HIV prevalence (12.3% to 6.3%, p = 0.16) was insignificant. CONCLUSION: The current evaluation provides evidence for successful scale up and coverage of target population by Avahan interventions in Maharashtra. The assessment findings showed improved accessibility to condoms and reduced risk behaviours with male sexual partners. Syphilis prevalence declined; however HIV prevalence did not change and is still a major concern. Continued strengthening of core programmatic strategies are needed to effectively improve condom use with all partner types and to help bring sustained reductions in HIV risk in HR-MSM/TG and its onward transmission.

Factors associated with HIV among female sex workers in a high HIV prevalent state of India.

The study was carried out to assess the factors associated with HIV seropositivity among female sex workers (FSWs) in Dimapur, Nagaland, a high HIV prevalence state of India. A total of 426 FSWs were recruited into the study using respondent driven sampling (RDS). Data on demographic characteristics, sexual and injecting risk behaviours were collected from them and were tested for HIV, Syphilis, Neisseria gonorrhoeae and Chlamydia trachomatis. RDS-weighted univariate and multivariate logistic regression analysis was performed to assess the factors associated with HIV seropositivity. Consistent condom use with regular and occasional sexual clients was 9% and 16.4%, respectively. About 25% of the participants ever used and 5.7% ever injected illicit drugs. RDS adjusted HIV prevalence was 11.6%. In the univariate analysis, factors associated with HIV were initiating sexual intercourse before the age of 15 years, ≥2 years duration of sex work, serving clients at lodge/hotel, positive test result for one or more sexually transmitted infections (STIs), lifetime history of injecting drug use, lifetime history of consuming illicit drugs, ever having exchanged sex for drugs, having sexual partners who engaged in risky injecting practices and having been widowed or divorced. In multivariate analysis, factors found to be independently associated with HIV included lifetime injecting drug use, initiating sexual intercourse before the age of 15 years, positive test result for one or more STIs and having been widowed. Injecting drug use was found to be most potent independent risk factor for HIV (OR: 3.17, CI: 1.02-9.89). Because of lower consistent condom use among them, FSWs may act as bridge for HIV transmission to general population from injecting drug users (IDU) through their sexual clients. The informations from this study may be useful for enriching the HIV preventions effort for FSWs in this region.

Factors associated with history of drug use among female sex workers (FSW) in a high HIV prevalence state of India.

BACKGROUND: The intersection between illicit drug use and female commercial sex work has been identified as an important factor responsible for rising HIV prevalence among female sex workers (FSW) in several northeastern states of India. But, little is know about the factors associated with the use of drugs among FSWs in this region. The objective of the paper was to describe the factors associated with history of drug use among FSWs in Dimapur, an important commercial hub of Nagaland, which is a high HIV prevalence state of India. METHODS: FSWs were recruited using respondent driven sampling (RDS), and were interviewed to collect data on socio-demographic characteristics and HIV risk behaviours. Biological samples were tested for HIV, syphilis gonorrhea and Chlamydia. Logistic regression analysis was performed to identify factors associated with drug use. RESULTS: Among the 426 FSWs in the study, about 25% (n = 107) reported having ever used illicit drugs. Among 107 illicit drug users, 83 (77.6%) were non-injecting and 24 (22.4%) were injecting drug users. Drug-using FSWs were significantly more likely to test positive for one or more STIs (59% vs. 33.5%), active syphilis (27.1% vs. 11.4%) and Chlamydia infection (30% vs. 19.9%) compared to their non-drug using peers. Drug-using FSWs were also significantly more likely to be currently married, widowed or separated compared with non-drug-using FSWs. In multiple logistic regression analysis, being an alcohol user, being married, having a larger volume of clients, and having sexual partners who have ever used or shared injecting drugs were found to be independently associated with illicit drug use. CONCLUSIONS: Drug-using FSWs were more vulnerable to STIs including HIV compared to their non-drug using peers. Several important factors associated with being an FSW who uses drugs were identified in this study and this knowledge can be used to plan more effectively targeted harm reduction strategies and programs.

Spatial distribution and characteristics of injecting drug users (IDU) in five Northeastern states of India.

BACKGROUND: Injecting drugs is the major driving force of human immunodeficiency virus (HIV) epidemic in Northeastern India. We have assessed the spatial distribution of locations where injecting drug users (IDU) congregate, as well as the risk behaviour and key characteristics of IDUs to develop new strategies strengthening intervention measures for HIV prevention in this region. METHODS: Locations of IDUs congregation for buying and injecting drugs were identified through Key Informants (KI). Verification of the location and its characteristics were confirmed through field visits. We also conducted semi-structured and structured interviews with IDUs to learn more about their injecting behaviour and other characteristics. RESULTS: Altogether, 2462 IDU locations were identified in 5 states. The number of IDU locations was found to be greater in the states bordering Myanmar. Private houses, parks, abandoned buildings, pharmacies, graveyards, and isolated places were the most frequently chosen place for injecting drugs. Many injecting locations were visited by IDUs of varying ages, of which about 10-20% of locations were for females. In some locations, female IDUs were also involved in sex work. Sharing of needle and syringes was reported in all the states by large proportion of IDUs, mainly with close friends. However, even sharing with strangers was not uncommon. Needle and syringes were mainly procured from pharmacies, drug peddlers and friends. Lack of access to free sterile needles and syringes, and inconsistent supplies from intervention programs, were often given as the cause of sharing or re-use of needles and syringes by IDUs. Most of the IDUs described a negative attitude of the community towards them. CONCLUSION: We highlight the injection of drugs as a problem in 5 Northeastern India states where this is the major driving force of an HIV epidemic. Also highlighted are the large numbers of females that are unrecognized as IDUs and the association between drug use and sex work. Understanding of risk behaviours and other key characteristics of IDUs in the region will help in strengthening harm reduction efforts that can prevent HIV transmission.

Targeted interventions of the Avahan program and their association with intermediate outcomes among female sex workers in Maharashtra, India.

BACKGROUND: Avahan, the India AIDS Initiative has been a partner supporting targeted interventions of high risk populations under India's National AIDS Control Organisation (NACO) since 2004 in the state of Maharashtra. This paper presents an assessment of the Avahan program among female sex workers (FSWs) in Maharashtra, its coverage, outcomes achieved and their association with Avahan program. METHODS: An analytical framework based on the Avahan evaluation design was used, addressing assessment questions on program implementation, intermediate outcomes and association of outcomes with Avahan. Data from routine program monitoring, two rounds of cross-sectional Integrated Behavioural and Biological Assessments (IBBAs) conducted in 2006 (Round 1- R1) and 2009 (Round 2 - R2) and quality assessments of program clinics were used. Bi-variate and multivariate analysis were conducted using the complex samples module in SPSS 15 (IBM, Somers NY). RESULTS: The Avahan program achieved coverage of over 66% of FSWs within four years of implementation. The IBBA data showed increased contact by peers in R2 compared to R1 (AOR:2.34; p=0.001). Reported condom use with clients increased in R2 and number of FSWs reporting zero unprotected sex acts increased from 76.2% (R1) to 94.6% (R2) [AOR: 5.1, p=0.001].Significant declines were observed in prevalence of syphilis (RPR) (15.8% to 10.8%; AOR:0.54; p=0.001), chlamydia (8% to 6.2%; AOR:.0.65; p=0.010) and gonorrohoea (7.4% to 3.9; AOR:.0.60; p=0.026) between R1 and R2. HIV prevalence increased (25.8% to 27.5%; AOR:1.29; p=0.04). District-wise analysis showed decline in three districts and increase in Mumbai and Thane districts.FSWs exposed to Avahan had higher consistent condom use with occasional (94.3% vs. 90.6%; AOR: 1.55; p=0.04) and regular clients (92.5% vs. 86.0%; AOR: 1.95, p=0.001) compared to FSWs unexposed to Avahan. Decline in high titre syphilis was associated with Avahan exposure. CONCLUSION: The Avahan program was scaled up and achieved high coverage of FSWs in Maharashtra amidst multiple intervention players. Avahan coverage of FSWs was associated with improved safe sexual practices and declines in STIs. Prevalence of HIV increased requiring more detailed understanding of the data and, if confirmed, new approaches for HIV control.

Condom use and prevalence of syphilis and HIV among female sex workers in Andhra Pradesh, India - following a large-scale HIV prevention intervention.

BACKGROUND: Avahan, the India AIDS initiative began HIV prevention interventions in 2003 in Andhra Pradesh (AP) among high-risk groups including female sex workers (FSWs), to help contain the HIV epidemic. This manuscript describes an assessment of this intervention using the published Avahan evaluation framework and assesses the coverage, outcomes and changes in STI and HIV prevalence among FSWs. METHODOLOGY: Multiple data sources were utilized including Avahan routine program monitoring data, two rounds of cross-sectional survey data (in 2006 and 2009) and STI clinical quality monitoring assessments. Bi-variate and multivariate analyses, Wald Chi-square tests and multivariate logistic regressions were used to measure changes in behavioural and biological outcomes over time and their association. RESULTS: Avahan scaled up in conjunction with the Government program to operate in all districts in AP by March 2009. By March 2009, 80% of the FSWs were being contacted monthly and 21% were coming to STI services monthly. Survey data confirmed an increase in peer educator contacts with the mean number increasing from 2.9 in 2006 to 5.3 in 2009. By 2008 free and Avahan-supported socially marketed condoms were adequate to cover the estimated number of commercial sex acts, at 45 condoms/FSW/month. Consistent condom use was reported to increase with regular (63.6% to 83.4%; AOR=2.98; p<0.001) and occasional clients (70.8% to 83.7%; AOR=2.20; p<0.001). The prevalence of lifetime syphilis decreased (10.8% to 6.1%; AOR=0.39; p<0.001) and HIV prevalence decreased in all districts combined (17.7% to 13.2%; AOR 0.68; p<0.01). Prevalence of HIV among younger FSWs (aged 18 to 20 years) decreased (17.7% to 8.2%, p=0.008). A significant increase in condom use at last sex with occasional and regular clients and consistent condom use with occasional clients was observed among FSWs exposed to the Avahan program. There was no association between exposure and HIV or STIs, although numbers were small. CONCLUSIONS: The absence of control groups is a limitation of this study and does not allow attribution of changes in outcomes and declines in HIV and STI to the Avahan program. However, the large scale implementation, high coverage, intermediate outcomes and association of these outcomes to the Avahan program provide plausible evidence that the declines were likely associated with Avahan. Declining HIV prevalence among the general population in Andhra Pradesh points towards a combined impact of Avahan and government interventions.

Ecological analysis of the association between high-risk population parameters and HIV prevalence among pregnant women enrolled in sentinel surveillance in four Southern India states.

BACKGROUND: The HIV epidemic is very heterogeneous at the district level in the four Southern states of India most affected by the epidemic and where transmission is mainly heterosexual. The authors carried out an ecological study of the relationship between high-risk population parameters and HIV prevalence among pregnant women (ANC HIV prevalence). METHODS: The data used in this study included: ANC HIV prevalence available from the National AIDS Control Organization (dependent variable); data on prevalence of HIV and other sexually transmitted infections among female sex workers (FSWs), their clients and high-risk men who have sex with men (HR-MSM) from studies carried out in 24 districts under Avahan; data on clients' volume reported by FSWs and on the size estimates of FSWs and HR-MSM in each district; and census data. The latter two sets of data were used to estimate the percentage of female (male) adults who are FSWs (HR-MSM). The latter was also multiplied by HIV prevalence in FSWs (HR-MSM) to obtain the percentage of HIV-positive FSWs (HR-MSM) in the adult female (male) population. Linear regression was used for statistical analyses. RESULTS: In univariate analyses, HIV (r=0.59, p=0.002) and HSV-2 (r=0.49, p=0.014) prevalence among FSWs and mean number of clients in the last week reported by FSWs (r=0.43, p=0.036) were significant predictors of ANC HIV prevalence. In multivariate analysis, only FSW HIV prevalence remained significant. CONCLUSIONS: This ecological study suggests that there is a link between HIV prevalence among FSWs and the spread of HIV to the general population in Southern India. Such an observation supports the rationale of interventions targeted at the sex industry.

Programme coverage, condom use and STI treatment among FSWs in a large-scale HIV prevention programme: results from cross-sectional surveys in 22 districts in southern India.

OBJECTIVE: This paper evaluates Avahan programme's coverage of female sex workers (FSWs), focus on high-risk FSWs and intermediate outcomes. METHODS: First round of cross-sectional survey data, Integrated Behavioral and Biological Assessments (IBBA), conducted in 22 districts, were aggregated into district categories: Solo, where Avahan was the sole service provider covering all FSWs and Major or Minor where Avahan was not the sole provider, but intended coverage was >50% or or=15 clients in the past week had a higher chance of being exposed to core services (AOR=1.56; 95% CI 1.03 to 2.35). Exposure to the three services in Solo Avahan districts was significantly associated with correct knowledge on condom use (AOR=1.36; 95% CI 1.05 to 1.78), consistent condom use with occasional clients (AOR=3.17; 95% CI 2.17 to 4.63) and regular clients (AOR=2.47; 95% CI 1.86 to 3.28) and STI treatment-seeking behaviour (AOR=3.00; 95% CI 1.94 to 4.65). CONCLUSIONS: Higher coverage of FSWs was achieved in districts where Avahan was the only intervention compared with districts having multiple and longstanding non-Avahan programmes. Exposure in Solo districts was associated with intermediate outcomes; this need to be further evaluated in comparison with non Avahan areas and substantiated through data from next IBBA.

Scale-up and coverage of Avahan: a large-scale HIV-prevention programme among female sex workers and men who have sex with men in four Indian states.

OBJECTIVE: Documenting the implementation of a public health programme as per its design is critical to interpretation of results from survey-led outcome and impact evaluation activities, the authors describe the scale-up and coverage of large-scale HIV-prevention services provided to female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) during the first 5 years of the Avahan programme in India. METHODS: Implementing NGO partner-generated denominator estimates from 70 districts were used to estimate the programme's intended coverage. Routine programme-monitoring data until December 2008 were used to describe the service and commodity availability, service utilisation to generate internal estimates of coverage. Coverage was validated in few districts using data from a cross-sectional survey. RESULTS: In December 2008, the estimated denominators for intended services were about 217,000 FSWs and 80,000 HR-MSM. By January 2007, 79% of eventual total clinics and 75% drop-in centres were established, and 83% of eventual peer educators were active. By month 48, sufficient condoms to cover all estimated FSW commercial sex acts were distributed free. By month 60, 75% of the estimated denominator intended to be covered was met monthly. 86% of FSWs and 67% of HR-MSM ever contacted had used sexually transmitted infections services at least once. Cross-sectional survey generated coverage results suggest that programme-monitoring data provide a proxy to coverage of services. CONCLUSION: Avahan's monitoring data show that Avahan achieved infrastructure scale by year 3 and high contact coverage through peers and with commodities by year 5 of implementation as per the design.

Substance use and risk of HIV infection among Men who have Sex with Men in India: Analysis of National IBBS data, India.

HIV prevalence is higher among Men who have Sex with Men (MSM), owing to their unsafe sexual behavior. Further, MSM indulge in behaviors such as consumption of alcohol/oral drugs and/or injecting during/before sex that poses the risk of unsafe behaviors, thereby increasing their vulnerability to HIV. The study aims to analyze the factors associated with HIV infection among the multi-risk MSM using any substances with those MSM who do not use substances.Community-based cross-sectional survey design using probability-based sampling between October 2014 and November 2015.For the nation-wide Integrated Biological and Behavioral Surveillance (IBBS), 23,081 MSM were recruited from 4067 hotspots in 108 districts across India. Information on demographics, sexual behaviors, substance use, sexual partners, and awareness on HIV and its management was collected from the consented respondents using computer-assisted personal interview (CAPI) by trained personnel. Blood samples were tested for HIV. Statistical analyses were done, to study the associations between substance use and its influence on high-risk sexual behaviors and HIV infection.One in 3 MSM (33.88%) in India were substance users, thus exhibiting "multi-risk" (MR) behaviors. Significantly higher HIV prevalence (3.8%, P < .05) was reported among MR-MSM, despite 97.2% of them being aware of HIV. Higher HIV prevalence among MSM exhibiting homosexual behavior for ≤1 year is of specific concern, as this accounts to recent infections and indicates the increased vulnerability of the infection among the new entrants.Substance-use resulting in high-risk sexual behavior was significantly associated with higher HIV prevalence among MR-MSM. Integrated targeted interventions focusing on safe sex and safe-IDU practices among MR-MSM are required to end the disease transmission.

Estimating the Population Size of Female Sex Workers in Namibia Using a Respondent-Driven Sampling Adjustment to the Reverse Tracking Method: A Novel Approach.

BACKGROUND: Key populations, including female sex workers (FSWs), are at a disproportionately high risk for HIV infection. Estimates of the size of these populations serve as denominator data to inform HIV prevention and treatment programming and are necessary for the equitable allocation of limited public health resources. OBJECTIVE: This study aimed to present the respondent-driven sampling (RDS) adjusted reverse tracking method (RTM; RadR), a novel population size estimation approach that combines venue mapping data with RDS data to estimate the population size, adjusted for double counting and nonattendance biases. METHODS: We used data from a 2014 RDS survey of FSWs in Windhoek and Katima Mulilo, Namibia, to demonstrate the RadR method. Information from venue mapping and enumeration from the survey formative assessment phase were combined with survey-based venue-inquiry questions to estimate population size, adjusting for double counting, and FSWs who do not attend venues. RadR estimates were compared with the official population size estimates, published by the Namibian Ministry of Health and Social Services (MoHSS), and with the unadjusted RTM. RESULTS: Using the RadR method, we estimated 1552 (95% simulation interval, SI, 1101-2387) FSWs in Windhoek and 453 (95% SI: 336-656) FSWs in Katima Mulilo. These estimates were slightly more conservative than the MoHSS estimates-Windhoek: 3000 (1800-3400); Katima Mulilo: 800 (380-2000)-though not statistically different. We also found 75 additional venues in Windhoek and 59 additional venues in Katima Mulilo identified by RDS participants' responses that were not detected during the initial mapping exercise. CONCLUSIONS: The RadR estimates were comparable with official estimates from the MoHSS. The RadR method is easily integrated into RDS studies, producing plausible population size estimates, and can also validate and update key population maps for outreach and venue-based sampling.

Relationship between mobility, violence and major depression among female sex workers: a cross-sectional study in southern India.

BACKGROUND: The relationship between mobility, violence and mental health has largely been unexplored in developing countries. This study screens for signs of major depression, and assesses its association with mobility and violence among female sex workers (FSWs) in southern India. METHODS: Data (N=2400) for this study were used from a cross-sectional Behavioral Tracking Survey (BTS-2014) conducted among FSWs from a southern state of India as part of the Avahan programme. Major depression of FSWs was assessed using the Patient Health Questionnaire-2 depression scale. Descriptive statistics, frequency, bivariate, interaction effect and multivariate logistic regression techniques were used for the analysis. RESULTS: More than one-fourth of FSWs (29%) screened positive for major depression. The likelihood of screening positive for major depression was 6 times higher among FSWs who were both mobile for sex work outside their district of residence and had experienced any violence (combined association) during the past 1 year (62% vs 19%, adjusted OR 6.1, 95% CI 4.4 to 8.6) compared with those who reported neither. The individual association results show that FSWs who reported being mobile outside the district, and FSWs who were beaten or raped in the past 1 year, were 3 times more likely to screen positive for major depression. CONCLUSIONS: The findings indicate that violence and mobility are independently associated with major depression among FSWs. The combined association of mobility and violence poses a greater risk to the mental health of FSWs than their independent association. These results point to the need for creating an enabling environment for FSWs to enhance existing efforts to reduce the spread of HIV and mental health problems. The study highlights that HIV prevention efforts among FSWs in India require evidence-based research and integrated programme approaches to address mental health issues.