Measurement of self, experienced, and perceived HIV/AIDS stigma using parallel scales in Chennai, India.

HIV/AIDS stigma can severely compromise the quality of life of people living with HIV/AIDS (PLHA) by reducing access and quality of care, adherence to therapy, and disclosure of HIV status, thereby potentially increasing transmission. The objective of this study was to develop and psychometrically test three parallel scales measuring self, experienced, and perceived stigma among PLHA (n=188) in Chennai, India. Exploratory factor analysis (EFA), which was used to facilitate item reduction and assess construct validity, confirmed the presence of three underlying theoretical domains. The final number of items and Cronbach's Alpha for each scale were: 8 items, Alpha of 0.84, for self stigma; 7 items, Alpha of 0.86, for experienced stigma; and 7 items, Alpha of 0.83, for perceived stigma. External validity was ascertained by confirming a significant positive association between the measure of each type of stigma and depression (measured using CES-D), using structural equation modeling (SEM). Therefore, scales were parsimonious, reliable, and were found to be valid measures of HIV/AIDS stigma. Using these validated scales, researchers can accurately collect data to inform the design of stigma reduction programs and interventions and enable subsequent evaluation of their effectiveness.

The intersection between sex and drugs: a cross-sectional study among the spouses of injection drug users in Chennai, India.

BACKGROUND: It is estimated that there are up to 1.1 million injection drug users (IDUs) in India; the majority are likely married. We characterize HIV, hepatitis B (HBV) and hepatitis C (HCV) prevalence and the risk environment of a sample of spouses of IDUs. METHODS: A cohort of 1158 IDUs (99% male) was recruited in Chennai, India from 2005-06. A convenience sample of 400 spouses of the male IDUs in this cohort was recruited in 2009. A risk assessment questionnaire was administered and a blood sample collected. Logistic regression was used to identify factors associated with prevalent HIV. RESULTS: Median age was 31 years; thirteen percent were widowed and 7% were not currently living with their spouse. Only 4 (1%) reported ever injecting drugs; Twenty-two percent and 25% reported ever using non-injection drugs and alcohol, respectively. The majority had one lifetime sexual partner and 37 (9%) reporting exchanging sex. Only 7% always used condoms with their regular partner. HIV, HBV and HCV prevalence were 2.5%, 3.8% and 0.5%, respectively; among spouses of HIV+ IDUs (n = 78), HIV prevalence was 10.3%. The strongest predictor of HIV was spousal HIV status (OR: 17.9; p < 0.001). Fifty-six percent of women had ever experienced intimate partner violence; Eight-six percent reported sexual violence. CONCLUSIONS: Our finding of a 10-fold higher HIV prevalence among spouses of IDUs compared with general population women indicates their vulnerability; prevalence is likely to increase given the context of low condom use and frequent sexual violence. Prevention efforts directed at IDUs should also include programs for spouses.

High prevalence of forced sex among non-brothel based, wine shop centered sex workers in Chennai, India.

Sexual violence has been shown to increase women's risk of HIV infection. India is a country where the HIV epidemic is growing among women and intimate partner violence (IPV) is pervasive. This study examined prevalence of and factors associated with forced sex among female sex workers (FSWs) in Chennai, India. We conducted a probability survey among FSWs in 24 slum venues and identified predictive factors for recent forced sex using univariate and multivariable proportional odds models. Among 522 FSWs, 28% reported having forced sex with one partner and 35% with 2+ partners. In the final multivariable model, women who had a high number of partners who had a strong tendency to drink alcohol before sex were more likely to have experienced forced sex, and women who had both unprotected sex with a nonspousal partner and > 20 days of alcohol consumption in the last 30 days were more likely to have experienced forced sex. Discussion about family violence with larger social networks was independently associated with lower odds of forced sex among FSWs. HIV interventions for FSWs and their clients aimed at reducing alcohol consumption and encouraging condom use could be enhanced by violence prevention interventions to facilitate discourse about sexual violence.

Factors associated with the perpetration of sexual violence among wine-shop patrons in Chennai, India.

With an estimated 2.5 million people living with HIV/AIDS, India has the third highest number of HIV-infected people in the world. Despite reductions in prevalence among the general population, the percentage of all infections occurring among Indian women is continuing to rise. Women's risk of HIV infection from their partner and observed associations between sexual violence and HIV infection in India underscore the importance of understanding determinants of forced sex. A probability survey was conducted from June 2003 to August 2007 in Chennai, India, among alcohol venue ("wine shops") patrons to estimate the prevalence of sexual violence and to identify risk factors associated with perpetrating forced sex. Among 1499 men, 28.5% reported forced sex with at least one partner in the past 3 months. In multivariate analysis, earning income for less than 12 months a year, visiting the wine shop with friends, STD symptoms, perpetration of physical violence, and number of sexual partners were statistically significantly associated with perpetrating forced sex. Men who reported having 3 or more close friends were less likely to perpetrate violence. HIV interventions that facilitate formal groups that foster positive social support and address a range of HIV risk behaviors including sexually and physically abusive behaviors are recommended to reduce sexual violence.

A descriptive profile of abused female sex workers in India.

This descriptive study presents the profiles of abused female sex workers (FSWs) in Chennai, India. Of 100 abused FSWs surveyed using a structured questionnaire, severe forms of violence by intimate partners were reported by most (98%) respondents. Of the total sample, 76% experienced violence by clients. Sexual coercion experiences of the FSWs included verbal threats (77%) and physical force (87%) by intimate partners and forced unwanted sexual acts (73%) by clients. While 39% of the women consumed alcohol before meeting a client, 26% reported that their drunkenness was a trigger for violence by clients. The findings suggest that there is an urgent need to integrate services, along with public-health interventions among FSWs to protect them from violence. Recognition of multiple identities of women in the contexts of intimate relationships versus sex work is vital in helping women to stay safe from adverse effects on health.

Domestic violence and forced sex among the urban poor in South India: implications for HIV prevention.

This article examined the prevalence of physical and sexual violence among 1,974 married women from 40 low-income communities in Chennai, India. The authors found a 99% and 75% lifetime prevalence of physical abuse and forced sex, respectively, whereas 65% of women experienced more than five episodes of physical abuse in the 3 months preceding the survey. Factors associated with violence after multivariate adjustment included elementary/middle school education and variables suggesting economic insecurity. These domestic violence rates exceed those in prior Indian reports, suggesting women in slums may be at increased risk for HIV and other sexually transmitted infections.

Intimate partner violence is as important as client violence in increasing street-based female sex workers' vulnerability to HIV in India.

OBJECTIVES: There are no studies that examine street-based female sex workers' vulnerability to HIV from both clients and intimate partners. This study documents street-based female sex workers' experiences of client and intimate partners, examines the intersections of violence, alcohol use in condom use, and highlights survival strategies used to avert harm. METHODS: Ethnographic data were collected from 49 female sex workers through focus group discussions and in-depth interviews. RESULTS: Female sex workers experienced multifarious forms of severe client and intimate partner violence. Sexual coercion and forced group sex in the context of alcohol use posed formidable barriers for condom use negotiation. Further, traditional gender norms dictated women's inabilities to negotiate condom-use with intimate partners. However, there was evidence of adoption of successful survival strategies in the face of danger and women's positive evaluations of the benefits of sex work and their contributions to family well-being. CONCLUSIONS: Harm reduction efforts with female sex workers need to account for their vulnerability to HIV from intimate partners in addition to clients. HIV prevention programmes need to include male clients in order to reduce harm among street-based female sex workers. There is an urgent need to build on sex workers' strengths and involve them in designing individual level, community, and structural interventions that could help in reducing women's vulnerability to intimate partner violence and HIV in India.

HIV/AIDS stigma: reliability and validity of a new measurement instrument in Chennai, India.

HIV/AIDS stigma is a frequently cited barrier to HIV prevention, including voluntary counseling and testing. A reliable and valid measurement instrument is critical to empirically assess the extent and effects of HIV/AIDS stigma. The paper reports the development and psychometric testing of an HIV/AIDS stigma scale among 200 men in India. The resulting 24-item scale and the four subscales had good internal consistency (Cronbach's alpha overall was 0.81; subscales were 0.86, 0.73, 0.72 and 0.76, respectively). The scale and distinct subscales suggest a valid and reliable measure for HIV/AIDS stigma in a setting with highly prevalent HIV risk behaviors.

HIV rates and risk behaviors are low in the general population of men in Southern India but high in alcohol venues: results from 2 probability surveys.

BACKGROUND: As the HIV epidemic continues to expand in India, empiric data are needed to determine the course of the epidemic for high-risk populations and the general population. METHODS: Two probability surveys were conducted in Chennai slums among a household sample of men and alcohol venue patrons ("wine shops") to compare HIV and other sexually transmitted disease (STD) prevalence and to identify STD behavioral risk factors. RESULTS: The wine shop sample (n = 654) had higher rates of HIV and prevalent STDs (HIV, herpes simplex virus 2 [HSV-2], syphilis, gonorrhea, or chlamydia) compared with the household sample (n = 685) (3.4% vs. 1.2%, P = 0.007 and 21.6% vs. 11.8%, P < 0.0001, respectively). High-risk behaviors in the household sample was rare (<4%), but 69.6% of wine shop patrons had >2 partners, 58.4% had unprotected sex with a casual partner, and 54.1% had exchanged sex for money in the past 3 months. A multivariate model found that older age, ever being married, ever being tested for HIV, and having unprotected sex in the past 3 months were associated with STD prevalence in wine shop patrons. CONCLUSIONS: Prevalent HIV and STDs, and sexual risk behaviors are relatively low among the general population of men. We found that men who frequent alcohol venues practice high-risk behaviors and have high rates of STDs, including HIV, and may play an important role in expanding the Indian epidemic.

Development of an opinion leader-led HIV prevention intervention among alcohol users in Chennai, India.

In 1999, we began a community-based randomized controlled prevention trial in Chennai, which aims to test the efficacy of HIV prevention messages disseminated through members of an individual's social group called community popular opinion leaders, or CPOLs. We targeted patrons of 100 bars or wine shops in the city of Chennai, India. In this article we report on the process of development of an HIV prevention intervention for wine shop patrons. First, we conducted detailed ethnography to understand social norms and CPOL and social network characteristics, including 41 in-depth interviews among wine shop patrons and gatekeepers. Second, we tailored a generic HIV education training manual to appropriately address the needs of Chennai wine shop patrons. Field-testing involved 16 focus groups with wine shop patrons and 12 sessions of participant observations in wine shops. Finally, we piloted the intervention to determine the appropriateness of the training program and its content among wine shop patrons. Our ethnographic data indicated that wine shops are a common meeting place for men. We were able to identify CPOLs influential in these settings and train them to deliver appropriate prevention messages to their close friends and associates. We found that HIV prevention messages in this population need to dispel misperceptions about HIV transmission, provide strategies and skills to adopt and sustain condom use, and target the role of alcohol in sexual behavior. We outline specific lessons we learned in intervention development in this population.

High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India.

OBJECTIVE: To estimate HIV and sexually transmitted disease (STD) prevalence and behavioral risk characteristics of men who have sex with men (MSM) in Chennai, India. METHODS: A cross-sectional population-based random sample survey was conducted in 2001. Randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors through face-to-face interviews. Sera and urine were examined for syphilis, HIV-1, gonorrhea, and chlamydia. Logistic regression analyses were used to assess associations between MSM status and HIV infection and to identify risk characteristics of MSM. RESULTS: Of 774 men, 46 reported (5.9%) sex with other men. MSM were more likely to be seropositive for HIV (odds ratio [OR] = 8.57; 95% confidence interval [CI]: 1.83, 40.23) and were more likely to have a history of STD (OR = 2.66; 95% CI: 1.18, 6.02) than non-MSM. Men who used illicit drugs in past 3 months (adjusted odds ratio [AOR] = 4.01; 95% CI: 1.92, 8.41), ever exchanged money for sex (AOR = 3.93; 95% CI: 1.97, 7.84), or were ever tested for HIV (AOR = 3.72; 95% CI: 1.34, 10.34) were significantly more likely to report sex with men. CONCLUSIONS: MSM in Chennai slums are at high risk for HIV. HIV prevention strategies aimed at changing unsafe drug and sexual practices should target the general population of men, with specific attention to areas with high rates of MSM.