Community-based prevention leads to an increase in condom use and a reduction in sexually transmitted infections (STIs) among men who have sex with men (MSM) and female sex workers (FSW): the Frontiers Prevention Project (FPP) evaluation results.

BACKGROUND: India has an estimated 2.0 million to 3.1 million people living with HIV; it has the highest number of HIV-positive people in Asia and ranks third in the world. The Frontiers Prevention Project (FPP) was implemented in 2002 to conduct targeted prevention intervention geared towards female sex workers (FSW) and men who have sex with men (MSM) in the state of Andhra Pradesh (AP). This paper reports the overall changes in behaviour and STI outcomes between 2003/4 and 2007 and also describes the changes attributed to the FPP. METHODS: The evaluation used two cross-sectional surveys among MSM and FSW at 24 sites in AP. Surveys were implemented using a similar methodology. Univariate analyses were conducted by comparing means: baseline vs. four-year follow-up and FPP vs. non-FPP. For both MSM and FSW, random and fixed-effects logit regression models at the site level were estimated for condom use with last partner, syphilis sero-positivity and HSV 2 sero-positivity. In addition, for FSW we estimated models for condom use with regular partner, and for MSM we estimated models for condom use with last female partner. RESULTS: Among MSM, fixed-effects analysis revealed that FPP was positively correlated with the probability of condom use with last female sexual partner and negatively correlated with the individual probability of sero-positivity to syphilis and HSV 2. Among FSW, the FPP intervention was significantly correlated with increased condom use with regular partners and with lower probability of STI sero-positivity. DISCUSSION: Important changes in behaviours related to an increase in prevention activities translated to reductions in STI sero-prevalence in AP, India. In contrast with non-FPP sites, the FPP sites experienced an intense community approach as part of the FPP intervention, and the general increase in condom use and its effect on STI sero-prevalence reflected the efficacy of these intense prevention activities focused on key populations in AP.

The China-UK Global Health Support Programme: looking for new roles and partnerships in changing times.

China's engagement in global affairs has changed substantially in the 2010s. One aspect of the country's global reorientation has been its increased interest in, and willingness to play a role in, global health. In the early 2010s, the UK Department for International Development (DFID) initiated a collaboration with the Chinese government on a programme to support the country to play a greater and more effective global role in health and explore how the UK and China could work together on issues of key concern and contribute to improved global development outcomes. The programme worked with key Chinese agencies to carry out capacity building, support analysis of China's approaches to engagement in global health governance and assistance, and provide support to government decision making. It also trialled several small-scale interventions in third countries through which Chinese agencies gained experience of working on health programmes overseas. The article reports on the main findings of an evaluation commissioned by DFID to learn from the programme. The programme provided support at a key time in China's global reorientation; however, there is a need for continued development of capacity and systems for China to play the role envisaged by the country's leadership. There is also a need for continued exploration on the part of China and partners of how to effectively collaborate to support improved global outcomes.

How much attention is needed towards men who sell sex to men for HIV prevention in India?

BACKGROUND: HIV prevention in India has mostly focussed on heterosexual transmission. Data on homosexual transmission are not readily available from India. We therefore assessed the probability of acquiring and transmitting HIV for men who sell sex to men and compared this with women who sell sex in India. METHODS: Sexual behaviour characteristics of 6661 men who have sex with men and 6648 women who sell sex were obtained in the Indian state of Andhra Pradesh through confidential interviews. These, along with estimates of HIV rates among them and risk of HIV transmission per unprotected sex act from other sources, were used to calculate their annual probability of acquiring and transmitting HIV. RESULTS: Of 6661 men who have sex with men in this sample, 1776 (26.7%) had sold sex to men. For every 1000 men who sell sex to men, annually 146 (95% confidence interval [CI] 116-179) would acquire HIV and HIV would be transmitted to 55 (95% CI 42-71) men who do not sell sex or women. These estimates were higher by 6.7 (95% CI 4.9-9.2) times for acquiring HIV and 2.5 (95% CI 2.0-3.2) times for transmitting HIV to sex partners outside their group, as compared with similar estimates for women who sell sex. In this sample, the average annual probability of acquiring HIV was higher among men who have sex with men but do not sell sex as compared with women who sell sex. CONCLUSION: These data indicate that men who sell sex to men are at much higher risk of acquiring and transmitting HIV than women who sell sex. Therefore, men who sell sex to men and their clients warrant substantial attention for comprehensive HIV prevention in India.

Demography and sex work characteristics of female sex workers in India.

BACKGROUND: The majority of sex work in India is clandestine due to unfavorable legal environment and discrimination against female sex workers (FSWs). We report data on who these women are and when they get involved with sex work that could assist in increasing the reach of HIV prevention activities for them. METHODS: Detailed documentation of demography and various aspects of sex work was done through confidential interviews of 6648 FSWs in 13 districts in the Indian state of Andhra Pradesh. The demography of FSWs was compared with that of women in the general population. RESULTS: A total of 5010 (75.4%), 1499 (22.5%), and 139 (2.1%) street-, home-, and brothel-based FSWs, respectively, participated. Comparison with women of Andhra Pradesh revealed that the proportion of those aged 20-34 years (75.6%), belonging to scheduled caste (35.3%) and scheduled tribe (10.5%), illiterate (74.7%), and of those separated/divorced (30.7%) was higher among FSWs (p < 0.001). The FSWs engaged in sex work for >5 years were more likely to be non-street-based FSWs, illiterate, living in small urban towns, and to have started sex work between 12-15 years of age. The mean age at starting sex work (21.7 years) and gap between the first vaginal intercourse and the first sexual intercourse in exchange for money (6.6 years) was lower for FSWs in the rural areas as compared with those in large urban areas (23.9 years and 8.8 years, respectively). CONCLUSION: These data highlight that women struggling with illiteracy, lower social status, and less economic opportunities are especially vulnerable to being infected by HIV, as sex work may be one of the few options available to them to earn money. Recommendations for actions are made for long-term impact on reducing the numbers of women being infected by HIV in addition to the current HIV prevention efforts in India.

Access to condoms for female sex workers in Andhra Pradesh.

BACKGROUND: Condoms are an essential part of comprehensive HIV prevention and care programmes. We report the accessibility of male condoms for female sex workers (FSWs) and the associated characteristics that may play a major role in determining access to condoms for FSWs. METHODS: Confidential interviews of 6509 street- and home-based FSWs in 13 districts of the Indian state of Andhra Pradesh provided data on the number of paying clients and various aspects of access to free condoms and purchase of condoms. Access to condoms was defined as having ever obtained condoms either through free distribution or through purchase. Multivariate analyses were done separately for street- and home-based FSWs to describe correlates of their access to condoms. The requirement of condoms was assessed based on the number of paying clients during the past 15 days. RESULTS: Data on condom access were available for 6465 (99.3%) FSWs. A total of 2850 (44.1%; 95% CI: 36.2%-52.0%) reported accessing free condoms ever and 2336 (36.1%; 95% CI: 30.6%-41.6%) had purchased condoms ever (not mutually exclusive). The primary sources for condoms were non-governmental organization facilities (73.8%) and pharmacies (79.7%) for free and purchased condoms, respectively. A total of 3510 (54.3%; 95% CI: 48.5%-60.1%) FSWs reported no access to free or purchased condoms during the past 15 days, and this no access was significantly higher for those > 30 years of age, with no schooling, street-based FSWs, and with no participation in a FSW support group (p < 0.001 for each in univariate analysis). Participation in a FSW support group was the main predictor of access to free condoms for both types of FSWs during the past 15 days with multivariate analysis. Condom requirements during the past 15 days were met for 67.5% of FSWs who had accessed only free condoms and for 33.8% of those who had accessed only purchased condoms. CONCLUSIONS: One-fourth of FSWs had never accessed condoms, and a little over half of those who had ever accessed reported no access during the past 15 days. Condom requirements were not met for three-fifths of the FSWs. HIV prevention programmes need to Increase access to free condoms for FSWs in Andhra Pradesh as access to condoms is a necessary prerequisite for condom use.

Sex behaviour of men who have sex with men and risk of HIV in Andhra Pradesh, India.

OBJECTIVE: To obtain information on sex behaviour of a large sample of men who have sex with men (MSM) in India that would assist in planning HIV prevention. METHODS: Homosexual/bisexual behaviour of 6661 MSM at 62 urban-rural locations of various sizes in the Indian state of Andhra Pradesh was assessed through detailed interview. Multivariate analyses were performed to understand the associations with unprotected penetrative sex and barriers to condom use assessed. RESULTS: The average number of different male sex partners in past 4 weeks was six. In last three sex encounters with men, totalling 19 640, anal sex occurred in 16 769, at least once by 6121 (91.9%) MSM of which 3423 [55.9%; 95% confidence interval (CI), 51.7-60.1%] did not use condom at least once. A total of 2785 (41.8%) were currently married to women and 3354 (50.4%) had had vaginal/anal sex with women in the past 3 months, of which 2818 (84%; 95% CI, 81.1-86.9%) did not use a condom. Furthermore, 1585 (25.9%; 95% CI, 22.7-29.1%) had anal sex without a condom with men and also vaginal/anal sex without a condom with women. This was prevalent across urban-rural locations and its strongest association was with currently married MSM (odds ratio 15.1; 95% CI, 12.5-18.2). The predominant reason for not using a condom with women was 'do not use with regular partner' (68.4%). CONCLUSION: This high rate of unprotected penetrative sex by MSM with both men and women suggests that HIV prevention efforts in India should include a focus on MSM as well as their wives across many urban-rural locations and not only in large cities.

HIV testing among female sex workers in Andhra Pradesh, India.

Of 6648 female sex workers (FSW) in 13 districts of Andhra Pradesh state in India, only 7.9% reported having undergone HIV testing, and three-quarters of the rest were unwilling to undergo HIV testing in the future. The risk of HIV infection as a result of the non-use of condoms was higher among FSW who reported not having been tested and were also unwilling to get tested, and they also held significantly more negative beliefs about HIV/AIDS.

High risk of HIV in non-brothel based female sex workers in India.

BACKGROUND: Heterosexual contact is the most common mode of HIV transmission in India that is largely linked to sex work. We assessed the non-use of condoms in sex work and with regular sex partners by female sex workers (FSWs), and identified its associations that could assist in planning HIV prevention programmes. METHODS: Detailed documentation of various aspects of sex work, and sexual behaviour with regular sex partners, was done through confidential interviews for 6,648 FSWs in 13 districts in the Indian state of Andhra Pradesh. Multivariate analysis was done to understand condom non-use with clients. RESULTS: 5,010 (75.4%), 1,499 (22.5%), and 139 (2.1%) FSWs were street-, home-, and brothel-based, respectively. Of the total 6,648 FSWs, 6,165 (92.7%) had penetrative vaginal/anal sex with at least one client in the last 15 days, and of these 2,907 (47.2%; 95% CI 41.2-53.2%) reported non-use of condom with at least one of her last three clients. Lack of knowledge that HIV could be prevented (odds ratio 5.01; 95% CI 4.38-5.73), no access to free condoms (odds ratio 3.45; 95% CI 2.99-3.98), being street-based as compared with brothel-based (odds ratio 3.36; 95% CI 1.87-6.04), and no participation in FSW support groups (odds ratio 2.02; 95% CI 1.50-2.70) were the most significant predictors of condom non-use with clients. Other associations included lower social support, lower income, age >24 years, illiteracy, and living in medium-size urban or rural areas. Of the 2582 who had penetrative sex with regular sex partner within the last 7 days, 2428 (94%; 95% CI 92.1-95.9%) had not used condom at last sex, and 1032 (41.8%) had neither used condom consistently with clients nor with regular sex partner. CONCLUSION: About half the FSWs do not use condom consistently with their clients in this Indian state putting them at high risk of HIV infection. Non-brothel-based FSWs, who form the majority of sex workers in India, were at a significantly higher risk of HIV infection as compared with brothel-based FSWs. With their high vulnerability, the success of expansion of HIV prevention efforts will depend on achieving and sustaining an environment that enables HIV prevention with the non-brothel based FSWs.