Comparison of Sexual Risk, HIV/STI Prevalence and Intervention Exposure Among Men Who Have Sex with Men and Women (MSMW) and Men Who Have Sex with Men Only (MSMO) in India: Implications for HIV Prevention.

Using data from a cross-sectional bio-behavioral survey conducted among men who have sex with men (n = 3833) in India, we examined differences related to HIV-related sexual risk, HIV/STI prevalence and intervention exposures between men who have sex with men and women (MSMW, 35 % of the sample) and men who have sex with men only (MSMO). Among MSMW, 93 % reported having female regular partners, 14 % had female paid partners, and all types of male partners (regular 55 %; casual 77.1 %; paying 47 %; paid 19 %). Logistic regression revealed that MSMW had higher odds of being aged 26 years and above (AOR 4.45, 95 % CI 3.66-5.42), lower odds of inconsistently using condoms with male partners (AOR 0.82, 95 % CI 0.67-0.98) and lower odds of having kothi (feminine/mostly receptive) identity (AOR 0.07, 95 % CI 0.06-0.09). HIV intervention exposure and HIV/STI prevalence did not differ significantly between MSMW and MSMO (HIV 13.1 vs. 12.2 %; active syphilis 3.5 vs. 3.1 %, respectively). Concurrent sexual partnerships with men and women pose risk of HIV transmission/acquisition for MSM and their male and female partners. All subgroups of MSM require tailored information and skills to consistently use condoms with different types of partners of either gender.

Association between alcohol use and HIV-related sexual risk behaviors among men who have sex with men (MSM): findings from a multi-site bio-behavioral survey in India.

This paper examines the association between alcohol use and HIV-related sexual risk behaviors among men who have sex with men (MSM). A cross-sectional bio-behavioral survey was conducted among 3,880 MSM, recruited using time-location cluster sampling from cruising sites in three Indian states. Nearly three-fifths of the participants reported alcohol use. Among frequent users (40 % of the sample), defined as those who consumed alcohol daily or at least once a week, 66 % were aged 25 years and above, 53 % self-identified as kothi (feminine/receptive), and 63 % consistently used condoms with male paying partners. Multivariate logistic regression demonstrated that frequent users were more likely to be aged 25 years and above, less likely to self-identify as kothi, and less likely to consistently use condoms with male paying (AOR = 0.7; 95 % CI 0.5-0.9) and male regular (AOR = 0.7; 95 % CI 0.6-0.9) partners. HIV prevention interventions for MSM need to provide tailored information on alcohol use-related sexual risk, especially for MSM in sex work and MSM with male regular partners.

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.

High rates of reinfection and incidence of bacterial sexually transmitted infections in a cohort of female sex workers from two Indian cities: need for different STI control strategies?

BACKGROUND: Female sex workers (FSWs) in India are provided a standardised package of clinical interventions for management of sexually transmitted infections (STIs). A study was conducted among FSWs at known high STI prevalence sites to determine the effectiveness of the service package. METHODS: A cohort of FSW clinic attendees in two cities, Hyderabad and Mumbai, were enrolled and followed up from October 2008 to November 2009. At each visit, behavioural and clinical data were obtained and vaginal swabs collected for laboratory testing of cervical infections (gonorrhoea and chlamydia). RESULTS: 417 participants were enrolled, of whom 360 attended at least a follow-up visit. Prevalence of cervical infections did not change between the baseline and final visits (27.7% and 21.3% respectively, p=0.08) in spite of presumptive treatment at baseline and syndromic management at all visits. The proportion of asymptomatic cervical infections increased from 36% at baseline to 77% at the final visit. Incidence rate of cervical infections was high (85.6/100 person years) and associated with a prevalent cervical infection at baseline (HR=2.7, p<0.001) and inconsistent condom use with non-commercial partners (HR=2.5, p=0.014). CONCLUSIONS: High rates of STIs persisted despite the interventions due to poor condom use, minimal partner treatment, and high prevalence and incidence of STIs with a large proportion of asymptomatic infections. High-prevalence FSW sites in India need to design more effective partner treatment strategies and consider increasing the frequency of presumptive treatment as a temporary measure for quickly reducing STI prevalence, with renewed emphasis on consistent condom use with all partners.

Consistent condom use with regular, paying, and casual male partners and associated factors among men who have sex with men in Tamil Nadu, India: findings from an assessment of a large-scale HIV prevention program.

BACKGROUND: Men who have sex with men (MSM) are a marginalized population at high risk for HIV infection. Promoting consistent condom use (CCU) during anal sex is a key risk reduction strategy for HIV prevention among MSM. To inform effective HIV prevention interventions, we examined the factors associated with CCU among MSM with their regular, paying, and casual partners, as well as with all three types of partners combined. METHODS: Data for this analysis were from a large-scale bio-behavioural survey conducted during 2009-2010 in Tamil Nadu, India. MSM aged 18 years or older were recruited for the survey using time-location cluster sampling at cruising sites in four districts of Tamil Nadu. Binary logistic regression analyses were conducted to assess the association of CCU with selected socio-demographic characteristics and other contextual factors. RESULTS: Among 1618 MSM interviewed, CCU during anal sex with regular, paying, and a casual male partner was 45.3%, 50.8% and 57.9%, respectively. CCU with all three types of partners combined was 52.6%. Characteristics associated with increased odds for CCU with MSM having all three types of partners combined were frequent receptive anal sex acts with regular partners (adjusted odds ratio [AOR] 2.17, 95% confidence interval [CI] 1.01-4.65), fewer number of casual partners (AOR 3.41, 95% CI 1.50-7.73) and membership in a community-based organization (CBO) for MSM (AOR 3.54, 95% CI 1.62-7.74). CCU with regular partners was associated with membership in a CBO (AOR 1.96, 95% CI 1.23-3.11), whereas CCU with paying, and casual male partners was associated with perceived higher risk of acquiring HIV (AOR 1.92, 95% CI 1.22-3.01) and exposure to any HIV prevention intervention (AOR 3.62, 95% CI 1.31-10.0), respectively. Being aged 26 years or older, being in debt, and alcohol use were factors associated with inconsistent condom use across partner types. CONCLUSION: HIV interventions among MSM need to promote CCU with all types (regular, paying, and causal) of male partners, and need to reach MSM across all age groups. In addition to enhancing interventions that focus on individual level risk reduction, it is important to undertake structural interventions that promote social acceptance of same-sex sexuality and address contextual barriers to condom use such as alcohol use.

Exploring access to HIV-related services and programmatic gaps for Men having Sex with Men (MSM) in rural India- a qualitative study.

BACKGROUND: Despite the Link Worker Scheme to address the HIV risk and vulnerabilities in rural areas, reaching out to unreached men having sex with men (MSM) remains a challenge in rural India. This study explored issues around health care access and programmatic gaps among MSM in rural settings of India. METHODS: We conducted eight Focused Group Discussions (FGDs), 20 Key Informant Interviews (KIIs), and 20 In-Depth Interviews (IDIs) in four rural sites in Maharashtra, Odisha, Madhya Pradesh, and Uttar Pradesh between November 2018 and September 2019. The data in the local language were audio-recorded, transcribed, and translated. Data were analyzed in NVivo version 11.0 software using the grounded theory approach. RESULTS: Primary barriers to health care access were lack of knowledge, myths and misconceptions, not having faith in the quality of services, program invisibility in a rural setting, and anticipated stigma at government health facilities. Government-targeted intervention services did not seem to be optimally advertised in rural areas as MSM showed a lack of information about it. Those who knew reported not accessing the available government facilities due to lack of ambient services, fear of the stigma transforming into fear of breach of confidentiality. One MSM from Odisha expressed, "…they get fear to go to the hospital because they know that hospital will not maintain confidentiality because they are local people. If society will know about them, then family life will be disturbed" [OR-R-KI-04]. Participants expressed the desire for services similar to those provided by the Accredited Social Health Activists (ASHA), frontline health workers for MSM. CONCLUSION: Programme invisibility emerges as the most critical issue for rural and young MSM. Adolescent and panthis emerged as Hidden MSM and they need focused attention from the programme. The need for village-level workers such as ASHA specifically for the MSM population emerged. MSM-friendly health clinics would help to improve healthcare access in rural MSMs under Sexual and Reproductive Health Care.

Introduction of rapid tests for large-scale syphilis screening among female, male, and transgender sex workers in Mumbai, India.

BACKGROUND: Despite widespread availability of rapid plasma reagin (RPR) for syphilis screening at sex worker (SW)-dedicated project clinics, uptake of syphilis testing remains low and prevalence of syphilis remains high among SWs in Maharashtra, India. The primary reasons given for refusal of RPR were fear of venipuncture and long waiting times for results. METHODS: Between December 2007 and February 2008, rapid point of contact diagnostic tests (Syphicheck-WB, Qualpro Diagnostics, India) using finger-prick samples were introduced for syphilis screening, with RPR confirmation test of positives. RESULTS: Uptake of syphilis screening among clinic attenders increased to 63.1% compared with an average of 14.3% before the intervention. Among the 19,809 SWs who were screened, 598 tested positive (3% prevalence of lifetime infection). Of these, 395 (66.1%) accepted RPR confirmation test; 337 (88.3%) were seroreactive, 160 (40.5%) had titers ≥1:8 (active syphilis). The projected overall prevalence of active syphilis among all SWs screened was 1.2% but varied by site and typology of sex work (brothel-based, 2.4%; bar-based, 0.5%; street-based, 2.3%; male SWs, 0.2%; transgender, 11.3%; home-based, 0.6%). CONCLUSIONS: The introduction of rapid tests dramatically increased the uptake of syphilis screening in this large-scale intervention among a high-risk population in India. However, only two-thirds of SWs with a positive rapid test accepted a confirmatory RPR test. The high proportion (40.5%) of active syphilis among those testing positive on the rapid screening test justifies treatment even if confirmatory testing is declined. A commercially available, simple, rapid nontreponemal test is needed to further strengthen syphilis screening.

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.

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

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

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.

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

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

Inconsistent condom use by male clients during anal intercourse with occasional and regular female sex workers (FSWs): survey findings from southern states of India.

OBJECTIVES: Self-reported anal intercourse by female sex workers (FSWs) documented in recent studies from India range between 11.9% and 22%. However, comparable data on anal intercourse and condom use from male clients of FSWs is lacking. Using data from a bio-behavioural survey (2009-2010), we examined prevalence of anal intercourse, male clients' self-reported inconsistent condom use during anal intercourse with FSWs, and correlates of this behaviour in India's high HIV prevalence southern states (Andhra Pradesh, Maharashtra and Tamil Nadu combined). METHODS: Using two-stage time location cluster sampling, we recruited 4803 clients of FSWs, ages 18-60 years, who had purchased sex from an FSW in the past month. After obtaining informed consent, respondents were interviewed and tested for HIV and sexually transmitted infections (syphilis, gonorrhoea and chlamydia). Logistic regression analysis was used to identify the factors associated with inconsistent condom use during anal intercourse (in the past 6 months) with FSWs. RESULTS: Overall, 12.3% clients reported anal intercourse in the past 6 months, of whom 48.4% used condoms inconsistently. Clients of FSWs who were ages 26 years or older (AOR 2.68, p=0.032); employed as manual labourers (AOR 2.43, p=0.013); consumed alcohol (AOR 2.63, p=0.001); reported five or more sex acts with FSWs in the past month (AOR 2.53, p=0.031); and perceived themselves to be at higher risk for HIV (AOR 4.82, p=0.001) were more likely to inconsistently use condoms during anal intercourse. CONCLUSIONS: The results suggest that sex workers and their clients commonly practice anal intercourse, but a relatively high proportion of clients do not consistently use condoms, leading to a greater risk of acquiring HIV and its further transmission to other male and female sexual partners. Given the multidirectional risk, safer sex communication on heterosexual anal intercourse must be incorporated into HIV prevention programmes.

An assessment of an HIV prevention intervention among people who inject drugs in the states of Manipur and Nagaland, India.

BACKGROUND: The present study describes an assessment of a large-scale intervention, "Avahan", using an evaluation framework that assesses the program coverage, changes in injection patterns, condom use, and STI and HIV prevalence among People Who Inject Drugs (PWID) in two states of India - Manipur and Nagaland. METHODS: Program monitoring data and results from two rounds of a cross sectional biological and behavioural surveys in 2006 (Round 1) and 2009 (Round 2) were used. The sample included 839 and 860 PWIDs from Manipur and 821 and 829 PWIDs from Nagaland in Round 1 and Round 2 respectively for current analysis. Bivariate and multivariate analyses were done to measure the changes in behavioural and biological outcomes between the two rounds and to examine the association between programme exposure and behavioural outcomes. RESULTS: In Manipur, about 77% of the PWIDs were contacted by the peer educators/outreach workers every month and about 18% of the PWIDs visited the clinic every month by March 2010. In Nagaland, however, the proportion of PWIDs visiting the clinic monthly remained low (11% in March 2010). PWIDs in both states were more likely to report 'consistent safe injection practice in the last six months' in Round 2 compared to Round 1 (Manipur: adjusted odds ratio (aOR): 1.88, 95% confidence intervals (CI): 1.46-2.43; Nagaland: aOR: 2.35, 95% CI: 1.86-2.80) PWIDs were also more likely to report consistent condom use with regular partners in Round 2. The prevalence of Hepatitis B virus (HBV) increased in Round 2 in Manipur (11% vs 6%, p<0.001) and Nagaland (8% vs 6%, p=0.05). The prevalence of Hepatitis C virus (HCV) was high and did not change, either in Manipur (67.3% vs 69.9%, p=0.42) and Nagaland (14.7% vs 15.1%, p=0.82). Similarly, the prevalence of HIV did not change significantly between the two Rounds either in Manipur (27.8% in Round 1 vs 29.2% in Round 2, p=0.59) or in Nagaland (1.2% in Round 1 and 1.6% in Round 2 of the IBBA, p=0.82). CONCLUSION: Improvements in safe injection practices and consistent condom use with regular partners suggest effectiveness of prevention efforts. However, increase in HBV prevalence and non-decline in HCV and HIV prevalence in both the states also underscore the need to continue and intensify targeted interventions (such as Hepatitis B vaccination, needle exchange programmes, condom distribution) for long term risk reduction among PWID population.

Role of community group exposure in reducing sexually transmitted infection-related risk among female sex workers in India.

BACKGROUND: Empowering female sex workers (FSWs) to address structural barriers and forming community groups (CGs) through community mobilization are seen as essential components of HIV prevention programs in India. Taking the membership of a CG as an exposure intervention, we hypothesized whether participation in a CG lead to reduced sexually transmitted infections (STIs) and increased treatment-seeking behavior among FSWs in three selected states of India--Andhra Pradesh, Maharashtra and Tamil Nadu. METHODS AND FINDINGS: The propensity score matching (PSM) approach examined the effect of CG membership, as against no membership, on STI-related risk, described as selected outcome measures--presence of any STI, self-reported STI symptoms, and treatment-seeking behavior among FSWs. A cross sectional bio-behavioral survey was administered in 2009-2010 and covered 7,806 FSWs through two-stage probability-based conventional and time location cluster sampling in 23 administrative districts of Andhra Pradesh, Maharashtra and Tamil Nadu. Only 2,939 FSWs were reported to be members of a CG and among them 4.5% had any STIs. A majority of FSWs were aged above 24 years (86.4%), had ever been married (73%), operated from a public place for solicitation (81.5%), and had ever received HIV test results (75.6%). The average effect of CG exposure was reduction in STI prevalence by 4%, while self-reported STI symptom treatment-seeking behavior increased by 13.7%. CONCLUSION: FSWs who were exposed to a CG were at a substantially lower risk of STIs than those who were unexposed. The FSWs exposed to a CG had a higher chance of seeking STI treatment from public and private health facilities. Collectivization related challenges must be overcome to provide access to tailored STI prevention and care services.

Factors Associated with Use of Latex Condom-Compatible Lubricants by Men Who Have Sex with Men in India: Implications for HIV Prevention.

We examined the prevalence and type of rectal lubricants use and factors associated with exclusive use of latex-condom compatible lubricants (water-based lubricants) among men who have sex with men (MSM) using data from a large-scale cross-sectional survey conducted in 2009/10 in three Indian states. Using time-location cluster sampling, 3880 MSM were recruited from cruising sites. We used multiple logistic regression to assess the association between type of lubricants used and sociodemographic and programmatic indicators. Among those who reported using lubricants (64%) more than half (53%) exclusively used water-based lubricants, less than one-tenth used exclusively oil-based lubricants, and nearly 40% used both water-based and oil-based lubricants. Factors associated with exclusive use of water-based lubricants were exposure to HIV prevention interventions (AOR: 6.18, 95% CI 4.82 to 7.92) and kothi-identified MSM-feminine/anal-receptive (AOR: 2.56, 95% CI 2.12 to 3.10). Targeted HIV interventions among MSM need to promote and distribute latex condom-compatible lubricants for use during anal sex-irrespective of their presumed or stated sexual role in anal sex, and educate them not to use oil-based lubricants with condoms.

An assessment of a large-scale HIV prevention programme for high-risk men who have sex with men and transgenders in Andhra Pradesh, India: using data from routine programme monitoring and repeated cross-sectional surveys.

OBJECTIVES: To assess a large-scale intervention, the Avahan intervention, using an evaluation framework that included programme coverage, condom use and changes in sexually transmitted infection (STI) and HIV prevalence among high-risk men who have sex with men/transgender (HR-MSM/TG) in the state of Andhra Pradesh, India. DESIGN: Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis. SETTING: Programme monitoring data and cross-sectional surveys from Andhra Pradesh, India. PARTICIPANTS: Data from 1218 and 1203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts. PRIMARY AND SECONDARY OUTCOMES: (1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention. RESULTS: By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HR-MSM/TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52). CONCLUSION: The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HR-MSM/TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.