Changes in HIV and syphilis prevalence among female sex workers from three serial cross-sectional surveys in Karnataka state, South India.

OBJECTIVES: This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India. DESIGN: Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time. SETTING: Five districts in Karnataka state, India. PARTICIPANTS: 7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included. INTERVENTIONS: The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation. RESULTS: HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8% (adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low. CONCLUSIONS: The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

Vulnerability re-assessed: the changing face of sex work in Guntur district, Andhra Pradesh.

We conducted a qualitative study to examine the impact of an HIV prevention programme on female sex workers' lives in Guntur district, Andhra Pradesh. The study found evidence that, in addition to the HIV prevention programme, structural and environmental factors had recently changed the way sex work was being practiced. Recent closure of the brothels and implementation of a late-night street curfew by the police meant sex work had become more hidden, with clients often solicited using mobile phones from home or their work place (e.g., in the fields or factories). Sex work had become safer, with violence by non-regular partners rarely reported. Women understood the risks of unprotected vaginal sex and reported using condoms with their clients. However, clients were more frequently requesting anal sex, possibly due to recent exposure to pornography following increased accessibility to modern technologies such as mobile phones and the Internet. Anal sex with clients was common but women were often unaware of the associated risks and reported unprotected anal sex. HIV positive and/or older women faced severe financial hardship and difficulty soliciting sufficient clients, and reported unprotected vaginal and anal sex to earn enough to survive. Taken together, the findings from this study suggest changing vulnerability to HIV in this setting. It will be important for HIV prevention programmes to be flexible and creative in their approaches if they are to continue to reach this target community effectively.

Is HIV prevalence declining in southern India? Evidence from two rounds of general population surveys in Bagalkot District, Karnataka.

OBJECTIVES: To assess the levels and trends in the prevalence of HIV and sexually transmitted infections in the general population in Bagalkot district using 2 cross-sectional surveys undertaken in 2003 and 2009. METHODS: In both surveys, a target sample of 6600 adult males and females was selected systematically from a sample of 10 rural villages and 20 urban blocks in 3 of the 6 talukas (subdistrict units) in the district. Urine and blood samples were collected from all consenting participants for HIV and sexually transmitted infection testing. Changes in HIV prevalence in age subgroups were determined by logistic regression, taking into account the survey design. RESULTS: HIV prevalence fell not significantly from 3.2% to 2.5% during the 6-year study period. It decreased significantly (P = 0.023) among persons aged 15 to 24 years, from 2.4% in 2003 (95% confidence interval [95% CI]: 1.2-3.7) to 1.3% in 2009 (95% CI: 0.6 -2.0). However, among males aged 35 and above, HIV prevalence increased significantly (P = 0.008), from 3.0% (95% CI: 1.1-4.8) to 4.2% (95% CI: 1.8-6.6), a level similar to that found in the younger age-group in 2003. CONCLUSIONS: We observed a significant decline in HIV prevalence among people aged 15 to 24 years, where HIV prevalence more closely reflects incidence. The increase in HIV prevalence among older males may have been because of the aging of a cohort of men among whom HIV prevalence was highest in the 2003 survey. It may also have in part reflected increased survival, as a result of the scaling up of antiretroviral treatment programs throughout the district and state.

Evaluation of stepping stones as a tool for changing knowledge, attitudes and behaviours associated with gender, relationships and HIV risk in Karnataka, India.

BACKGROUND: Stepping Stones training aims to help individuals explore sexual relationships and recognize gender inequalities, the structural drivers of the HIV epidemic, in order to understand risk behaviours and to seek solutions to factors that increase HIV vulnerability. Despite earlier studies suggesting the success of Stepping Stones, little data exist to show diffusion to trainees' social networks or the wider community. METHODS: A mixed-methods evaluation of this approach was undertaken using in-depth interviews of trainees and friends, and polling booth surveys in 20 villages where Stepping Stones training took place and in another 20 villages with no Stepping Stones intervention. RESULTS: The interview respondents and their friends reported significant changes in their relationships after training, and benefit from discussion of gender, sexuality, condom use and HIV vulnerability issues. However, though diffusion of this knowledge at the level of personal contacts was strong, the evaluation revealed that diffusion to the community level was limited. CONCLUSIONS: The qualitative part of this study reflects other studies in different settings, in that SS participants gained immensely from the training. Wider behaviour change is a challenging goal that many programmes fail to attain, with most interventions too limited in scope and intensity to produce larger community effects. This may have contributed to the fact that we observed few differences between interventions and non-intervention villages in this study. However, it is also possible that we had excessive expectations of individual change at the community level, and that it might have been more appropriate to have had broader community level rather than individual behavioural change indicators. We suggest that SS could be enhanced by efforts to better engage existing community opinion leaders, to empower and train participants as community change agents, and to support the development of village-level action plans that combat sexual stereotyping and risky behaviours that lead to unhealthy sexual relationships.

Blood, men and tears: keeping IUDs in place in Bangladesh.

The Intra-Uterine Device (IUD) is an effective method of contraception, but in Bangladesh is associated with high levels of discontinuation within the first year. This study involved data collection from a retrospective cohort of women who had an IUD inserted 12 months earlier. In the cohort, 330 women were interviewed to identify factors associated with discontinuation. Later, 20 women, of the 103 who reported discontinuing because of excessive menstrual bleeding, were interviewed again and in depth about these issues. Of 330 women who had an IUD inserted, 47.3% had discontinued use one year post-insertion. In univariate and multivariate analyses, IUD discontinuation was strongly associated with side-effects (heavier periods; abdominal pain) and spousal factors (not discussing IUD with husband pre-insertion), but not with service delivery factors. In-depth interviews with women who reported excessive blood loss as the main reason for discontinuation found a doubling of both menstrual days and blood loss after IUD insertion. In Bangladesh, women cannot pray, have sexual intercourse, perform household tasks or participate in community activities during menstruation. Thus, women with menstrual side-effects faced serious physical, social and psychological challenges that made continuation difficult. Among those who discontinued, spouses were generally unsupportive and sometimes abusive, particularly when not involved in the decision to use the IUD.

Participatory evaluation of reproductive health care quality in developing countries.

Participatory approaches are becoming increasingly important in the field of health, and many organizations, governments and donors have recognized the need to increase stakeholder involvement to ensure sustainable and real change. However, commitment to participation is often lacking and participatory processes, if applied, tend to be short-term and discrete, especially in institutional settings. Rarely, for example, are stakeholders involved in long-term monitoring and evaluation activities, due the time-consuming nature of participation, and to perceptions on the part of donors and other decision-makers that participation lacks the rigor and objectivity of external evaluation. This paper describes the strategies used by an international reproductive health organization to collaborate with local stakeholders in a long-term participatory approach to quality improvement, focusing on defining quality of care, identifying problems in health facilities, setting goals and seeking solutions to those problems, tracking changes in quality over time, and feeding this monitoring and evaluation information back into the quality improvement process. The paper also illustrates how greater participation was achieved over time as local stakeholders moved away from traditional models and relationships and started working together to meet their quality improvement goals. The paper argues that participatory techniques are essential if the real needs of clients are to be met through sustained change and continuous quality improvement at the site level.