Geographic and socioeconomic inequalities in the coverage of contraception in Uttar Pradesh, India.

BACKGROUND: Uttar Pradesh (UP) is the most populous state in India, with a historically lower level of family planning coverage than the national average. In recent decades, family planning coverage in UP has significantly increased, yet there are considerable geographic and socio-economic inequalities. METHODS: The data used for the study is derived from a cross-sectional quantitative survey of 12,200 currently married women conducted during December 2020-February 2021 in UP by the Technical Support Unit. Univariate and bivariate analyses were performed and equiplots were used to make visualizing inequalities easy. RESULTS: The findings of the study reveal significant variation in family planning coverage indicators amongst currently married women in reproductive ages by administrative divisions in UP. For instance, in the Jhansi division, it was 72.4%, while in Faizabad, it was 39.3%. Jhansi division experienced the highest modern contraceptive coverage with the lowest inequity compared to other divisions. However, the range of coverage within the division by Accredited Social Health Activist (ASHA) areas is 25% to 75%. In fact, for some ASHA areas in the Jhansi division, the family planning demand satisfied for modern contraception ranged from more than 85% to less than 22%. On the other hand, the Gonda division with the lowest coverage and lowest inequity for demand satisfied for modern contraception has some ASHA areas with less than 5% and some with more than 36%. The study also revealed intersectionality of education, wealth, place of residence and geographic divisions in identifying inequity patterns. For instance, in case of Mirzapur and Varanasi, the demand satisfied among the illiterates was 69% and the corresponding percentage for literates was 49%. With respect to place of residence, Basti division, where the coverage for modern contraception is extremely low, demand satisfied for modern contraceptive methods is 16.3% among rural residents compared to 57.9% in the case of urban residents. CONCLUSIONS: The findings showed inequality in the modern family planning methods coverage in UP in both best and worst performing divisions. The inequalities exist even in extremely small geographies such as ASHA areas. Within the geographies as well, the socio-economic inequalities persisted. These inequalities at multiple levels are important to consider for effective resource allocation and utilization.

Declining fertility and increasing use of traditional methods of family planning: a paradox in Uttar Pradesh, India?

Uttar Pradesh (UP), with more than 220 million people, is the most populous state in India. Despite a high unmet need for modern family planning methods, the state has experienced a substantial decline in fertility. India has also seen a decline during this period which can be attributed to the increased prevalence of modern methods of family planning, particularly female sterilisation, but in UP, the corresponding increase was marginal. At the same time, Traditional Family Planning Methods (TMs) increased significantly in UP in contrast to India, where it was marginal. The trends in UP raise questions about the drivers in fertility decline and question the conventional wisdom that fertility declines are driven by modern methods, and the paper aims to understand this paradox. Fertility trends and family planning practices in UP were analysed using data from different rounds of National Family Health Surveys (NFHS) and the two UP Family Planning Surveys conducted by the UP Technical Support Unit to understand whether the use of TMs played a role in the fertility decline. As per NFHS-4, the prevalence of TM in India (6%) was less than half that of UP (13%). The UP Family Planning Survey in 25 High Priority Districts estimated that 22% of women used TMs. The analysis also suggested that availability and accessibiility of modern contraceptives might have played a role in the increased use of TMs in UP. If there are still couples who make a choice in favour of TMs, they should be well informed about the risks associated with the use of traditional methods as higher failure rate is observed among TMs users.

Low Birth Weight, the Differentiating Risk Factor for Stunting among Preschool Children in India.

Background: The prevalence of low birth weight (LBW) is a major public health issue in India; however, the optimal growth pattern for such infants is not clear. The purpose of this study is to understand the causal association between LBW and stunting of preschool children in India. Methods: The National Family Health Survey-4 is a large cross-sectional survey based on a nationally representative sample of 699,686 women in the age group of 15−49 years and was conducted during 2015−2016 in India. The study used the children's file with a sample of 259,002 of 0−59 months for investigation. Results: The data revealed that 38.7% of the children in India were stunted. The bivariate analysis revealed that, of the women who did not attend any antenatal care (ANC) meetings, 46.8% had stunted children compared to the women who attended more than three ANC meetings, which 30.7% had stunted children. The low birth weight children experienced a much higher chance of stunting compared to children with a normal birth weight (44.3% vs. 33.8%). The multivariable odds ratios of logistic regression, after adjusting for the confounding characteristics, showed that pregnant women attending more than three ANC meetings compared to not attending any ANC meetings experienced a 19% lower adjusted odds ratio (AOR) of having stunted children (AOR = 0.81; CI 0.78, 0.85; p < 0.001). Another important variable, such as women with underweight body mass index (BMI) compared with normal BMI, had 6% higher odds of having stunted children (AOR = 1.06; CI 1.03, 1.10; p < 0.001). Similarly, women who belong to the Scheduled Caste compared to the General Caste had 36% higher odds of having stunted children (AOR = 1.36; CI 1.30, 1.42; p < 0.001); and children aged 13−23 months compared to children up to one-year-old or younger had 141% higher odds of being stunted (AOR = 2.41; CI 2.32, 2.51; p < 0.001). The conspicuous finding is that LBW babies, after adjusting for other important confounding factors, such as BMI and ANC, experienced 19% higher odds of stunted children (AOR = 1.19; CI 1.14, 1.24; p < 0.001) compared to normal birth weight babies. Conclusions: The results revealed LBW is associated with stunting of preschool children in India.

Suicidality among gender minorities in Karnataka, South India.

BACKGROUND: It is argued that Indian gender minorities displayed differential mental health problems and suicide attempts. Hence, the study was intended to understand the prevalence of anxiety, depression and suicidality among this group, specifically those living in a metropolitan city in South India. METHODS: The data was generated from a cross-sectional study that employed a structured questionnaire to collect information about experiences of anxiety, depression and suicidal behavior among gender-diverse individuals in Bangalore, the capital city of Karnataka state. The study used stratified simple random sampling of eligible individuals who were 18 years of age and older and who were enrolled in an HIV prevention program implemented for gender-diverse individuals run by the Karnataka Health Promotion Trust and the University of Manitoba at the time of the study (2012). Bivariate and multivariate analyses were used to assess the relative contribution of various factors that affect suicide ideation or actual attempts among the gender diverse participants. RESULTS: Results showed that 62% whose main source of income was Basti (socially sanctioned practice of begging), 52% of Hijras, 56% who lived with their Gurus, 58% who were not happy with their physical appearance, 55% who consumed alcohol daily, and 63% who experienced high depression had ever thought of or attempted suicide in the month prior to the survey. However, multivariate analysis showed that respondents who were not happy with their physical appearance and thought of changing it had significantly higher odds (AOR = 2.861; CI 1.468,5.576; p = 0.002) of either having thoughts that it was better being dead or wished they died. Similarly, those who experienced high depression, their odds of either having had thoughts of or having attempted suicide increased by three times (AOR = 3.997; CI 1.976, 8.071; p < 0.000). CONCLUSIONS: It is observed that a high percentage of gender minorities had attempted suicide or thought of suicide during the month preceding the data collection. The findings bring new insights on the proximate determinant of physical appearance on the suicidality of gender minorities assigned male at birth and appropriate to account for this while addressing the mental health issues.

Increased blood glucose level following hysterectomy among reproductive women in India.

BACKGROUND: In recent years, the hysterectomy, a surgical removal of the uterus, has received increased attention in health policy debates in India. The trigger for this was a series of media reports that highlighted an unusual surge in the number of women undergoing hysterectomies with a significant number of cases involving young and early menopausal women from low-income families. When menopause occurs as a result of hysterectomy, then the hormones such as estrogen and progesterone affect how the body cells respond to insulin. To date, we have not come across a national study following blood glucose levels among women who undergo a hysterectomy. METHODS: The study used the Indian fourth round of National Family Health Survey data, which is a cross-sectional nationally representative sample of 699,686 women in the age group 15-49 years and conducted during 2015-16. Bivariate and multivariate logistic regressions were used to examine the effect of hysterectomy on blood glucose level of > 140 mg/dl among women of reproductive age groups. RESULTS: The blood glucose level of > 140 mg/dl was much higher among women who had undergone a hysterectomy (12.2%) compared to non-hysterectomy women (5.7%). The pattern holds true among relevant background characteristics such as age, place of residence, education, caste, religion, wealth, marital status, body mass index (BMI), anaemia and consumption of tobacco. The adjusted odds after controlling for significant background factors, women who underwent hysterectomy experienced 15% higher odds of blood glucose level of > 140 mg/dl compared those who did not. CONCLUSIONS: The results indicated increased blood glucose level among women post hysterectomy. Hence, the government of India should consider developing evidence-based policies and programming to provide effective targeted interventions for the better reproductive health of women.

Gender differences in the risk factors for high and very high blood glucose levels: A study of Kerala.

BACKGROUND AND AIMS: Worldwide, lifestyle is a significant risk factor for diabetes. Lifestyle changes can lead to differences in the extent of risk of diabetes among women and men. Kerala, a state with one of the best health indicators in India, has a high prevalence of diabetes. This study aimed at comparing the variations in the risk factors for HBG and VHBG among adult women and men in Kerala. METHODS: Data from the fourth round of the National Family Health Survey (2015-16) used to examine the differences in the risk factors for HBG and VHBG in men and women aged 15-49 years. We used bivariate, multivariate and Population Attributable Risk (PAR) techniques for analysing the data. RESULTS: Bivariate results have shown the pattern of HBG and VHBG prevalence in women and men was same among all the age groups; however, men show a higher HBG and VHBG than women in all the age groups. Prevalence of HBG and VHBG was higher in women with a primary education, who were poor and not working as compared to their male counterparts. PARs results show that the prevalence of VHBG was higher among obese men and women as compared to normal men and underweight women. Prevalence of HBG was higher among men as compared to women due to alcohol use and weekly consumption of non-vegetarian food. CONCLUSIONS: The study suggests that there is an urgent need for targeted intervention programs to address the problem of HBG and VHBG in both men and women in Kerala to control blood glucose levels.

Increased hypertension following hysterectomy among reproductive women in India.

BACKGROUND: In recent years, hysterectomy has received increased attention in health policy debates in India. On the other hand, based non-communicable disease specific data for India, in 2011, WHO portray a grim picture and recommended to the government a 20% reduction in hypertension by 2020; however, the trends show that it is increasing. Yet, to date, there has not been a single nationally representative study of hypertension prevalence among women who undergo a hysterectomy. METHODS: The study has used the Indian fourth round of National Family Health Survey data, which is a cross-sectional nationally representative sample of 699,686 women in the age group 15-49 years and conducted during 2015-16. Bivariate and multivariate logistic regressions were used to examine the effect of hysterectomy on increased odds of hypertension among women of reproductive age groups. RESULTS: The age adjusted prevalence of hypertension was higher among women those who undergone hysterectomy (11.9%) compared to non-hysterectomy women (10.6%). The pattern holds true among relevant background characteristics such as age, place of residence, education, caste, religion, wealth, family size, years since hysterectomy, body mass index (BMI), anaemia and consumption of tobacco. The adjusted odds of hypertension among women who underwent hysterectomy compared to those who did not was 1.72 (95% CI: 1.14-2.58). CONCLUSIONS: The results indicated increased hypertension level among hysterectomy women. However, these results are based on a cross-sectional study, and hence, further through investigation based on a prospective study is necessary before undertaking any policy changes. Meanwhile, the government of India may like to suggest surveillance to the general practitioners as well as obstetricians and gynaecologists following a hysterectomy in order to better understand the effect of hysterectomy on hypertension.

Fertility and family planning in Uttar Pradesh, India: major progress and persistent gaps.

BACKGROUND: Uttar Pradesh (UP) is the most populous state in India with historically high levels of fertility rates than the national average. Though fertility levels in UP declined considerably in recent decades, the current level is well above the government's target of 2.1. DATA AND METHODS: Fertility and family planning data obtained from the different rounds of Sample Registration System (SRS) and the National Family Health Survey (NFHS). We analyzed fertility and family planning trends in India and UP, including differences in methods mix, using SRS (1971-2016) and NFHS (1992-2016). Bivariate and multivariate regression analyses were used. RESULTS: From 2000, while the total fertility rate (TFR) declined in UP, it is still well above the national level in 2015-16 (2.7 vs 2.18, respectively). The demand for family planning satisfied increased from 52 to 72% during 1998-99 to 2015-16 in UP, compared to an increase from 75 to 81% in India. Traditional methods play a much greater role in UP than in India (22 and 9% of the demand satisfied respectively), while use of sterilization was relatively low in UP when compared to the national averages (18.0 and 36.3% of current married women 15-49 years in UP and India, respectively in 2015-16). Within UP, district fertility ranged from 1.6 to 4.4, with higher fertility concentrated in districts with low female schooling, predominantly located in north-central UP. Fertility declines were largest in districts with high fertility in the late nineties (B = 7.33, p < .001). Among currently married women, use of traditional methods increased and accounted for almost one-third of users in 2015-16. Use of sterilization declined but remained the primary method (ranging from 33 to 41% of users in high and low fertility districts respectively) while condom use increased from 17 and 16% in 1998-99 to 23 and 25% in 2015-16 in low and high fertility districts respectively. CONCLUSIONS AND IMPLICATIONS: Greater reliance on traditional methods and condoms coupled with relatively low demand for modern contraception suggest inadequate access to modern contraceptives, especially in district with high fertility rates. Family planning activities need to be appropriately scaled according to need and geography to ensure the achievement of state-level improvements in family planning programs and fertility outcomes.

An Estimation of Mortality Risks among People Living with HIV in Karnataka State, India: Learnings from an Intensive HIV/AIDS Care and Support Programme.

BACKGROUND: In Indian context, limited attempts have been made to estimate the mortality risks among people living with HIV (PLHIV). We estimated the rates of mortality among PLHIV covered under an integrated HIV-prevention cum care and support programme implemented in Karnataka state, India, and attempted to identify the key programme components associated with the higher likelihood of their survival. METHODS: Retrospective programme data of 55,801 PLHIV registered with the Samastha programme implemented in Karnataka state during 2006-11 was used. Kaplan-Meier survival methods were used to estimate the ten years expected survival probabilities and Cox-proportional hazard model was used to examine the factors associated with risk of mortality among PLHIV. We also calculated mortality rates (per 1000 person-year) across selected demographic and clinical parameters. RESULTS: Of the total PLHIV registered with the programme, about nine percent died within the 5-years of programme period with an overall death rate of 38 per 1000 person-years. The mortality rate was higher among males, aged 18 and above, among illiterates, and those residing in rural areas. While the presence of co-infections such as Tuberculosis leads to higher mortality rate, adherence to ART was significantly associated with reduction in overall death rate. Cox proportional hazard model revealed that increase in CD4 cell counts and exposure to intensive care and support programme for at least two years can bring significant reduction in risk of death among PLHIV [(hazard ratio: 0.234; CI: 0.211-0.260) & (hazard ratio: 0.062; CI: 0.054-0.071), respectively] even after adjusting the effect of other socio-demographic, economic and health related confounders. CONCLUSION: Study confirms that while residing in rural areas and presence of co-infection significantly increases the mortality risk among PLHIV, adherence to ART and improvement in CD4 counts led to significant reduction in their mortality risk. Longer exposure to the intervention contributed significantly to reduce mortality among PLHIV.

Pregnancy wastage among HIV infected women in a high HIV prevalence district of India.

BACKGROUND: Bagalkot district in Karnataka state is one of the highest HIV prevalence districts in India. A large proportion of the girls also marry at early age in the district and negative pregnancy outcomes among the HIV positive women likely to have large pregnancy wastages. Therefore, this study examined the pregnancy wastages and the associated factors among HIV positive women in a high prevalent district in India. METHODS: We used data from a cross-sectional survey conducted recently among randomly selected currently married HIV positive women, 15-29 years of age, in one of the high HIV prevalence districts in India. The study used the experience of reported pregnancy wastage as an outcome variable, and both bi-variate and multivariate logistic regression analyses were carried out to understand the factors associated with the pregnancy wastage among HIV infected women. RESULTS: Overall, 17% of the respondents reported pregnancy wastage, of which 81% were due to spontaneous abortions. Respondents who became pregnant since testing HIV positive reported significantly higher level of pregnancy wastage as compared to those were pregnant before they were tested for HIV. (AOR = 1.9; p = 0.00). While a positive association between duration of marriage and pregnancy wastage was noticed (AOR = 7.4; p = 0.01), there was a negative association between number of living children and pregnancy wastage (AOR = 0.24; p = 0.00). Living in a joint family was associated with increased reporting of pregnancy wastage as compared to those living in nuclear families (AOR = 1.7; p = 0.03). CONCLUSIONS: HIV prevention and care programs need to consider the reproductive health needs of HIV infected married women as a priority area since large proportion of these women reported negative pregnancy outcomes. There is also a need to explore ways to raise the age at marriage in order to stop women getting married before the legal age at marriage.

Variations over four decades in body mass index trajectories prior to diagnosis of diabetes mellitus: The Manitoba Follow-up Study, 1948-2007.

OBJECTIVE: The aim of the study was to explore the variations in body mass index (BMI) trajectories during the 20 years before diagnosis of type 2 diabetes mellitus (T2DM) over four decades between 1968 and 2007. METHODS: Longitudinal measurements of BMI from 437 men, all with a diagnosis of T2DM, were used in the analysis. A mixed method approach was used to fit individual patterns of BMI measurements during the 20 years before diagnosis of T2DM. RESULTS: The mean BMI at diagnosis was 26.7 kg/m2 (95% confidence interval, 26.4-27.1). Compared with men whose condition was diagnosed between 1968 and 1977, for men with a diagnosis between 1978 and 2007 the mean BMI about 10 years before diagnosis significantly increased by 0.92 to 1.54 BMI units. Decades also varied in how long there was a persistent increase in BMI during the 20 years before diagnosis. The rate of change in mean BMI among men whose T2DM was diagnosed in the most recent two decades increased by 8.8% to 22.6% during the 10-year interval before diagnosis, but there was no significant difference among men given a diagnosis between 1978 and 1987. The quadratic trend of BMI prior to diagnosis was also significantly affected by age at diagnosis. CONCLUSION: The BMI trajectories during the 20 years leading up to T2DM varied by decade of diagnosis. The increase in BMI persisted for much longer among relatively younger men with a diagnosis in more recent decades. Strategies to prevent T2DM, informed by the pattern of BMI trajectories, should be customized to consider a potential age-period effect.

Intimate relationships of Devadasi sex workers in South India: An exploration of risks of HIV/STI transmission.

Global literature on female sex workers suggests that being in an intimate relationship is associated with barriers to practising safe sex behaviours. Condom use within intimate relationships is often seen as a sign of infidelity and fosters mistrust which could affect longevity, trust and intimacy within partnerships. Using qualitative data from Devadasi sex workers and their intimate male partners in Bagalkot District, Karnataka, India, we examined both partners' perspectives to understand the quality and dynamics of these relationships and the factors that influence condom use in intimate relationships. Our thematic analysis of individual interviews conducted in May 2011 with 20 couples suggests that many Devadasi sex workers and their intimate partners define their relationships as 'like marriage' which reduced their motivation to use condoms. Evidence from this study suggests that active participation in sex workers' collectives (sanghas) can increase condom use, education and family planning services, among other things, and could be helpful for both Devadasis and their intimate partners to better understand and accept safer sexual practices. Our work has direct implications for designing couple-based health interventions for traditional Devadasi sex workers and their intimate partners in India.

Risky Behaviors among HIV-Positive Female Sex Workers in Northern Karnataka, India.

Purpose. Little is known about the risky sexual behaviors of HIV-positive female sex workers (FSWs) in the developing world, which is critical for programmatic purposes. This study aims to shed light on their condom use with regular clients as well as husband/cohabiting partner, a first in India. Methods. Multivariate logistic regression analyses for consistent condom use with regular clients and husband/cohabiting partner are conducted for the sample of 606 HIV-positive FSWs. Results. Older FSWs are 90% less likely and nonmobile FSWs are 70% less likely to consistently use condoms. FSWs on ART are 3.84 times more likely to use condoms. Additionally, FSWs who changed their occupation after HIV diagnosis are 70% less likely to use condoms. FSWs who are currently cohabiting are more likely to consistently use condoms with repeat clients and are 3.22 times more likely to do so if they have felt stigma associated with being HIV-positive. FSWs who have multiple repeat clients, and who do not know the sexual behavior of these clients, are more likely to use condoms consistently. Conclusion. This study would help inform programs to target the following particularly vulnerable HIV-positive FSWs: those who are older, those who changed their occupation post-HIV diagnosis, and those who are nonmobile.

Understanding out-migration among female sex workers in South India.

BACKGROUND: Migrant sex workers are known to be vulnerable to HIV. There is substantial female sex worker (FSW) mobility between the borders of Maharashtra and Karnataka, but little programming emphasis on migrant FSWs in India. We sought to understand the individual/cultural, structural, and contextual determinants of migration among FSWs from Karnataka. METHODS: A cross-sectional face-to-face interview of 1567 FSWs from 142 villages in 3 districts of northern Karnataka, India was conducted from January to June 2008. Villages having 10+ FSWs, a large number of whom were migrant, were selected following mapping of FSWs. Multinomial logistic regression was conducted to identify characteristics associated with migrant (travelled for ≥ 2 weeks outside the district past year) and mobile (travelled for <2 weeks outside the district past year) FSWs; adjusting for age and district. RESULTS: Compared with nonmigrants, migrant FSWs were more likely to be brothel than street based (Adjusted Odds Ratio (AOR): 5.7; 95% confidence interval: 1.6-20.0), have higher income from sex work (Adjusted Odds Ratio (AOR): 42.2; 12.6-142.1), speak >2 languages (AOR: 5.6; 2.6-12.0), have more clients (AOR per client: 2.9; 1.2-7.2), and have more sex acts per day (AOR per sex act: 3.5; 1.3-9.3). Mobile FSWs had higher income from sex work (AOR: 13.2; 3.9-44.6) relative to nonmigrants, but not as strongly as for migrant FSWs. CONCLUSION: Out-migration of FSWs in Karnataka was strongly tied to sex work characteristics; thus, the structure inherent in sex work should be capitalized on when developing HIV preventive interventions. The important role of FSWs in HIV epidemics, coupled with the potential for rapid spread of HIV with migration, requires the most effective interventions possible for mobile and migrant FSWs.

The Female Sex Work Industry in a District of India in the Context of HIV Prevention.

HIV prevalence in India remains high among female sex workers. This paper presents the main findings of a qualitative study of the modes of operation of female sex work in Belgaum district, Karnataka, India, incorporating fifty interviews with sex workers. Thirteen sex work settings (distinguished by sex workers' main places of solicitation and sex) are identified. In addition to previously documented brothel, lodge, street, dhaba (highway restaurant), and highway-based sex workers, under-researched or newly emerging sex worker categories are identified, including phone-based sex workers, parlour girls, and agricultural workers. Women working in brothels, lodges, dhabas, and on highways describe factors that put them at high HIV risk. Of these, dhaba and highway-based sex workers are poorly covered by existing interventions. The paper examines the HIV-related vulnerability factors specific to each sex work setting. The modes of operation and HIV-vulnerabilities of sex work settings identified in this paper have important implications for the local programme.

Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India.

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.

Motivations for entry into sex work and HIV risk among mobile female sex workers in India.

This paper assesses the reasons for entry into sex work and its association with HIV risk behaviours among mobile female sex workers (FSWs) in India. Data were collected from a cross-sectional survey conducted in 22 districts across four high HIV prevalence states in India during 2007-2008. Analyses were limited to 5498 eligible mobile FSWs. The reasons given by FSWs for entering sex work and associations with socio-demographic characteristics were assessed. Reported reasons for entering sex work include poor or deprived economic conditions; negative social circumstances in life; own choice; force by an external person; and family tradition. The results from multivariate analyses indicate that those FSWs who entered sex work due to poor economic conditions or negative social circumstances in life or force demonstrated elevated levels of current inconsistent condom use as well as in the past in comparison with those FSWs who reported entering sex work by choice or family tradition. This finding indicates the need for a careful assessment of the pre-entry contexts among HIV prevention interventions since these factors may continue to hinder the effectiveness of efforts to reduce the spread of HIV/AIDS in India and elsewhere.

Relationship between reported prior condom use and current self-perceived risk of acquiring HIV among mobile female sex workers in southern India.

BACKGROUND: With the evolution of Health Belief Model, risk perception has been identified as one of several core components of public health interventions. While female sex workers (FSWs) in India continue to be at most risk of acquiring and transmitting HIV, little is known about their perception towards risk of acquiring HIV and how this perception depends upon their history of consistent condom use behavior with different type of partners. The objective of this study is to fill this gap in the literature by examining this relationship among mobile FSWs in southern India. METHODS: We analyzed data for 5,413 mobile FSWs from a cross-sectional behavioral survey conducted in 22 districts from four states in southern India. This survey assessed participants' demographics, condom use in sex with different types of partners, continuation of sex while experiencing STI symptoms, alcohol use before having sex, and self-perceived risk of acquiring HIV. Descriptive analyses and multilevel logistic regression models were used to examine the associations between risky sexual behaviors and self-perceived risk of acquiring HIV; and to understand the geographical differences in HIV risk perception. RESULTS: Of the total mobile FSWs, only two-fifths (40%) perceived themselves to be at high risk of acquiring HIV; more so in the state of Andhra Pradesh (56%) and less in Maharashtra (17%). FSWs seem to assess their current risk of acquiring HIV primarily on the basis of their past condom use behavior with occasional clients and less on the basis of their past condom use behaviors with regular clients and non-paying partners. Prior inconsistent condom use with occasional clients was independently associated with current perception of high HIV risk (adjusted odds ratio [aOR)] = 2.1, 95% confidence interval [CI]: 1.7-2.6). In contrast, prior inconsistent condom use with non-paying partners was associated with current perception of low HIV risk (aOR= 0.7, 95% CI: 0.5-0.9). The congruence between HIV risk perception and condom use with occasional clients was high: only 12% of FSWs reported inconsistent condom use with occasional clients but perceived themselves to be at low risk of acquiring HIV. CONCLUSION: The association between high risk perception of acquiring HIV and inconsistent condom use, especially with regular clients and non-paying partners, has not been completely internalized by this high risk group of mobile FSWs in India. Motivational efforts to prevent HIV should emphasize the importance of accurately assessing an individual's risk of acquiring HIV based on condom use behavior with all types of partners: occasional and regular clients as well as non-paying partners; and encourage behavior change based on an accurate self-assessment of HIV risk.

Devising a female sex work typology using data from Karnataka, India.

BACKGROUND: We examine the extent to which an existing sex work typology captures human immunodeficiency virus (HIV) risk in Karnataka and propose a systematic approach for devising evidence-based typologies. METHODS: The proposed approach has four stages: (i) identifying main places of solicitation and places of sex; (ii) constructing possible typologies based on either or both of these criteria; (iii) analysing variations in indicators of risk, such as HIV/sexually transmitted infection (STI) prevalence and client volume, across the categories of the typologies; and (iv) identifying the simplest typology that captures the risk variation experienced by female sex workers (FSWs) across different settings. Analysis is based on data from 2312 participants in integrated biological and behavioural assessments of FSWs conducted in Karnataka, India. Logistic regression was used to predict HIV/STI status (high-titre syphilis, gonorrhea or chlamydia) and linear regression to predict client volume. RESULTS: Our analysis suggests that the most appropriate typology in Karnataka consists of the following categories: brothel to brothel (i.e. solicit and have sex in brothels) (11% of sampled FSWs); home to home (32%), street to home (11%), street to rented room (9%), street to lodge (22%), street to street (9%) and other FSWs (8%). Street to lodge FSWs had high HIV (30%) and STI prevalence (27%), followed by brothel to brothel FSWs (34 and 13%, respectively). CONCLUSIONS: The proposed typology identifies street to lodge FSWs as being at particularly high risk, which was obscured by the existing typology that distinguishes between FSWs based on place of solicitation alone.

Assessing HIV risk in workplaces for prioritizing HIV preventive interventions in Karnataka State, India.

OBJECTIVE: To develop a model for prioritizing economic sectors for HIV preventive intervention programs in the workplace. METHODS: This study was undertaken in Karnataka state, India. A 3-stage survey process was undertaken. In the first stage, we reviewed secondary data available from various government departments, identified industries in the private sector with large workforces, and mapped their geographical distribution. In the second stage, an initial rapid risk assessment of industrial sectors was undertaken, using key-informant interviews conducted in relation to a number of enterprises, and in consultation with stakeholders. In the third stage, we used both quantitative (polling booth survey) and qualitative methods (key informant interviews, in-depth interviews, focus group discussions) to study high-risk sectors in-depth, and assessed the need and feasibility of HIV workplace intervention programs. RESULTS: The highest risk sectors were found to be mining, garment/textile, sugar, construction/infrastructure, and fishing industries. Workers in all sectors had at best partial knowledge about HIV/AIDS, coupled with common misconceptions about HIV transmission. There were intersector and intrasector variations in risk and vulnerability across different geographical locations and across different categories of workers. This has implications for the design and implementation of workplace intervention programs. CONCLUSIONS: There is tremendous scope for HIV preventive interventions in workplaces in India. Given the variation in HIV risk across economic sectors and limited available resources, there will be increased pressure to prioritize intervention efforts towards high-risk sectors. This study offers a model for rapidly assessing the risk level of economic sectors for HIV intervention programs.