Prevalence and Social-Structural Correlates of Gender-Based Violence Against Women Living With HIV in Metro Vancouver, Canada.

Violence experienced by cisgender (cis) and gender minority women living with HIV is known to be high. More work is needed to better understand how to support women living with HIV who have experienced violence. The objectives of this study are therefore to identify the prevalence and correlates of violence by any perpetrator among women living with HIV in a Canadian setting. Data were drawn from 9 years (January, 2010 to February, 2019) of a longitudinal community-based open cohort study of 350+ cis and trans women living with HIV who were living and/or accessed care in Metro Vancouver, Canada (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment "SHAWNA"). Participants completed baseline and biannual follow-up interviews. Bivariate and multivariable logistic regression with generalized estimating equations (GEE) were performed to identify correlates of recent (last 6 months) violence (physical and/or sexual) by any perpetrator. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CIs) are presented. At baseline, prevalence of violence was high: 95.5% (recent = 19.4%) of participants reported lifetime physical and/or sexual violence, 94.8% (recent = 17.9%) reported lifetime physical violence, and 84.5% (recent = 5.7%) reported lifetime sexual violence. In multivariable logistic regression with GEE, the following variables were associated with higher odds of recent physical/sexual violence: youth (<30 years) (AOR: 1.60, 95% CI [1.15, 2.22]), recent unstable housing/homelessness (AOR: 1.96, 95% CI [1.30, 2.97]), recent food insecurity (AOR: 1.57, 95% CI [1.13, 2.17]), recent incarceration (AOR: 1.85, 95% CI [1.18, 2.91]), recent opioid use (AOR: 1.38, 95% CI [1.04, 1.82]), recent stimulant use (AOR: 2.48, 95% CI [1.72, 3.56]), and lifetime HIV status disclosure without consent (AOR: 1.59, 95% CI [1.13, 2.24]). Trauma- and violence-informed (TVI) policies that include a focus on confidentiality and safe disclosure practices should be integrated into existing housing, incarceration, and harm reduction programs, and HIV care and practice for women living with HIV. Programs and policies that address high levels of violence remain critical.

Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study.

ABSTRACT: This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.

Prevalence and Correlates of HIV Stigma Among Women Living with HIV in Metro Vancouver, Canada.

This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH.

Exploring pathways from violence and HIV disclosure without consent to depression, social support, and HIV medication self-efficacy among women living with HIV in Metro Vancouver, Canada.

We used path analysis to investigate complex pathways from HIV status disclosure without consent, physical/verbal violence and depression, social support, and HIV medication self-efficacy through mediators of HIV stigma among women living with HIV in Canada. In the final model, internalized stigma fully mediated the relationship between physical/verbal violence and reduced medication self-efficacy. Enacted stigma fully mediated the relationship between HIV status disclosure without consent and depression. Internalized stigma (ß = 0.252; p < 0.001) had a significant negative direct effect on medication self-efficacy. Enacted stigma had a significant direct effect on depression (ß = 0.162; p = 0.037). Findings will help improve services and interventions to promote quality of life and well-being of women living with HIV.

Food Insecurity Increases HIV Risk Among Young Sex Workers in Metro Vancouver, Canada.

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010-2013). We examined the independent relationship between YSWs' food insecurity and being pressured into sex without a condom by clients ("client condom refusal"). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23-3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs' particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity.

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners.

BACKGROUND: Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada. METHODS: Baseline data (2010-2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]). RESULTS: Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53-11.66]) or non-cohabiting intimate partner (2.15[1.11-4.19]) (versus casual partner), providing drugs (3.04[1.47-6.30]) or financial support to an intimate partner (2.46[1.05-5.74]), physical intimate partner violence (2.20[1.17-4.12]), and an intimate partner providing physical safety (2.08[1.11-3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17-0.60]). CONCLUSIONS: Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.

Fertility intentions, power relations and condom use within intimate and other non-paying partnerships of women in sex work in Bagalkot District, South India.

This study aimed to: (1) examine the relationship between interpersonal as well as social-demographic, cultural and structural factors, and condom non-use by sex workers' main intimate or other non-paying male sex partners (NPPs), as reported by a sample of sex workers (SWs); and (2) understand HIV/sexually transmitted infections (STIs) risk (e.g., numbers of sexual partners; condom use with different partners) among couples comprised of a sub-set of SWs and their NPPs. Bivariate and multivariable logistic regression was used to identify factors associated with condom non-use at last sex by the main NPP, as reported by SWs. Adjusted odds ratios and 95% confidence intervals are reported (AOR[95%CIs]). Data were drawn from cross-sectional surveys in Bagalkot District, Karnataka State, South India. Responses by SWs whose main NPPs agreed to enrol in the study and the main NPP enroled were linked; these responses by couples (pairs of SWs and NPPs) were examined to assess sexual risk for HIV/STIs. Overall, this study included 257 SWs and 76 NPPs. The data from 67 couples (88.2%) could be linked. In over a quarter of partnerships, at least one (SW or NPP) partner reported having another type of partner besides each other (and clients of SWs). In multivariable analysis, significantly increased odds of condom non-use at last sex with the main NPP were found for the following key factors: planning to have a child with their main NPP (AOR = 3.71[1.44-9.58]); and having decisions about condom use made by their main NPP (AOR = 9.87[4.03-24.16]) or both equally (AOR = 3.18[1.39-7.80]) (versus by the SWs herself). Our study highlights the potential risk for HIV/STI acquisition and transmission between NPPs and SWs, and between NPPs and their non-SWs wives and other sex partners. Study results underscore the need for HIV/STI prevention approaches that incorporate informed decision-making about childbearing and parenting, and empowerment strategies for SWs in the context of their relationships with NPPs.

Sexual relationship power and intimate partner violence among sex workers with non-commercial intimate partners in a Canadian setting.

There is little information on the private lives of women engaged in sex work, particularly how power dynamics within intimate relationships may affect intimate partner violence (IPV). Using baseline data of sex workers enrolled in a longitudinal cohort, "An Evaluation of Sex Workers' Health Access" (AESHA), the present study examined the association between sexual relationship power and IPV among sex workers in non-commercial partnerships in Vancouver, Canada. Pulweritz's Sexual Relationship Power Scale (SRPS) and The World Health Organization (WHO) Intimate Partner Violence against Women Scale (Version9.9) were used. Bivariable and multivariable logistic regression techniques were used to investigate the potential confounding effect of sexual relationship power on IPV among sex workers. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were reported. Of 510 sex workers, 257 (50.4%) reported having an non-commercial intimate partner and were included in this analysis. In the past 6 months, 84 (32.7%) sex workers reported IPV (physical, sexual or emotional). The median age was 32 years, 39.3% were of Aboriginal ancestry, and 27.6% were migrants. After controlling for known confounders (e.g., age, Aboriginal ancestry, migrant status, childhood trauma, non-injection drug use), low relationship power was independently associated with 4.19 increased odds (95% CI: 1.93-9.10) and medium relationship power was associated 1.95 increased odds (95% CI: 0.89-4.25) of IPV. This analysis highlights how reduced control over sexual-decision making is plays a critical role in IPV among sex workers, and calls for innovation and inclusive programming tailored to sex workers and their non-commercial intimate partnerships.

Relationship between exposure to the Avahan intervention and levels of reported condom use among men who have sex with men in southern India.

BACKGROUND: The Avahan intervention promotes consistent (100%) condom use amongst men who have sex with men in southern India. We assessed how condom use varies with intervention exposure for men who have sex with men in Bangalore. METHODS: Self-reported condom use and intervention exposure data were derived from a cross-sectional survey. Consistent condom use and condom use at last sex act with all, main, and casual male sex partners were assessed. Binary and continuous variables reflecting intervention exposure (including contact(s) with intervention staff, receiving condoms and seeing condom demonstrations) were used. Multivariable logistic regression was employed to assess the relationship between condom use with each type of partner and each exposure variable independently, controlling for socio-demographic and behavioural factors associated with condom use or intervention exposure. RESULTS: Condom use with all partners was higher among those who had ever been contacted by, received condoms from, or seen a condom demonstration by intervention staff (adjusted odds ratio >2, p < 0.02 for all). Consistent condom use with all types of partner increased with the number of condom demonstrations seen in the last month (adjusted odds ratio = 2.1 per demonstration, p < 0.025), while condom use at last sex act with a casual (but not main) partner increased with the number of condoms received from the intervention (adjusted odds ratio = 1.4 per condom, p = 0.04). CONCLUSIONS: Direct contact with Avahan program staff is associated with increased reported condom use among men who have sex with men in Bangalore. Reported consistent condom use and condom use at last sex act are associated with contacts involving demonstrations of correct condom use, and with receiving condoms, respectively.

High prevalence and partner correlates of physical and sexual violence by intimate partners among street and off-street sex workers.

OBJECTIVES: Intimate partner violence (IPV) is associated with increased risk of HIV among women globally. There is limited evidence and understanding about IPV and potential HIV risk pathways among sex workers (SWs). This study aims to longitudinally evaluate prevalence and correlates of IPV among street and off-street SWs over two-years follow-up. METHODS: Longitudinal data were drawn from an open prospective cohort, AESHA (An Evaluation of Sex Workers Health Access) in Metro Vancouver, Canada (2010-2012). Prevalence of physical and sexual IPV was measured using the WHO standardized IPV scale (version 9.9). Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine interpersonal and structural correlates of IPV over two years. RESULTS: At baseline, 387 SWs had a male, intimate sexual partner and were eligible for this analysis. One-fifth (n = 83, 21.5%) experienced recent physical/sexual IPV at baseline and 26.2% over two-years follow-up. In multivariable GEE analysis, factors independently correlated with physical/sexual IPV in the last six months include: childhood (<18 years) sexual/physical abuse (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [CI]: 1.14-3.69), inconsistent condom use for vaginal and/or anal sex with intimate partner (AOR = 1.84, 95% CI: 1.07-3.16),

A systematic review of the correlates of violence against sex workers.

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally. We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32% to 55%. Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks. This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical.

Piloting a 'spatial isolation' index: the built environment and sexual and drug use risks to sex workers.

BACKGROUND: Employing innovative mapping and spatial analyses of individual and neighbourhood environment data, we examined the social, physical and structural features of overlapping street-based sex work and drug scenes and explored the utility of a 'spatial isolation index' in explaining exchanging sex for drugs and exchanging sex while high. METHODS: Analyses drew on baseline interview and geographic data (January 2010-October 2011) from a large prospective cohort of street and off-street sex workers (SWs) in Metropolitan Vancouver and external publically-available, neighbourhood environment data. An index measuring 'spatial isolation' was developed from seven indicators measuring features of the built environment within 50m buffers (e.g., industrial or commercial zoning, lighting) surrounding sex work environments. Bivariate and multivariable logistic regression was used to examine associations between the two outcomes (exchanged sex for drugs; exchanged sex while high) and the index, as well as each individual indicator. RESULTS: Of 510 SWs, 328 worked in street-based/outdoor environments (e.g., streets, parks, alleys) and were included in the analyses. In multivariable analysis, increased spatial isolation surrounding street-based/outdoor SWs' main places of servicing clients as measured with the index was significantly associated with exchanging sex for drugs. Exchanging sex for drugs was also significantly positively associated with an indicator of the built environment suggesting greater spatial isolation (increased percent of parks) and negatively associated with those suggesting decreased spatial isolation (increased percent commercial areas, increased count of lighting, increased building footprint). Exchanging sex while high was negatively associated with increased percent of commercial zones but this association was removed when adjusting for police harassment. CONCLUSIONS: The results from our exploratory study highlight how built environment shapes risks within overlapping street-based sex work and drug scenes through the development of a novel index comprised of multiple indicators of the built environment available through publicly available data, This study informs the important role that spatially-oriented responses, such as safer-environment interventions, and structural responses, such as decriminalization of sex work can play in improving the health, safety and well-being of SWs.

HIV infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed.

PURPOSE OF REVIEW: This article reviews the current state of the epidemiological literature on female sex work and HIV from the past 18 months. We offer a conceptual framework for structural HIV determinants and sex work that unpacks intersecting structural, interpersonal, and individual biological and behavioural factors. RECENT FINDINGS: Our review suggests that despite the heavy HIV burden among female sex workers (FSWs) globally, data on the structural determinants shaping HIV transmission dynamics have only begun to emerge. Emerging research suggests that factors operating at macrostructural (e.g., migration, stigma, criminalized laws), community organization (e.g., empowerment) and work environment levels (e.g., violence, policing, access to condoms HIV testing, HAART) act dynamically with interpersonal (e.g., dyad factors, sexual networks) and individual biological and behavioural factors to confer risks or protections for HIV transmission in female sex work. SUMMARY: Future research should be guided by a Structural HIV Determinants Framework to better elucidate the complex and iterative effects of structural determinants with interpersonal and individual biological and behavioural factors on HIV transmission pathways among FSWs, and meet critical gaps in optimal access to HIV prevention, treatment, and care for FSWs globally.

A cross-sectional study of sexually transmitted pathogen prevalence and condom use with commercial and noncommercial sex partners among clients of female sex workers in southern India.

BACKGROUND: Clients of female sex workers (FSWs) are an important bridging population for HIV and other sexually transmitted infections. However, the extent of risk to female noncommercial partners (NCPs) of clients has not been explored. METHODS: Data originated from a cross-sectional behavioral and biological survey of FSW clients from 5 districts in Karnataka state, southern India. Clients were classified into 3 groups: married, single with at least 1 NCP, and single without an NCP. Bivariate and multivariable logistic regression models were constructed to examine the association between group membership and condom use patterns with FSWs and, where applicable, NCPs. HIV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections were examined. Normalized weights were used to account for a complex sampling design. RESULTS: Most respondents in our sample (n = 2328) were married (61%). Compared with single respondents without an NCP, married clients were more likely to never use condoms with both occasional (adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.3-2.5; P < 0.0001) and regular (AOR, 1.7; 95% CI, 1.1-2.6; P = 0.015) FSWs. Among clients with an NCP, married clients were at higher odds of never using a condom with their NCP (AOR, 5.5; 95% CI, 3.7-8.1; P < 0.0001). Overall prevalence for HIV, HSV-2, syphilis, and chlamydia or gonorrhea infection was 5.7%, 28.3%, 3.6%, and 2.1%, respectively. The prevalence of HSV-2 was 37%, 16%, and 19% among those who were married, those single without an NCP, and those single with an NCP, respectively. CONCLUSIONS: Married respondents were least likely to use condoms with both commercial and noncommercial sexual partners, while also having the highest prevalence of HSV-2. These results illustrate the risk posed to both commercial partners and NCPs of married clients.

Client demands for unsafe sex: the socioeconomic risk environment for HIV among street and off-street sex workers.

OBJECTIVE: Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients' demand for sex without a condom. DESIGN: Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs. METHODS: A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money. RESULTS: The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places). CONCLUSIONS: These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

Positive impact of a large-scale HIV prevention programme among female sex workers and clients in South India.

OBJECTIVE: Estimate the potential impact of Avahan, the India AIDS Initiative, among female sex workers (FSWs) and their clients in five districts of Karnataka state, south India. DESIGN: Examination of time trends in sexually transmitted infection (STI)/HIV prevalence from serial cross-sectional surveys, combined with mathematical modelling. METHODS: Survey data from each district were used to monitor changes in FSW STI/HIV prevalence during Avahan. A deterministic model, parameterized with district-specific survey data, was used to simulate HIV/HSV-2/syphilis transmission among high-risk groups in each district. Latin hypercube sampling was used to obtain multiple parameter sets that reproduced district-specific HIV prevalence trends. A Bayesian framework tested whether self-reported increases in consistent condom use (CCU) during Avahan were more compatible with FSW HIV prevalence trends than assuming no or slow (preintervention rates) CCU increases, and were used to estimate HIV incidence and infections averted. RESULTS: Declines in FSW HIV prevalence occurred over 5 years in all districts, and were statistically significant in three. Self-reported increases in CCU were more consistent with observed declines in HIV prevalence in three districts. In all five districts, an estimated 25-64% (32-70%) HIV infections were averted among FSWs (clients) over 5 years. This corresponded to 142-2092 FSW infections averted depending on the district (two-fold to nine-fold more among clients). CONCLUSION: Empirical HIV prevalence trends combined with Bayesian modelling have provided plausible evidence that Avahan has reduced HIV transmission among FSWs and their clients. If current CCU levels are sustained, FSW HIV prevalence could decline to low levels by 2015, with many more infections averted.

Violence and HIV risk among female sex workers in Southern India.

BACKGROUND: This study characterized the type and frequency of violence against female sex workers (FSWs) perpetrated by their clients and their main intimate or other nonpaying partner (NPP) and examined the relationship between violence and inconsistent condom use (ICU, G100%). The factors associated with client violence were also assessed. METHODS: Data were analyzed from cross-sectional surveys of FSWs in Karnataka state (2007-2008), India. Multivariable logistic regression was used to assess the following: (1) relationship between client or NPP violence (physical and/or sexual) and ICU by occasional/repeat clients or the NPP and (2) relationship between social and environmental factors and client violence. RESULTS: Of 1219 FSWs, 9.6% (111) and 3.7% (42) reported experiencing violence by clients and the NPP, respectively. In multivariable analysis, after adjusting for social and environmental factors, the odds of ICU by occasional clients were significantly higher for women who had experienced client violence (adjusted odds ratio [AOR], 2.7; 95% confidence interval (CI), 1.6-4.4). Similar results were found with repeat clients (AOR, 2.2; 95% CI, 1.4-3.4). Nonpaying partner violence was not significantly associated with ICU by the NPP. In multivariable analysis, only being recently arrested remained significantly associated with experiencing client violence (AOR, 1.8; 95% CIs, 1.0-3.3). CONCLUSIONS: The findings from this study provide evidence of a relationship between experiencing client violence and ICU by occasional and repeat clients, and a relationship between being arrested and client violence. Comprehensive structural/policy programming for FSWs, including within HIV-focused prevention programs, is urgently needed to help reduce FSWs' vulnerability to violence

Differences between seven measures of self-reported numbers of clients of female sex workers in southern India: implications for individual- and population-level analysis.

Quantifying sexual activity of sub-populations with high-risk sexual behaviour is important in understanding HIV epidemiology. This study examined inconsistency of seven outcomes measuring self-reported clients per month (CPM) of female sex workers (FSWs) in southern India and implications for individual/population-level analysis. Multivariate negative binomial regression was used to compare key social/environmental factors associated with each outcome. A transmission dynamics model was used to assess the impact of differences between outcomes on population-level FSW/client HIV prevalence. Outcomes based on 'clients per last working day' produced lower estimates than those based on 'clients per typical day'. Although the outcomes were strongly correlated, their averages differed by approximately two-fold (range 39.0-79.1 CPM). The CPM measure chosen did not greatly influence standard epidemiological 'risk factor' analysis. Differences across outcomes influenced HIV prevalence predictions. Due to this uncertainty, we recommend basing population-based estimates on the range of outcomes, particularly when assessing the impact of interventions.

Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis.

BACKGROUND: Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall effectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention. METHODS: We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the first 4 years (2004-07 or 2005-08 dependent on the district) and the full 10 years (2004-13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the effectiveness estimates. Using regression analysis, we extrapolated the prevention effect in the districts covered by IBBAs to all 69 Avahan districts. FINDINGS: In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32700 HIV infections (95% credibility interval 17900-61600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62800 (32000-118000) averted infections, and extrapolation suggested that 202000 (98300-407000) infections were averted across all 69 Avahan districts in South India, increasing to 606000 (290000-1 193000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted. INTERPRETATION: This is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives. FUNDING: Bill & Melinda Gates Foundation.

Factors associated with sexual violence against men who have sex with men and transgendered individuals in Karnataka, India.

OBJECTIVES: There is a lack of information on sexual violence (SV) among men who have sex with men and transgendered individuals (MSM-T) in southern India. As SV has been associated with HIV vulnerability, this study examined health related behaviours and practices associated with SV among MSM-T. DESIGN: Data were from cross-sectional surveys from four districts in Karnataka, India. METHODS: Multivariable logistic regression models were constructed to examine factors related to SV. Multivariable negative binomial regression models examined the association between physician visits and SV. RESULTS: A total of 543 MSM-T were included in the study. Prevalence of SV was 18% in the past year. HIV prevalence among those reporting SV was 20%, compared to 12% among those not reporting SV (p = .104). In multivariable models, and among sex workers, those reporting SV were more likely to report anal sex with 5+ casual sex partners in the past week (AOR: 4.1; 95%CI: 1.2-14.3, p = .029). Increased physician visits among those reporting SV was reported only for those involved in sex work (ARR: 1.7; 95%CI: 1.1-2.7, p = .012). CONCLUSIONS: These results demonstrate high levels of SV among MSM-T populations, highlighting the importance of integrating interventions to reduce violence as part of HIV prevention programs and health services.