Targeted interventions of the Avahan program and their association with intermediate outcomes among female sex workers in Maharashtra, India

<p>Abstract</p> <p>Background</p> <p>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.</p> <p>Methods</p> <p>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).</p> <p>Results</p> <p>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].</p> <p>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.</p> <p>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.</p> <p>Conclusion</p> <p>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.</p

Assessment of the population-level eff ectiveness 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 eff ectiveness 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 fi rst 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 eff ectiveness estimates. Using regression analysis, we extrapolated the prevention eff ect 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 32 700 HIV infections (95% credibility interval 17 900–61 600) were averted over the fi rst 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 62 800 (32 000–118 000) averted infections, and extrapolation suggested that 202 000 (98 300–407 000) infections were averted across all 69 Avahan districts in South India, increasing to 606 000 (290 000–1 193 000) over 10 years. Over the fi rst 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted. Interpretation This is the fi rst 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 fi ndings suggest that substantial preventive eff ects can be achieved by targeted behavioural HIV prevention initiatives

Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention.

INTRODUCTION: Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs. METHODS: Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS. RESULTS: Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%-12.6%). Typology (AOR 2.20, 95% CI 1.64-2.95) and literacy (AOR 1.28, 95% CI 1.10-1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44-1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47-2.15), alcohol consumption (AOR 1.21, 95% CI 1.03-1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28-1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25-1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13-1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS. CONCLUSION: Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed

Female sex worker\u27s participation in the community mobilization process: Two distinct forms of participations and associated contextual factors

Background: Community mobilization is a participatory intervention strategy used among Female Sex Workers (FSW\u27s) to address HIV risks through behavior change and self empowerment. This study quantitatively measure and differentiate theoretically defined forms of FSW participation\u27s and identify their contextual associated factors. Method: Data was derived from cross-sectional Integrated Bio Behavioral Assessment conducted among FSW’s in Andhra Pradesh (AP) (n = 3370), Maharashtra (MH) (n = 3133) and Tamil Nadu (TN) (n = 2140) of India during 2009–2010. Information’s about socio-demography, community mobilization and participation experiences were collected. Conceptual model for two contexts of mobilization entailing distinct FSW participations were defined as participation in “collective” and “public” spaces respectively. Bivariate and multiple regression analysis were used. Result: The level of participation in “collective” and “public” spaces was lowest in MH (43.9% & 11.7% respectively), higher in TN (82.2% & 22.5% respectively) and AP (64.7% & 33.1%). Bivariate and multivariate regression analysis highlighted the distinct nature of “participations” through their varied associations with FSW mobilization and background status. | In MH, street FSWs showed significantly lower collective participation (36.5%) than brothel FSWs (46.8%) and street FSWs showed higher public participation (16.2%) than brothel FSWs (9.7%). In AP both collective and public participation were significantly high among street FSWs (62.7% and 34.7% respectively) than brothel FSW’s (55.2% and 25.4% respectively). | Regression analysis showed FSWs with “community identity”, were more likely to participate in public spaces in TN and AP (AOR 2.4, 1.5-3.8 & AOR 4.9, CI 2.3-10.7) respectively. FSWs with “collective identity” were more likely to participate in collective spaces in TN, MH and AP (AOR 27.2 CI 13.7-53.9; AOR 7.3, CI 3.8-14.3; AOR 5.7 CI 3–10.9 respectively). FSWs exhibiting “collective agency” were more likely to participate in public spaces in TN, MH and AP (AOR 2.3 CI 1–3.4; AOR 4.5- CI 2.6-7.8; AOR 2.2 CI 1.5-3.1) respectively. Conclusion: Findings reveal FSWs participation as a dynamic process inherently evolving along with the community mobilization process in match with its contexts. Participation in “Collective” and Public spaces” is indicators, symbolizing FSWs passage from the disease prevention objectives towards empowerment, which would help better understand and evaluate community mobilization interventions

Self-report of STI symptoms, inconsistent condom use and condom non-use are poor predictors of STI prevalence among men who have sex with men

Background: Biological testing for sexually transmitted infections (STI) are challenged by sample collection and high testing costs, where self-reports are used in predicting STI status. The validity of self-reports among populations at STI risk has not been established clearly. The objective of this paper is to assess the validity of self-reported ‘STI symptoms’, self-reported ‘recent condom non- use’ and ‘inconsistent condom use’ in comparison with laboratory diagnosed STIs among men who have sex with men (MSM) in India. Methods: Data were drawn from a cross sectional Integrated Behavioural and Biological Assessment survey conducted among MSM between 2005–2007 in India. Sensitivity analysis was used to assess the validity of self-reported ‘STI symptoms’, ‘recent condom non-use’ and ‘inconsistent condom use’ with laboratory diagnosed STIs (syphilis/Neisseria gonorrhoeae/ Chlamydia trachomatis). Multiple logistic regressions were used to identify population characteristics which were predictive of concordant self-reporting. Results: Of 3895 MSM surveyed, 14.3% were diagnosed with any STI while 8.3% and 3% reported any STI symptom in past and current respectively. Recent condom non-use and inconsistent condom use was reported by 43.1% and 77.6% of respondents. Self-reported STI symptoms showed very low sensitivity (5–13) in predicting laboratory diagnosis of STIs. Self-reported inconsistent condom use and recent condom non-use showed higher sensitivity than self-reported STI symptoms (50–74.4), but were less specific (21–52.9). Combined self reports showed relatively higher sensitivity (52.3–77.9) and low specificity (18.9–51.8). Overall self reports showed very high negative predictive value (84.4–87.9) and low positive predictive value (12.4–15.7). Education grade more than 12 [AOR: 3.2 (CI 1.7–5.9)], and STI/HIV information exposure [AOR: 1.4 (CI 1.0–2.0)] were predictive of concordant self-reporting of STI symptoms and inconsistent condom use respectively. Knowledge about STIs [AOR: 1.4 (CI 0.9–2.2)] and education grade more than 12 [AOR: 2.5 (CI 1.2–5.3)] were predictive of concordant self-reporting of symptoms/risk. Conclusions: Self-reports of STI symptoms, recent condom non-use and inconsistent condom use were not reliable in predicting true STI status of MSM and thus highlights the limitations in the validity of self-reports collected at different levels in the program setting. The study identified MSM education status, STI/HIV knowledge and information exposure, as predictors of concordant self-reporting of ‘symptoms’ and ‘inconsistent condom use’ with STI laboratory diagnosis, which could be utilized in future survey efforts for improving validity of self-reports

Bivariate and multivariate analysis for heterosexual anal sex: (logistic regression model using global weights).

<p>*OR-Odds Ratio; AOR-Adjusted Odds Ratio (Adjusted for literacy and years at sex work).</p>#<p>Denominators will change as per the distribution of missing data/non-responses for anal sex in categories. Percentages are calculated taking the appropriate denominator.</p

FSWs Heterosexual Anal Sex & condom used at last anal sex.

<p>FSWs Heterosexual Anal Sex & condom used at last anal sex.</p

Laboratory confirmed prevalence of STI.

<p>*of those who were tested.</p><p>HIV: Human Immunodeficiency Virus. RPR: Rapid Plasma Reagin for syphilis.</p><p>TPHA: Treponema pallidum HemoAgglutination confirmatory test for syphilis.</p><p>CT: Chlamydia trachomatis. NG: Neiserria gonorrhoea. HSV-2: Human Simplex Virus-2.</p