Determinants of condom breakage among female sex workers in Karnataka, India

<p>Abstract</p> <p>Background</p> <p>Condoms are effective in preventing the transmission of HIV and other sexually transmitted infections, when properly used. However, recent data from surveys of female sex workers (FSWs) in Karnataka in south India, suggest that condom breakage rates may be quite high. It is important therefore to quantify condom breakage rates, and examine what factors might precipitate condom breakage, so that programmers can identify those at risk, and develop appropriate interventions.</p> <p>Methods</p> <p>We explored determinants of reported condom breakage in the previous month among 1,928 female sex workers in four districts of Karnataka using data from cross-sectional surveys undertaken from July 2008 to February 2009. Using stepwise multivariate logistic regression, we examined the possible determinants of condom breakage, controlling for several independent variables including the district and client load.</p> <p>Results</p> <p>Overall, 11.4% of FSWs reported at least one condom break in the previous month. FSWs were much more likely to report breakage if under 20 years of age (AOR 3.43, p = 0.005); if divorced/ separated/widowed (AOR 1.52, p = 0.012); if they were regular alcohol users (AOR 1.63, p = 0.005); if they mostly entertained clients in lodges/rented rooms (AOR 2.99, p = 0.029) or brothels (AOR 4.77, p = 0.003), compared to street based sex workers; if they had ever had anal sex (AOR 2.03, p = 0.006); if the sex worker herself (as opposed to the client) applied the condom at last use (AOR 1.90, p < 0.001); if they were inconsistent condom users (AOR 2.77, p < 0.001); and if they had never seen a condom demonstration (AOR 2.37, p < 0.001).</p> <p>Conclusions</p> <p>The reported incidence of condom breakage was high in this study, and this is a major concern for HIV/STI prevention programs, for which condom use is a key prevention tool. Younger and more marginalized female sex workers were most vulnerable to condom breakage. Special effort is therefore required to seek out such women and to provide information and skills on correct condom use. More research is also needed on what specific situational parameters might be important in predisposing women to condom breakage.</p

Changes in HIV knowledge, and socio-cultural and sexual attitudes in South India from 2003-2009

<p>Abstract</p> <p>Background</p> <p>As communities face serious pressures on traditional values, such as those posed by HIV infection, cultural inertia may result, whereby existing trends towards more liberalized views of sexuality are stalled. We examined changes in attitudes around HIV in Bagalkot district, south India, between 2003 and 2009.</p> <p>Methods</p> <p>General population surveys were conducted in 2003 and 2009, among approximately 6,600 randomly sampled men and women in 10 villages and 20 urban blocks of Bagalkot. Questions about HIV knowledge, sexuality, gender and condoms were included. We compared responses in the two surveys using a multivariate logistic regression model.</p> <p>Results</p> <p>Awareness of HIV increased significantly from 76.9% in 2003 to 87.8% in 2009, and condom awareness increased significantly (37.4% to 65.4%) in all groups studied. However, in 2009, only 23% of people mentioned condoms as a means of prevention, an improvement from 8% in 2003 (adjusted odds ratio (AOR) 3.3; 95%CI 2.6-4.1, p <0.001). There was a significant increase in the number of women believing sex workers should be compulsorily tested for HIV (76.3%-86.4%%, AOR 1.8; 95%CI 1.4-2.4, p<0.001). An increasing number agreed that “it is wrong to talk about sex” (p=0.05), especially women (21.9% vs. 32.4%, p<0.01). There was an increase in women who thought it “wrong to talk about AIDS in a respectable family”, and more respondents in 2009 thought it improper to discuss condoms (15.6% vs. 27.4%, AOR 1.9, 95%CI 1.4-2.8, p=0.001). In 2003, 31.4% agreed that “access to condoms promotes promiscuity”, increasing to 45.2% in 2009 (AOR 1.7; 95%CI 1.3-2.3, p<0.001). Educated and young urban women were the most likely to believe this. In 2003, 19.3% and in 2009 30.2% (AOR 1.8, 95%CI 1.4-2.3, p<0.001) thought that sex education promotes sexual activity and promiscuity.</p> <p>Conclusions</p> <p>Despite increases over time in HIV-related knowledge and reductions in stigmatizing attitudes, resistance to changing cultural mores was apparent, with less willingness to embrace openness and discuss sexuality. Young and female respondents appeared to be the most resistant to change, reflecting a cultural inertia that mirrors studies of other pressures on traditional societal values. More effort is required to advocate among women and young people for healthy sexuality, openness and safe sex practices.</p

Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India

OBJECTIVES: To examine the impact of a large-scale HIV prevention programme for female sex workers (FSW) in Karnataka state, south India, on the prevalence of HIV/sexually transmitted infections (STI), condom use and programme coverage. METHODS: Baseline and follow-up integrated biological and behavioural surveys were conducted on random samples of FSW in five districts in Karnataka between 2004 and 2009. RESULTS: 4712 FSW participated in the study (baseline 2312; follow-up 2400), with follow-up surveys conducted 28-37 months after baseline. By follow-up, over 85% of FSW reported contact by a peer educator and having visited a project STI clinic. Compared with baseline, there were reductions in the prevalence of HIV (19.6% vs 16.4%, adjusted odds ratio (AOR) 0.81, 95% CI 0.67 to 0.99, p=0.04); high-titre syphilis (5.9% vs 3.4%, AOR 0.53, 95% CI 0.37 to 0.77, p=0.001); and chlamydia and/or gonorrhoea (8.9% vs 7.0%, AOR 0.72, 95% CI 0.54 to 0.94, p=0.02). Reported condom use at last sex increased significantly for repeat clients (66.1% vs 84.1%, AOR 1.98, 95% CI 1.58 to 2.48, p<0.001) and marginally for occasional clients (82.9% vs 88.0%, AOR 1.22, 95% CI 0.89 to 1.66, p=0.2), but remained stable for regular partners (32%). Compared with street and home-based FSW, brothel-based FSW were at highest risk of HIV and STI, despite high levels of reported condom use. CONCLUSIONS: This large-scale HIV prevention programme for FSW achieved reductions in HIV and STI prevalence, high rates of condom use with clients and high rates of programme coverage. Improved strategies to increase condom use with regular partners and reduce the vulnerability of brothel-based FSW to HIV are required

An integrated structural intervention to reduce vulnerability to HIV and sexually transmitted infections among female sex workers in Karnataka state, south India

BACKGROUND: Structural factors are known to affect individual risk and vulnerability to HIV. In the context of an HIV prevention programme for over 60,000 female sex workers (FSWs) in south India, we developed structural interventions involving policy makers, secondary stakeholders (police, government officials, lawyers, media) and primary stakeholders (FSWs themselves). The purpose of the interventions was to address context-specific factors (social inequity, violence and harassment, and stigma and discrimination) contributing to HIV vulnerability. We advocated with government authorities for HIV/AIDS as an economic, social and developmental issue, and solicited political leadership to embed HIV/AIDS issues throughout governmental programmes. We mobilised FSWs and appraised them of their legal rights, and worked with FSWs and people with HIV/AIDS to implement sensitization and awareness training for more than 175 government officials, 13,500 police and 950 journalists. METHODS: Standardised, routine programme monitoring indicators on service provision, service uptake, and community activities were collected monthly from 18 districts in Karnataka between 2007 and 2009. Daily tracking of news articles concerning HIV/AIDS and FSWs was undertaken manually in selected districts between 2005 and 2008. RESULTS: The HIV prevention programme is now operating at scale, with over 60,000 FSWs regularly contacted by peer educators, and over 17,000 FSWs accessing project services for sexually transmitted infections monthly. FSW membership in community-based organisations has increased from 8,000 to 37,000, and over 46,000 FSWs have now been referred for government-sponsored social entitlements. FSWs were supported to redress > 90% of the 4,600 reported incidents of violence and harassment reported between 2007-2009, and monitoring of news stories has shown a 50% increase in the number of positive media reports on HIV/AIDS and FSWs. CONCLUSIONS: Stigma, discrimination, violence, harassment and social equity issues are critical concerns of FSWs. This report demonstrates that it is possible to address these broader structural factors as part of large-scale HIV prevention programming. Although assessing the impact of the various components of a structural intervention on reducing HIV vulnerability is difficult, addressing the broader structural factors contributing to FSW vulnerability is critical to enable these vulnerable women to become sufficiently empowered to adopt the safer sexual behaviours which are required to respond effectively to the HIV epidemic

Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India

In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state government’s prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to accessing PPTCT services in the rural northern Karnataka district of Bagalkot using in depth interviews and focus group discussions with HIV-infected women who had participated in the PPTCT program, male and female family members, and HIV service providers. Participants discussed personal experiences, community perceptions of HIV, and decision-making related to accessing PPTCT services. They described stigma towards HIV-infected individuals from multiple sources: healthcare workers, community members, family and self. Stigma-related behaviors were based on fears of HIV transmission through personal contact and moral judgment. Experience and/or fears of discrimination led pregnant women to avoid using PPTCT interventions. Government, cultural and historical factors are described as the roots of much the stigma-related behavior in this setting. Based on these formative data, PPTCT program planners should consider further research and interventions aimed at diminishing institutional and interpersonal HIV-associated stigma experienced by pregnant women

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

Heterogeneity of the HIV epidemic in the general population of Karnataka state, south India

<p>Abstract</p> <p>Background</p> <p>In the context of <it>AVAHAN</it>, the India AIDS Initiative of the Bill & Melinda Gates Foundation, general population surveys (GPS) were carried out between 2006 and 2008 in Belgaum (northern), Bellary (mid-state) and Mysore (southern) districts of Karnataka state, south India. Data from these three surveys were analysed to understand heterogeneity in HIV risk.</p> <p>Methods</p> <p>Outcome variables were the prevalence of HIV and sexually transmitted infections (STIs). Independent variables included age, district, place of residence, along with socio-demographic, medical and behavioural characteristics. Multivariate logistic regression was undertaken to identify characteristics associated with HIV and differences between districts, incorporating survey statistics to consider weights and cluster effects.</p> <p>Results</p> <p>The participation rate was 79.0% for the interview and 72.5% for providing a blood or urine sample that was tested for HIV. Belgaum had the highest overall HIV (1.43%) and <it>Herpes simplex</it> type-2 (HSV-2) (16.93%) prevalence, and the lowest prevalence of curable STIs. In Belgaum, the HIV epidemic is predominantly rural, and among women. In Bellary, the epidemic is predominantly in urban areas and among men, and HIV prevalence was 1.18%. Mysore had the lowest prevalence of HIV (0.80%) and HSV-2 (10.89%) and the highest prevalence of curable STIs. Higher HIV prevalence among men was associated with increasing age (p<0.001), and with history of STIs (AOR=2.44,95%CI:1.15-5.17). Male circumcision was associated with lower HIV prevalence (AOR=0.33,95%CI:0.13-0.81). Higher HIV prevalence among women was associated with age (AOR_25-29years=11.22,95%CI:1.42-88.74, AOR_30-34years=13.13,95%CI:1.67-103.19 and AOR_35-39years=11.33,95%CI:1.32-96.83), having more than one lifetime sexual partner (AOR=4.61,95%CI:1.26-16.91) and having ever used a condom (AOR=3.32,95%CI:1.38-7.99). Having a dissolved marriage (being widowed/divorced/separated) was the strongest predictor (AOR=10.98,95%CI: 5.35-22.57) of HIV among women. Being a muslim woman was associated with lower HIV prevalence (AOR=0.27,95%CI:0.08-0.87).</p> <p>Conclusion</p> <p>The HIV epidemic in Karnataka shows considerable heterogeneity, and there appears to be an increasing gradient in HIV prevalence from south to north. The sex work structure in the northern districts may explain the higher prevalence of HIV in northern Karnataka. The higher prevalence of HIV and HSV-2 and lower prevalence of curable STIs in Belgaum suggests a later epidemic phase. Similarly, higher prevalence of curable STIs and lower HIV and HSV-2 prevalence in Mysore suggests an early phase epidemic.</p

Interim modelling analysis to validate reported increases in condom use and assess HIV infections averted among female sex workers and clients in southern India following a targeted HIV prevention programme.

OBJECTIVES: This study assesses whether the observed declines in HIV prevalence since the beginning of the 'Avahan' India HIV/AIDS prevention initiative are consistent with self-reported increases in condom use by female sex workers (FSWs) in two districts of southern India, and provides estimates of the fraction of new infections averted among FSWs and clients due to increases in condom use in commercial sex after 2004. METHODS: A deterministic compartmental model of HIV/sexually transmitted infection (STI) transmission incorporating heterogeneous sexual behaviour was developed, parameterised and fitted using data from two districts in Karnataka, India. Three hypotheses of condom use among FSWs were tested: (H(0)), that condom use increased in line with reported FSW survey data prior to the Avahan initiative but remained constant afterwards; (H(1)) that condom use increased following the Avahan initiative, in accordance with survey data; (H(2)) that condom use increased according to estimates derived from condom distribution data. The proportion of fits to HIV/STI prevalence data was examined to determine which hypothesis was most consistent. RESULTS: For Mysore 0/36/82.7 fits were identified per million parameter sets explored under hypothesis H(0)/H(1)/H(2), respectively, while for Belgaum 9.7/8.3/0 fits were identified. The HIV epidemics in Belgaum and Mysore are both declining. In Mysore, increases in condom use during commercial sex between 2004 and 2009 may have averted 31.2% to 47.4% of new HIV infections in FSWs, while in Belgaum it may have averted 24.8% to 43.2%, if there was an increase in condom use. DISCUSSION: Increased condom use following the Avahan intervention is likely to have played a role in curbing the HIV epidemic in Mysore. In Belgaum, given the limitations in available data, this method cannot be used alone to decide if there has been an increase in condom use