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Background: Targeted interventions (TIs) are one of the most effective strategies to control HIV/AIDS transmission, especially among the high-risk groups (HRGs). Implementation of HIV/AIDS control strategies relies heavily on estimation of the size of HRG population. Size estimation for key populations such as female sex workers (FSWs), men who have sex with men (MSM), and injecting drug users (IDUs) is a crucial component of national HIV strategic planning. Objective: The objective of this study was to estimate the size of FSWs, MSM, and IDUs in various states of India. Methods: The program multiplier method was used to estimate the size of FSWs, MSM, and IDUs across the country using two distinct but overlapping data sources – Integrated Bio-Behavioral Surveillance and TI program from the same geographical area at the same time period. Results: In India, as on 2018–2019, there were nearly 18.2 lakhs estimated FSWs accounting to 0.53% among female population aged 15–49 years, with a highest in West Bengal (4.5 lakhs); 5.7 lakhs estimated MSM accounting to 0.16% among male population aged 15–49 years, with a highest in Gujarat (0.7 lakh); and 3.9 lakhs estimated IDUs accounting to 0.11% among male population aged 15–49 years, with a highest in Uttar Pradesh (0.5 lakh). Conclusions: The current size estimates on HRGs will support the development of projections and estimations of the HIV epidemic at national and state levels. These estimates also help in framing national guidelines such as HIV strategic planning, program design, allocation of resources, prioritizing the interventions, and monitoring and evaluation.

Background Ending AIDS by 2030 is a global target, to which India is a signatory. HIV-self-test (HIVST) coupled with counselling and AIDS-care, including antiretroviral therapy, has the potential to achieve this. However, national programs are at varying stages of acceptance of HIVST, as discussions around its introduction spark controversy and debates. HIV-self-test, as yet, is not part of the AIDS control program in India. Against this backdrop, we explored acceptability of an HIV oral self-test (HIVOST) among truckers and young men and women. Methods A qualitative investigation with 41 in-depth-interviews and 15 group discussions were conducted in the district of Pune, in the western state of Maharashtra, India. These interactions were built around a prototype HIVOST kit, helped in taking the discussions forward. The software N-vivo (version 11.0) was used to manage the volumes of data generated through the aforementioned process. The study was conducted during June through December, 2019. Results While the truckers belonged to the age bracket 21–67 year, the youths were in the age group 18–24 year. ‘Ease of doing HIVOST’ and ‘fear of needle pricks’ were the reasons behind acceptance around HIVOST by both the study groups. Truckers felt that HIVOST would encourage one to know one’s HIV status and seek help as appropriate. Accuracy of HIVOST result and disposal of the kits following use were concerns of a few. Most of the participants preferred saliva over blood as the specimen of choice. Instructions in local language reportedly would enable test-use by self. The truck drivers preferred undertaking HIVOST at the truckers-friendly ‘Khushi clinics’ or in the vehicle, while youths preferred the privacy of home. Some of the young men mis-perceived the utility of HIVOST by referring to doing a test on a partner immediately prior to sexual encounter. On the other hand, a few truckers had wrong information on HIV cure. Conclusions Overall, the study communities expressed their acceptance towards HIV-self-test. The National AIDS Control Program, India would benefit by drawing upon the findings of the current investigation. Existing myths and misconceptions around HIV test and treatment require program attention.

Supplemental Digital Content is available in the text, HIV prevalence is higher among Men who have Sex with Men (MSM), owing to their unsafe sexual behavior. Further, MSM indulge in behaviors such as consumption of alcohol/oral drugs and/or injecting during/before sex that poses the risk of unsafe behaviors, thereby increasing their vulnerability to HIV. The study aims to analyze the factors associated with HIV infection among the multi-risk MSM using any substances with those MSM who do not use substances. Community-based cross-sectional survey design using probability-based sampling between October 2014 and November 2015. For the nation-wide Integrated Biological and Behavioral Surveillance (IBBS), 23,081 MSM were recruited from 4067 hotspots in 108 districts across India. Information on demographics, sexual behaviors, substance use, sexual partners, and awareness on HIV and its management was collected from the consented respondents using computer-assisted personal interview (CAPI) by trained personnel. Blood samples were tested for HIV. Statistical analyses were done, to study the associations between substance use and its influence on high-risk sexual behaviors and HIV infection. One in 3 MSM (33.88%) in India were substance users, thus exhibiting “multi-risk” (MR) behaviors. Significantly higher HIV prevalence (3.8%, P

Background: Long-distance truckers (LDTs) belong to a special sentinel group with potentially high risk of acquisition of HIV owing to their high mobility, sociodemographic vulnerability, and high-risk behaviors. Objective: The objective is to estimate the prevalence of HIV and identifies its sociodemographic correlates among a representative population of LDTs in West Bengal, India. Methods: Between May and July 2017, HIV Sentinel Surveillance (HSS) was conducted in West Bengal by the National AIDS Control Organization. A total of 749 LDTs were recruited for the study, were interviewed, and tested for HIV. Descriptive and logistic regression analysis of socio-demographics, sexual risk behavior, and HIV serostatus were performed using SAS 9.3.2. Results: The prevalence of HIV among LDT was 1.2% (95% confidence interval [CI] = 0.4–2.0). Mean age was 32.8 years (standard deviation 8.5), 77.1% were currently married, 89.9% were literate, 85.7% visited HSS site for collecting condoms or seeking medical care and treatment, 53.1% were rural residents, 86.7% had sex at least once with a female partner other than wife in the past 6 months, 2.7% had sex with a male partner and 1.7% injected drugs for recreational purpose. Higher age (odds ratio [OR] = 1.1 [95% CI = 1.0–1.1]), literate (OR = 0.3 [95% CI = 0.1–0.9]), visiting HSS sites for collecting condoms or seeking medical care and treatment (adjusted OR [AOR] = 0.2 [95% CI = 0.1–0.6]), rural residence (OR = 0.2 [95% CI = 0.1–0.3]) and duration of stay in home (AOR = 1.3 [95% CI = 1.1–1.5]) were found to be significant predictors of having sex with a female partner other than wife.Conclusion: High HIV burden calls for urgency in the implementation of targeted intervention to minimize HIV risk among LDTs in West Bengal to fight against HIV/AIDS.

Background: HIV/AIDS is a global public health issue and its transmission in a defined geographic region is influenced by the interplay of sociodemographic and behavioral factors. Better understanding of sociodemographic characteristics of HIV-positive individuals is required to prevent the spread of HIV among the general population. Objectives: The objective of the study was to find the association between HIV prevalence and sociodemographic characteristics of pregnant women aged 15–49 years attending the antenatal clinics (ANCs) in six Southern states of India. Methods: The data from the latest round of HIV sentinel surveillance, a cross-sectional study, conducted during January–March 2017 among ANC attendees were considered for this analysis. Blood samples along with other relevant information were collected from 98,634 pregnant women from 248 sites across the states. The association between HIV prevalence and sociodemographic variables was examined using multivariable logistic regression. Results: The highest HIV prevalence was reported in Karnataka (0.38%) and Andhra Pradesh (0.38%), followed by Telangana (0.33%), Odisha (0.28%), Tamil Nadu (0.27%), and Kerala (0.05%). In all states, the prevalence was highest among illiterate pregnant women exception being Kerala, wherein the prevalence was highest in pregnant women with schooling up to primary education. A significant association was found between HIV prevalence and spouse occupation in Karnataka and Odisha and spouse migration in Andhra Pradesh and Karnataka. Conclusions: Need for improvising the interventions for the young, illiterates, having a migrant spouse, and spouse occupation as truckers/hotel staff is recommended to the stakeholders involved in HIV management of the six southern states of India.

Background Key populations, including female sex workers (FSWs), are at a disproportionately high risk for HIV infection. Estimates of the size of these populations serve as denominator data to inform HIV prevention and treatment programming and are necessary for the equitable allocation of limited public health resources. Objective This study aimed to present the respondent-driven sampling (RDS) adjusted reverse tracking method (RTM; RadR), a novel population size estimation approach that combines venue mapping data with RDS data to estimate the population size, adjusted for double counting and nonattendance biases. Methods We used data from a 2014 RDS survey of FSWs in Windhoek and Katima Mulilo, Namibia, to demonstrate the RadR method. Information from venue mapping and enumeration from the survey formative assessment phase were combined with survey-based venue-inquiry questions to estimate population size, adjusting for double counting, and FSWs who do not attend venues. RadR estimates were compared with the official population size estimates, published by the Namibian Ministry of Health and Social Services (MoHSS), and with the unadjusted RTM. Results Using the RadR method, we estimated 1552 (95% simulation interval, SI, 1101-2387) FSWs in Windhoek and 453 (95% SI: 336-656) FSWs in Katima Mulilo. These estimates were slightly more conservative than the MoHSS estimates-Windhoek: 3000 (1800-3400); Katima Mulilo: 800 (380-2000)-though not statistically different. We also found 75 additional venues in Windhoek and 59 additional venues in Katima Mulilo identified by RDS participants' responses that were not detected during the initial mapping exercise. Conclusions The RadR estimates were comparable with official estimates from the MoHSS. The RadR method is easily integrated into RDS studies, producing plausible population size estimates, and can also validate and update key population maps for outreach and venue-based sampling.

BACKGROUND Key populations, including female sex workers (FSWs), are at a disproportionately high risk for HIV infection. Estimates of the size of these populations serve as denominator data to inform HIV prevention and treatment programming and are necessary for the equitable allocation of limited public health resources. OBJECTIVE This study aimed to present the respondent-driven sampling (RDS) adjusted reverse tracking method (RTM; RadR), a novel population size estimation approach that combines venue mapping data with RDS data to estimate the population size, adjusted for double counting and nonattendance biases. METHODS We used data from a 2014 RDS survey of FSWs in Windhoek and Katima Mulilo, Namibia, to demonstrate the RadR method. Information from venue mapping and enumeration from the survey formative assessment phase were combined with survey-based venue-inquiry questions to estimate population size, adjusting for double counting, and FSWs who do not attend venues. RadR estimates were compared with the official population size estimates, published by the Namibian Ministry of Health and Social Services (MoHSS), and with the unadjusted RTM. RESULTS Using the RadR method, we estimated 1552 (95% simulation interval, SI, 1101-2387) FSWs in Windhoek and 453 (95% SI: 336-656) FSWs in Katima Mulilo. These estimates were slightly more conservative than the MoHSS estimates—Windhoek: 3000 (1800-3400); Katima Mulilo: 800 (380-2000)—though not statistically different. We also found 75 additional venues in Windhoek and 59 additional venues in Katima Mulilo identified by RDS participants’ responses that were not detected during the initial mapping exercise. CONCLUSIONS The RadR estimates were comparable with official estimates from the MoHSS. The RadR method is easily integrated into RDS studies, producing plausible population size estimates, and can also validate and update key population maps for outreach and venue-based sampling.

Papers on the HIV epidemic in India published under the programme. (DOCX 37 kb)

Summary 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 32 700 HIV infections (95% credibility interval 17 900–61 600) 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 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 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.

Background: ‘Condom’ is a stigmatized topic in India. Open discussion about its use and promotion are considered inappropriate. This study examines the association between exposure to public service announcements (PSA) around condoms and discussion, attitude and behavioral intentions about condom use among married men by their age and socio-economic status. Methods: A sub-sample of monogamous married men (N=2502) was obtained from 2009 BBC World Service Trust’s condom normalization survey among men in four high HIV prevalence states in India. The multiple logistic regression models were used to analyze the association of exposure to PSA around condoms with discussion, attitudes and behavioral intentions about condom and its usage. Result: More than half married men (55%) were younger (

The study was carried out to assess the factors associated with HIV seropositivity among female sex workers (FSWs) in Dimapur, Nagaland, a high HIV prevalence state of India. A total of 426 FSWs were recruited into the study using respondent driven sampling (RDS). Data on demographic characteristics, sexual and injecting risk behaviours were collected from them and were tested for HIV, Syphilis, Neisseria gonorrhoeae and Chlamydia trachomatis. RDS-weighted univariate and multivariate logistic regression analysis was performed to assess the factors associated with HIV seropositivity. Consistent condom use with regular and occasional sexual clients was 9% and 16.4%, respectively. About 25% of the participants ever used and 5.7% ever injected illicit drugs. RDS adjusted HIV prevalence was 11.6%. In the univariate analysis, factors associated with HIV were initiating sexual intercourse before the age of 15 years, ≥2 years duration of sex work, serving clients at lodge/hotel, positive test result for one or more sexually transmitted infections (STIs), lifetime history of injecting drug use, lifetime history of consuming illicit drugs, ever having exchanged sex for drugs, having sexual partners who engaged in risky injecting practices and having been widowed or divorced. In multivariate analysis, factors found to be independently associated with HIV included lifetime injecting drug use, initiating sexual intercourse before the age of 15 years, positive test result for one or more STIs and having been widowed. Injecting drug use was found to be most potent independent risk factor for HIV (OR: 3.17, CI: 1.02-9.89). Because of lower consistent condom use among them, FSWs may act as bridge for HIV transmission to general population from injecting drug users (IDU) through their sexual clients. The informations from this study may be useful for enriching the HIV preventions effort for FSWs in this region.

Background Avahan, the India AIDS Initiative, is a large-scale targeted intervention. Data on condom use prior to Avahan are unavailable. The authors used a novel method of analysing cross-sectional survey data to ‘reconstruct’ condom use rates in presurvey years, and to assess the relationship between Avahan and time trends in condom use among female sex workers (FSWs). Methods Among FSWs reporting consistent condom use (CCU) with clients in surveys from 21 districts in southern India (n=7358), data on length of time using condoms, and length of time selling sex, were converted into number of FSWs using condoms (numerator) and selling sex (denominator) by year, to give yearly rates of CCU from 2001 to year of survey. Linear regression with generalised estimating equations was used to assess time trends and to compare the rate of increase in condom use before and after Avahan initiation in 2003. Results In all 21 districts, the rate of increase in CCU from 2001 to time of the surveys was highly significant. Overall CCU increased from 27% (22%) with occasional (regular) clients in 2001, to 76% (68%) in 2006, respectively. The yearly rate of increase in CCU was significantly greater after (slope 2003–2006: 12.7% (12.0%) per year for occasional (regular) clients) than prior to Avahan (slope 2001–2003: 5.1% (5.3%) per year for occasional (regular) clients) implementation (p

Objective Documenting the implementation of a public health programme as per its design is critical to interpretation of results from survey-led outcome and impact evaluation activities, the authors describe the scale-up and coverage of large-scale HIV-prevention services provided to female sex workers (FSWs) and high-risk men who have sex with men (HR-MSM) during the first 5 years of the Avahan programme in India. Methods Implementing NGO partner-generated denominator estimates from 70 districts were used to estimate the programme9s intended coverage. Routine programme-monitoring data until December 2008 were used to describe the service and commodity availability, service utilisation to generate internal estimates of coverage. Coverage was validated in few districts using data from a cross-sectional survey. Results In December 2008, the estimated denominators for intended services were about 217 000 FSWs and 80 000 HR-MSM. By January 2007, 79% of eventual total clinics and 75% drop-in centres were established, and 83% of eventual peer educators were active. By month 48, sufficient condoms to cover all estimated FSW commercial sex acts were distributed free. By month 60, 75% of the estimated denominator intended to be covered was met monthly. 86% of FSWs and 67% of HR-MSM ever contacted had used sexually transmitted infections services at least once. Cross-sectional survey generated coverage results suggest that programme-monitoring data provide a proxy to coverage of services. Conclusion Avahan9s monitoring data show that Avahan achieved infrastructure scale by year 3 and high contact coverage through peers and with commodities by year 5 of implementation as per the design.

Objective This paper evaluates Avahan programme9s coverage of female sex workers (FSWs), focus on high-risk FSWs and intermediate outcomes. Methods First round of cross-sectional survey data, Integrated Behavioral and Biological Assessments (IBBA), conducted in 22 districts, were aggregated into district categories: Solo, where Avahan was the sole service provider covering all FSWs and Major or Minor where Avahan was not the sole provider, but intended coverage was >50% or ≤ 50% of FSWs respectively. Multivariate logistic regression was applied to compare exposure by district categories, vulnerability factors and intermediate outcomes associated with exposure. Results Reported exposure, evaluated on basis of having received any of three core services, was higher in Solo (75%) compared with Minor (66%) districts. Logistic regression showed that FSWs in solo districts were more likely to be exposed (adjusted odds ratio (AOR)=1.5; 95% CI 1.20 to 1.86) compared with FSWs in Minor districts. Multivariate analysis in Solo districts revealed that FSW with ≥15 clients in the past week had a higher chance of being exposed to core services (AOR=1.56; 95% CI 1.03 to 2.35). Exposure to the three services in Solo Avahan districts was significantly associated with correct knowledge on condom use (AOR=1.36; 95% CI 1.05 to 1.78), consistent condom use with occasional clients (AOR=3.17; 95% CI 2.17 to 4.63) and regular clients (AOR=2.47; 95% CI 1.86 to 3.28) and STI treatment-seeking behaviour (AOR=3.00; 95% CI 1.94 to 4.65). Conclusions Higher coverage of FSWs was achieved in districts where Avahan was the only intervention compared with districts having multiple and longstanding non-Avahan programmes. Exposure in Solo districts was associated with intermediate outcomes; this need to be further evaluated in comparison with non Avahan areas and substantiated through data from next IBBA.

Background The HIV epidemic is very heterogeneous at the district level in the four Southern states of India most affected by the epidemic and where transmission is mainly heterosexual. The authors carried out an ecological study of the relationship between high-risk population parameters and HIV prevalence among pregnant women (ANC HIV prevalence). Methods The data used in this study included: ANC HIV prevalence available from the National AIDS Control Organization (dependent variable); data on prevalence of HIV and other sexually transmitted infections among female sex workers (FSWs), their clients and high-risk men who have sex with men (HR-MSM) from studies carried out in 24 districts under Avahan; data on clients' volume reported by FSWs and on the size estimates of FSWs and HR-MSM in each district; and census data. The latter two sets of data were used to estimate the percentage of female (male) adults who are FSWs (HR-MSM). The latter was also multiplied by HIV prevalence in FSWs (HR-MSM) to obtain the percentage of HIV-positive FSWs (HR-MSM) in the adult female (male) population. Linear regression was used for statistical analyses. Results In univariate analyses, HIV (r=0.59, p=0.002) and HSV-2 (r=0.49, p=0.014) prevalence among FSWs and mean number of clients in the last week reported by FSWs (r=0.43, p=0.036) were significant predictors of ANC HIV prevalence. In multivariate analysis, only FSW HIV prevalence remained significant. Conclusions This ecological study suggests that there is a link between HIV prevalence among FSWs and the spread of HIV to the general population in Southern India. Such an observation supports the rationale of interventions targeted at the sex industry.

OBJECTIVE: In four states in southern India we explored the determinants of HIV prevalence among female sex workers (FSW) as well as factors associated with district-level variations in HIV prevalence among FSW. METHODS: Data from cross-sectional surveys in 23 districts were analysed with HIV prevalence as the outcome variable and sociodemographic and sex work characteristics as predictor variables. Multilevel logistic regression was applied to identify factors that could explain variations in HIV prevalence among districts. RESULTS: HIV prevalence among the 10 096 FSW surveyed was 14.5% (95% confidence interval 14.0-15.4) with a large interdistrict variation ranging from 2% to 38%. Current marital status and the usual place of solicitation emerged as important factors that determine individual probability of being HIV positive as well as the HIV prevalence within districts. In multivariate analysis compared with home-based FSW the odds of being HIV positive was greater for brothel-based FSW [adjusted odds ratio (AOR) 2.17 P

Background: Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes. Objectives: This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning. Methods: The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework. Results: Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities. Conclusion: Rather than a small set of monofocal Outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution. (C) 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

To evaluate HIV/STI prevalence among female sex workers (FSWs) in Botswana, and assess HIV-related risk behaviors. Cross-sectional study using time-location sampling in three districts of Botswana. Adjusted HIV prevalence at district level ranged from 53.5 to 68.5 %. Syphilis prevalence ranged from 3.7 to 14.5 %; chlamydia prevalence ranged from 4.8 to 16.3 %; and gonorrhoea prevalence ranged from 8.3 to 11.7 %. FSWs had been practicing sex work for a mean of 4.7 years, and had a mean of 7.6 sex partners in the week before the survey. While 67.1 % of FSWs surveyed reported always using condoms with clients in the past month. 59.5 % reported one or more of the following: being paid more not to use a condom, having a condom break, or being forced not to use a condom by clients. Predictors of HIV infection in the multivariate analysis included: age (over 30 years), perceiving oneself to be at high risk of HIV, selling sex for 2 or more years, and having a mean of 11 or more partners in the last week. High HIV prevalence, high rates of partner exchange, a sizable population, and Inconsistent condom use combine together help fuel the country's hyper epidemic. HIV prevention interventions need to take into account the important influence of clients and boyfriends on condom use behavior.

INTRODUCTION:Studies exploring the linkages between financial vulnerabilities and community collectivization of female sex workers (FSWs) are scarce in India despite having potential policy implications. To fill this gap in the literature, this study attempts to understand the financial vulnerabilities among FSWs and assess the relationship between community collectivization and financial vulnerabilities in southern India. DATA AND METHODS:Data were drawn from a cross-sectional, behavioral tracking survey (BTS)-2014, conducted among FSWs (N = 2400) in Andhra Pradesh, a southern state of India under the Avahan-India AIDS initiative program. Adjusted odds ratios (AOR) and their 95% confidence intervals (CI) were estimated through multivariate logistic regression, to assess the independent relationships of the degree of community collectivization indicators with financial vulnerability indicators, adjusting for socio-demographic characteristics. RESULTS:Most FSWs (87%) reported having either one or more financial vulnerability and nearly one-fifth had a high financial vulnerability. The risk of facing financial vulnerability was significantly lower among FSWs with a high degree of perceived collective efficacy (15% vs 31%; AOR: 0.4; 95% CI: 0.3-0.5) and collective agency (4% vs 21%; AOR: 0.2; 95% CI: 0.1-0.3) as compared to their respective counterparts, after controlling for their individual socio-demographic characteristics. FSWs with a high degree of collective efficacy are also less likely to report different components of financial vulnerability (e.g. income, saving, expenditure, and debt). CONCLUSION:This study finding suggests that community-led interventions such as improving collectivization are promising strategies to address financial vulnerabilities and a path to a sustainable reduction of HIV risk. This study calls for further evidence-based research and measurement of the effects of community-led approaches in addressing the financial vulnerabilities of the key population at risk for HIV.

The HIV epidemic in Manipur, the highest HIV prevalence state of India, is primarily driven by injecting drug use. Reliable estimate of population size of injecting drug users (IDU) is critical for aiding HIV prevention program in the state to combat drug driven HIV epidemic. The study described multiplier method, an indirect technique of estimation of IDU size in five districts of Manipur, India making use of existing records of rapid intervention and care (RIAC) programs. Number of IDUs who accessed RIAC services during the past 12 months was taken as the benchmark data for the size estimation. The benchmark data were then multiplied by the inverse of the proportion of the IDUs who reported having accessed RIAC services during the same period to derive the sizes of IDU population in each study districts. The estimated sizes of IDU population in five districts were: 7353 (95% CI: 6759-8123) in Imphal West, 5806 (95% CI: 5635-6054) in Imphal East, 3816 (95% CI: 3571-4139) in Thoubal, 2615 (95% CI: 2528-2731) in Churachandpur and 2137 (95% CI: 1979-2343) in Bishenpur district. Multiplier method seems to be a feasible indirect technique which can be applied to estimate of IDU population using existing data from intervention programs in settings like Manipur where reliable size estimation of IDU population is lacking.

Background Avahan, the India AIDS initiative began HIV prevention interventions in 2003 in Andhra Pradesh (AP) among high-risk groups including female sex workers (FSWs), to help contain the HIV epidemic. This manuscript describes an assessment of this intervention using the published Avahan evaluation framework and assesses the coverage, outcomes and changes in STI and HIV prevalence among FSWs. Methodology Multiple data sources were utilized including Avahan routine program monitoring data, two rounds of cross-sectional survey data (in 2006 and 2009) and STI clinical quality monitoring assessments. Bi-variate and multivariate analyses, Wald Chi-square tests and multivariate logistic regressions were used to measure changes in behavioural and biological outcomes over time and their association. Results Avahan scaled up in conjunction with the Government program to operate in all districts in AP by March 2009. By March 2009, 80% of the FSWs were being contacted monthly and 21% were coming to STI services monthly. Survey data confirmed an increase in peer educator contacts with the mean number increasing from 2.9 in 2006 to 5.3 in 2009. By 2008 free and Avahan-supported socially marketed condoms were adequate to cover the estimated number of commercial sex acts, at 45 condoms/FSW/month. Consistent condom use was reported to increase with regular (63.6% to 83.4%; AOR=2.98; p Conclusions The absence of control groups is a limitation of this study and does not allow attribution of changes in outcomes and declines in HIV and STI to the Avahan program. However, the large scale implementation, high coverage, intermediate outcomes and association of these outcomes to the Avahan program provide plausible evidence that the declines were likely associated with Avahan. Declining HIV prevalence among the general population in Andhra Pradesh points towards a combined impact of Avahan and government interventions.

Background Injecting drugs is the major driving force of human immunodeficiency virus (HIV) epidemic in Northeastern India. We have assessed the spatial distribution of locations where injecting drug users (IDU) congregate, as well as the risk behaviour and key characteristics of IDUs to develop new strategies strengthening intervention measures for HIV prevention in this region. Methods Locations of IDUs congregation for buying and injecting drugs were identified through Key Informants (KI). Verification of the location and its characteristics were confirmed through field visits. We also conducted semi-structured and structured interviews with IDUs to learn more about their injecting behaviour and other characteristics. Results Altogether, 2462 IDU locations were identified in 5 states. The number of IDU locations was found to be greater in the states bordering Myanmar. Private houses, parks, abandoned buildings, pharmacies, graveyards, and isolated places were the most frequently chosen place for injecting drugs. Many injecting locations were visited by IDUs of varying ages, of which about 10-20% of locations were for females. In some locations, female IDUs were also involved in sex work. Sharing of needle and syringes was reported in all the states by large proportion of IDUs, mainly with close friends. However, even sharing with strangers was not uncommon. Needle and syringes were mainly procured from pharmacies, drug peddlers and friends. Lack of access to free sterile needles and syringes, and inconsistent supplies from intervention programs, were often given as the cause of sharing or re-use of needles and syringes by IDUs. Most of the IDUs described a negative attitude of the community towards them. Conclusion We highlight the injection of drugs as a problem in 5 Northeastern India states where this is the major driving force of an HIV epidemic. Also highlighted are the large numbers of females that are unrecognized as IDUs and the association between drug use and sex work. Understanding of risk behaviours and other key charecteristics of IDUs in the region will help in strengthening harm reduction efforts that can prevent HIV transmission.

OBJECTIVES: To describe formal external to programme methods for size estimation of high-risk populations and compare execution challenges and validity of results. DESIGN: A cross-sectional HIV risk behavioural and biological survey was implemented among 24 10 and five female sex workers high-risk men who have sex with men and injecting drug user survey groups respectively. Size estimates were calculated using three formal methods: capture-recapture the multiplier method and the reverse tracking method (RTM) a new method. METHODS: Estimates were compared with each other and programme data. RESULTS: In general when appropriately executed formal methods produced smaller estimates to programme data although the RTM tended to be closer to programme estimates. CONCLUSIONS: Capture-recapture requires some knowledge of site location. It can be used as a community mobilization measure at the initiation of a programme. The multiplier method presumes the existence of high quality external data and requires care in selecting the appropriate multiplier. All size estimation methods require careful planning and a full understanding of population dynamics and limitations of data. Before selecting a size estimation method one must be aware of the strengths weaknesses and applicability of each method. Use of size estimation methods in large-scale programmes should be considered carefully with adequate importance given to planning and implementation.

Objective: To characterize and describe patterns of HIV, sexually transmitted infections (STI) and sexual behaviour of male clients of female sex workers (FSW). Methods: A cross-sectional study was conducted among 4821 clients of FSW from 12 districts in three states in India: Andhra Pradesh, Maharashtra and Tamil Nadu. A structured questionnaire was administered to elicit demographic characteristics and sexual behavioural patterns. Blood and urine samples were tested for HIV, syphilis and herpes simplex type 2 serology, gonococal and chlamydial infection. Results: The median age of clients surveyed was 30 years; 57% were married and 64% had a steady sexual partner; 61% had sex with more than one FSW and 39% had four or more sexual encounters in the past month. The prevalence of HIV ranged from 2.0% to 10.9%, syphilis ranged from 3.1% to 10.1%; gonorrhoea and chlamydia ranged between 0% and 4.5%. Clients older than 30 years [odds ratio (OR) 1.65; 95% confidence interval (CI) 1.33–2.05] and having a different mix of commercial and non-commercial partners (OR 1.56; 95% CI 1.25–1.96) had a higher volume of sex acts with FSW. Inconsistent condom use with FSW was significantly associated with older clients (OR 4.2; 95% CI 3.33–5.29), illiteracy (OR 1.39; 95% CI 1.14–1.69), age

Background Measuring consistent condom use (CCU) is crucial in understanding the trajectory of the HIV epidemic and in evaluating HIV preventive interventions that promote condom use. We examine how one measure of CCU varies across different populations, and compare it to condom use in the last sex act. Methods Using data from cross-sectional behavioural and biological surveys (2005–2007), we compare responses concerning self-reported level of condom use and condom use in the last act by female sex workers (FSWs), their clients, and men who have sex with men (MSM) in districts from Andhra Pradesh, Maharashtra and Tamil Nadu states in India. For FSWs/clients, the question related to sex with occasional clients/FSWs. For MSM, the question was for non-commercial, non-regular male partners. The time period was unspecified. Levels of condom use were defined as every time", “most of the time/sometimes”, and “never”. We define CCU as those who reply “every time”. Results 95.2% of all FSWs reported using a condom in the last act, compared to 72.9% of clients and 80.0% MSM. However, only 36.7% of clients and 29.6% of MSM reported CCU compared to 80.0% of FSWs. Abstract P1-S5-16 table 1 shows condom use in the last act stratified by reported level of condom use. For all populations reporting CCU “always”, condom use in the last act was >98%. Of those who reported “most of the time/sometimes”, there was a significant difference between condom use in the last act between clients and the other groups (χ 2 test, p Conclusions CCU may not accurately reflect number of acts protected by condoms. Among males in particular, dividing condom users into CCU and non-CCU neglects many who almost always use condoms, and so will still have a high degree of protection. These individuals are an important group to consider when evaluating the effect of changes in condom use on the HIV epidemic, especially among MSM. HIV prevention programmes should try to identify reasons explaining lower CCU among MSM and clients who already use condoms “most of the time/sometimes”, and endeavour to increase consistency within this group.

Background Estimating the size of a high-risk population group is always challenging and is a requisite for planning and policy development. In India, the Bill & Melinda Gates Foundation implemented Avahan, a large-scale HIV prevention programme. As part of Avahan's overall evaluation strategy, two rounds of large-scale cross-sectional integrated behaviour and biological assessment (IBBA) surveys were carried out in 2006 (round 1) and 2009 (round 2) in selected districts in three states. Methods Two rounds of IBBA covered 23 female sex worker (FSW) and ten men who have sex with men (MSM) groups across 29 districts in three states. Sizes were estimated using three different methods: capture-recapture (CR), multiplier method (MM), and reverse tracking method (RTM), a technique mathematically similar to the Hansen-Hurwitz method. Findings Among the three methods, RTM was applied consistently in all groups in both the rounds. MM and CR were applied in the selected districts owing to the implementation issues and experiences in round 1 of the survey. The results from RTM showed that in Andhra Pradesh, the sizes of the FSW and MSM populations increased between rounds. In Maharashtra, FSW groups showed a decline from round 1 (13 459, 95% CI 13 431–13 487) to round 2 (8955, 8945–8964), whereas the MSM groups in Maharashtra showed an overall increase from round 1 (1498, 1480–1516) to round 2 (2667, 2605–2729). Tamil Nadu had mixed results in both FSW and MSM groups. The results from RTM were much more reliable and accurate compared with those obtained from CR and MM. Estimates from RTM also tended to be close to programme data. Interpretation Changes in high-risk population sizes captured through RTM were much more accurate and tended to be closer to the programme data. Also, in large-scale surveys where the sampling frame is exhaustive, using the RTM method for size estimation seems to be better than other indirect methods. Funding Bill & Melinda Gates Foundation.

Objectives To assess a large-scale intervention, the Avahan intervention, using an evaluation framework that included programme coverage, condom use and changes in sexually transmitted infection (STI) and HIV prevalence among high-risk men who have sex with men/transgender (HR-MSM/TG) in the state of Andhra Pradesh, India. Design Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis. Setting Programme monitoring data and cross-sectional surveys from Andhra Pradesh, India. Participants Data from 1218 and 1203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts. Primary and secondary outcomes (1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention. Results By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HR-MSM/TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52). Conclusion The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HR-MSM/TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.

Background The intersection between illicit drug use and female commercial sex work has been identified as an important factor responsible for rising HIV prevalence among female sex workers (FSW) in several northeastern states of India. But, little is know about the factors associated with the use of drugs among FSWs in this region. The objective of the paper was to describe the factors associated with history of drug use among FSWs in Dimapur, an important commercial hub of Nagaland, which is a high HIV prevalence state of India. Methods FSWs were recruited using respondent driven sampling (RDS), and were interviewed to collect data on socio-demographic characteristics and HIV risk behaviours. Biological samples were tested for HIV, syphilis gonorrhea and Chlamydia. Logistic regression analysis was performed to identify factors associated with drug use. Results Among the 426 FSWs in the study, about 25% (n = 107) reported having ever used illicit drugs. Among 107 illicit drug users, 83 (77.6%) were non-injecting and 24 (22.4%) were injecting drug users. Drug-using FSWs were significantly more likely to test positive for one or more STIs (59% vs. 33.5%), active syphilis (27.1% vs. 11.4%) and Chlamydia infection (30% vs. 19.9%) compared to their non-drug using peers. Drug-using FSWs were also significantly more likely to be currently married, widowed or separated compared with non-drug-using FSWs. In multiple logistic regression analysis, being an alcohol user, being married, having a larger volume of clients, and having sexual partners who have ever used or shared injecting drugs were found to be independently associated with illicit drug use. Conclusions Drug-using FSWs were more vulnerable to STIs including HIV compared to their non-drug using peers. Several important factors associated with being an FSW who uses drugs were identified in this study and this knowledge can be used to plan more effectively targeted harm reduction strategies and programs.

Background 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. Methods 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). Results 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]. 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. 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. Conclusion 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.

Background The present study assessed coverage, changes in condom use, and prevalence of HIV and other STIs among high-risk men who have sex with men (HR-MSM; highly visible, recruited from cruising sites/sex venues) and transgender (TG; male-to-female transgender persons, also called hijras) in the Indian state of Maharashtra. Methods Data from Avahan’s computerized management information system; two rounds of integrated behavioral and biological assessment (IBBA) surveys (Round 1 with 653 HR-MSM/TG and Round 2 with 652 HR-MSM/TG); and project-supported condom social marketing was used for the present analysis. Logistic regression models were used to assess changes in key indicators over these two rounds and to explore the association between exposure to Avahan interventions and condom use and STI prevalence in HR-MSM/TG. Results By December 2007, Avahan had reached about 90% of the estimated HR-MSM/TG population, and 83% of the estimated total population had visited STI clinics by March 2009. Free direct condom distribution by Avahan program NGOs and social marketing outlets in Maharashtra increased from about 2.7 million condoms in 2004 to 15.4 million in 2008. HR-MSM/TG were more likely to report higher consistent condom use (adjusted odds ratio [AOR]: 1.90; 95% confidence interval [CI] 1.01-3.58) with regular male partners (spouse/lover/boyfriend) in Round 2 of IBBA, compared to Round 1. HR-MSM/TG exposed to Avahan interventions were more likely to report consistent condom use with regular male partners (AOR: 2.46; CI 1.34-4.52) than those who were unexposed. Prevalence of reactive syphilis serology declined significantly from 8.8% in Round 1 to 1.1% in Round 2 (p = 0.001), while the observed change HIV prevalence (12.3% to 6.3%, p = 0.16) was insignificant. Conclusion The current evaluation provides evidence for successful scale up and coverage of target population by Avahan interventions in Maharashtra. The assessment findings showed improved accessibility to condoms and reduced risk behaviours with male sexual partners. Syphilis prevalence declined; however HIV prevalence did not change and is still a major concern. Continued strengthening of core programmatic strategies are needed to effectively improve condom use with all partner types and to help bring sustained reductions in HIV risk in HR-MSM/TG and its onward transmission.

This paper presents key methodological approaches and challenges in implementing and analysing the first round of the integrated biobehavioural assessment of most-at-risk populations, conducted in conjunction with evaluation of Avahan, the India AIDS initiative.The survey collected data on HIV risk behaviours, sexually transmitted infections and HIV prevalence in 29 districts in six high-prevalence states of India. Groups included female sex workers and clients, men who have sex with men, injecting drug users and truck drivers. Strategies for overcoming some challenges of the large-scale surveys among vulnerable populations, including sampling hidden populations, involvement of the communities targeted by the survey, laboratory and quality control in remote, non-clinic field settings, and data analysis and data use are presented.Satisfying the need for protocols, guidelines and tools that allowed for sufficient standardization, while being tailored enough to fit diverse local situations on such a large scale, with so many implementing partners, emerged as a major management challenge. A major lesson from the first round is the vital importance of investing upfront time in tailoring the sampling methods, data collection instruments, and analysis plan to match measurement objectives.Despite the challenges, the integrated biobehavioural assessment was a huge achievement, and was largely successful in providing previously unavailable information about the HIV situation among populations that are critical to the curtailment of HIV spread in India. Lessons from the first round will be used to evolve the second round into an exercise with increased evaluative capability for Avahan.