Understanding out-migration among female sex workers in South India

Vulnerability to Sexually Transmitted Infections (STI) / Human Immunodeficiency Virus (HIV) among adolescent girls and young women in India: A rapid review

Limited evidence is available on the vulnerability of Adolescent Girls and Young Women (AGYW) to sexual risk behaviour and STI/HIV. Though there are almost no statistics available on vulnerability, related literature suggests that AGYW have low awareness about sexual risk behaviour/ transmission and the prevalence of STI/HIV, making them vulnerable. We conducted a rapid review of peer-reviewed studies addressing transmission network, prevalence, incidence awareness, common determinants of sexual risk behaviour/STI/HIV, health-seeking behaviour and existing interventions addressing the situation among AGYW (age 15-24) to inform the evidence gap in this crucial area of research. We registered the study in PROSPERO (CRD42023403713). We developed detailed inclusion/exclusion criteria, searched JSTOR, PubMed, Google Scholar, Science Direct and Population Council Knowledge Commons databases and followed the guidance from Cochrane Rapid Review to develop the rapid review. We also searched the bibliography of the included studies. We included the English language peer-reviewed quantitative, qualitative, mixed method studies published from Jan 1 2000 to Mar 31 2023. Six reviewers extracted data, and the seventh reviewer independently assessed the quality. Ninety-six studies met the inclusion criteria. We used descriptive statistics and narrative synthesis methods for data analysis. We also conducted a Risk of Bias Assessment (RoB) to check the quality of the included studies. Inadequate literature was found on the transmission network. Prevalence and awareness of STI/HIV are low among AGYW. However, Female Sex Workers, sex-trafficked women or drug users in this age group suffer more. Age, education, income, relationship dynamics with spouses/partners, multiple partners, and substance use are crucial in determining STI/HIV. Traditional sources of health seeking are more popular than formal sources because of social stigma. Mass media campaigns, community mobilization programs, and life skills training programs increase awareness about HIV, condom use and self-efficacy. The inclusion of only English language studies and not conducting meta-analysis because of high heterogeneity are some of the limitations of the study.

Heterogeneity and Confinement of HIV Prevalence among Pregnant Women Calls for Decentralized HIV Interventions: Analysis of Data from Three Rounds of HIV Sentinel Surveillance in Karnataka: 2013-2017

Background

The HIV sentinel surveillance (HSS) serves to estimate the levels and trend of HIV prevalence among high-risk, bridge, and general population and monitors HIV management at national, state, and district levels. Data from HSS are valuable in understanding the risk factors associated with HIV transmission with particular demographic characteristics.

Objectives

The objective was to analyze the sociodemographic profile of the pregnant mothers attending the antenatal care (ANC) clinics in Karnataka, in order to understand the dynamics of HIV within the general population in Karnataka.

Materials and Methods

Study design: this was a cross-sectional study conducted using consecutive sampling method. Study setting: the surveillance was conducted at select antenatal clinics, in Karnataka, India, between January and March, in the years 2013, 2015, and 2017. Methodology: in total, 74,278 eligible pregnant women aged between 15 and 49 years, attending the sentinel sites for the first time during the surveillance period, were included in the study. Information on their sociodemographic characteristics and blood samples was collected.

Results

HIV prevalence among the ANC clinic attendees has significantly declined, reaching a recent stabilization. The risk factors significantly associated with HIV among pregnant women were age, education, occupation, and marital status. HIV is highly concentrated in the northern and southern districts of Karnataka.

Conclusion

Despite the declining trends of HIV prevalence in Karnataka, the epidemic is heterogeneous and concentrated within the state, calling for decentralized region-specific interventions.

Migrant female sex workers working at the Sino-Vietnamese border for a short time have a higher risk of HIV transmission: a consecutive cross-sectional study

OBJECTIVES

For migrant female sex workers (FSWs) at the Sino-Vietnamese border, the impact of work time in their current location on the spread of HIV/AIDS is not clear.

METHODS

Data were collected from the Sino-Vietnamese border cities of Guangxi, China. Migrant FSWs working in these cities were studied. FSWs who worked less than 6 months in their current location were assigned to the short-term work group (ST FSWs), and FSWs who worked equal to or longer than 6 months in their current location were assigned to the long-term work group (LT FSWs). Logistic regression was performed to examine the impact of work time in the current location and factors associated with HIV infection.

RESULTS

Among the 1667 migrant FSWs, 586 (35.2%) and 1081 (64.9%) were assigned to the ST FSW and LT FSW groups, respectively. Compared to LT FSWs, ST FSWs were more likely to be of Vietnamese nationality, be less than 18 years old when they first engaged in commercial sex work, and have a low-level of HIV-related knowledge and had higher odds of using condoms inconsistently, having more male clients, having no regular male clients, and having a history of male clients who used aphrodisiacs but lower odds of receiving free condoms distribution and education/HIV counselling and testing programme. The analysis of factors associated with HIV infection revealed that Vietnamese FSWs, less than 18 years old when they first engaged in commercial sex work, having no regular male clients, and having lower average charge per sex transaction were correlated with HIV infection.

CONCLUSION

FSWs with short-term work at the Sino-Vietnamese border had a higher risk of risky sex and were correlated with HIV risk factors. Vietnamese FSWs were at higher risk of HIV infection, and they were more likely to have short-term work. More targeted HIV prevention should be designed for new FSWs who recently began working in a locality to further control the spread of HIV, particularly cross-border FSWs.

Education, poverty and "purity" in the context of adolescent girls' secondary school retention and dropout: A qualitative study from Karnataka, southern India

BACKGROUND

Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation.

METHODS

Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses.

RESULTS

Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating.

CONCLUSIONS

In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication.

Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India

Purpose: Men and transgender women who have sex with men (MTWSM) continue to be an at-risk population for human immunodeficiency virus (HIV) infection in India. Identification of risk factors and determinants of HIV infection is urgently needed to inform prevention and intervention programming.

Methods: Data were collected from cross-sectional biological and behavioral surveys from four districts in Karnataka, India. Multivariable logistic regression models were constructed to examine factors related to HIV infection. Sociodemographic, sexual history, sex work history, condom practices, and substance use covariates were included in regression models.

Results: A total of 456 participants were included; HIV prevalence was 12.4%, with the highest prevalence (26%) among MTWSM from Bellary District. In bivariate analyses, district (P = 0.002), lack of a current regular female partner (P = 0.022), and reported consumption of an alcoholic drink in the last month (P = 0.004) were associated with HIV infection. In multivariable models, only alcohol use remained statistically significant (adjusted odds ratios: 2.6, 95% confidence intervals: 1.2–5.8; P = 0.02).

Conclusion: The prevalence of HIV continues to be high among MTWSM, with the highest prevalence found in Bellary district.

Human immunodeficiency virus, syphilis and hepatitis C virus prevalence trends among cross-border migrant Vietnamese female sex workers in Guangxi, China

Background

Global literature indicates the burden of human immunodeficiency virus (HIV), syphilis and hepatitis C virus (HCV) has disproportionately affected cross-border migrant female sex workers (FSW). However, few studies reported the HIV risk among Vietnamese FSW at borderline areas in China. We examined five consecutive years of HIV, syphilis, and HCV prevalence and corresponding risk factors among this group in Guangxi Province of China in the current study.

Method

Demographic and behavioral data as well as test results of blood samples for HIV/syphilis/HCV testing were collected from the annual National Sentinel Surveillance (NSS) from the year of 2010 to 2014. The prevalence trends were first examined by stratified demographic and behavioral status. Predictive models with logistic regression were further employed to identify risk predictors for HIV, syphilis and HCV combined with multiple imputation for missing data as well as restricted cubic splines for key continuous covariates. Moreover, weighted prevalence using the distribution of venue types among all FSW from the NSS survey as the standardized population was also reported.

Results

The overall prevalence of HIV, syphilis and HCV across the five year period was 3.2 % (95 % CI = 2.1 %,4.3 %), 6.9 % (95 % CI = 5.3 %,8. %), and 2.6 % (95 % CI = 1.6 %,3.6 %), respectively. HIV prevalence changed from 8.2 % (95 % CI = 0.5 %,15.9 %) in 2010 to 1.7 % (95 % CI = 0.4 %,3.0 %) in 2014, and the prevalence decreased notably among FSW who were younger than 25 years old, stayed less than six months, and who participated in the HIV prevention services (P < 0.05). The syphilis prevalence also ranged from 8.2 % (95 % CI = 0.5 %,15.9 %) in 2010 to 3.9 % (95 % CI = 1.9 %,5.9 %) in 2014, and the prevalence remained relatively stable among FSW who reported inconsistent condom use with clients in the past month, those who did not participate in HIV prevention services, and had lower HIV knowledge (P > 0.05). HCV prevalence increased from 0 % in 2010 to 2.2 % (95 % CI = 0.7 %, 3.7 %) in 2014. Multivariable analyses revealed that infection with HCV increased the odds of HIV and syphilis infection. Drug use (aOR = 44.0, 95C % = 16.3,129.5) increased the odds of HCV infection.

Conclusions

The relatively higher HIV, syphilis and HCV prevalence among Vietnamese FSW compared to their Chinese counterparts sets a challenge for health officials at both sides. To curb the epidemic among the cross-border FSW, preventive action requires bilateral cooperation and action by health authorities of China and Vietnam. A national-level response system should be launched in order to tackle the urgently ever-increasing epidemic.

Availability of emergency neonatal care in eight districts of Karnataka state, southern India: a cross-sectional study

BACKGROUND

Emergency Neonatal Care (EmNC) is an important service for the health and survival of newborns. The objective of our study was to assess the availability of emergency neonatal care services in the north-eastern region of Karnataka state in India.

METHODS

We undertook a cross-sectional epidemiologic study in the year 2010. We assessed the provision of eight life-saving 'signal functions' (Comprehensive EmNC) or at least five 'signal functions' (Basic EmNC) by self-reporting through a structured questionnaire, coupled with verification by direct observation for presence of drugs and equipment in the prior three months. The assessment was undertaken in 443 government and 422 private healthcare facilities of eight districts of Karnataka.

RESULTS

There was an average of 3.6 EmNC facilities available per 500,000 population for the entire region. Only three out of eight districts and 10 of 42 sub-districts in the region had the recommended [greater than or equal to 5] EmNC facilities per 500,000. Further, over 95 % of CEmNC facilities and 88 % of BEmNC facilities were within the private sector. About 80 % of government hospitals at district and sub-district levels did not have EmNC capability.

CONCLUSIONS

This study demonstrates the feasibility of using a simple assessment tool to measure health facility availability of life-saving services for newborn care. EmNC availability was seen to be suboptimal at the regional, district and sub-district levels within the northern part of Karnataka state. There is a need to improve availability of emergency newborn care in health facilities, with special emphasis on equity at population level.

Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India

Continued engagement throughout the HIV care continuum, from HIV diagnosis through retention on antiretroviral therapy (ART), is crucial for enhancing impact of HIV care programs. We assessed linkage and retention in HIV care among people living with HIV (PLHIV) enrolled at a private HIV care clinic in Pune, India. Of 1220 patients, 28% delayed linkage after HIV diagnosis with a median delay of 24 months (IQR = 8-43). Younger people, women, low socioeconomic status, and those diagnosed at facilities other than the study clinic were more likely to delay linkage. Those with advanced HIV disease at diagnosis and testing for HIV due to HIV-related illness were linked to care immediately. Of a total of 629 patients eligible for ART at first CD4 count, 68% initiated ART within 3 months. Among those not eligible for ART, only 46% of patients sought subsequent CD4 count in time. Multivariate logistic regression analysis revealed that patients with initial CD4 count of 350-500 cells/cu mm (OR: 2, 95% CI: 1.1-3.5) and >500 cells/cu mm (OR: 2.1, 95% CI: 1.2-3.7) were less likely to do subsequent CD4 test on time as compared to those with CD4 < 50 cells/cu mm. Among patients not eligible for ART, those having >12 years of education (OR: 0.4, 95% CI: 0.2-0.9) were more likely to have timely uptake of subsequent CD4 count. Among ART eligible patients, being an unskilled laborer (OR: 2.2, 95% CI: 1.1-4.2) predicted lower uptake. The study highlights a long delay from HIV diagnosis to linkage and further attrition during pre-ART and ART phases. It identifies need for newer approaches aimed at timely linkage and continued retention for patients with low education, unskilled laborers, and importantly, asymptomatic patients.

Association Between System Reach and Exposure to Interventions and Characteristics of Mobile Female Sex Workers in Four High HIV Prevalence States in India

Mobility among Female Sex Workers (FSWs) interrupts their demand for, and utilization of, health services under any intervention. Various strategic interventions are meant to provide access to care and reduce the incidence of HIV and other STIs among FSWs. This paper applies a bivariate probit regression analysis to explain the probability of mobile FSWs being reached by the system and being exposed to interventions jointly with a wide variety of characteristics of mobile FSWs in India. The data used are based on a cross-section survey among 5,498 mobile FSWs in 22 districts of four high HIV prevalence states in southern India. A majority of mobile FSWs (59%) were street-based and about 70 percent of them were members of SW organization and nearly half (46%) were highly mobile. The majority of them (90%) had been contacted by outreach workers from any system in the last two years in their current location and 94 percent were exposed to interventions in terms of getting free or subsidized condoms. Bivariate probit analysis revealed that comprehensive interventions are able to reach more vulnerable mobile FSWs effectively, e.g. new entrants, highly mobile, reported STIs, tested for HIV ever and serving a high volume of clients. The results complement the efforts of government and other agencies in response to HIV. However, the results highlight that specific issues related to various subgroups of this highly vulnerable population remain unaddressed calling for tailoring the response to the specific needs of the sub-groups.

HIV risks vary according to type of sex work in a cross-sectional survey from Nagaland, India

Background

Human immunodeficiency virus (HIV) infection is a significant problem among female sex workers (FSWs) in Nagaland, India. Place of solicitation and sex vary considerably in this context. The aim of this study was to investigate the relationship between categories of sex work and HIV risks.

Methods

In 2009 a survey was undertaken among 417 FSWs in Dimapur, Nagaland using an interviewer-administered questionnaire and blood and urine samples. Using this data, we constructed a typology of sex work by combining usual place of solicitation and place of sex, and examined variations in demographics, sex work patterns, sexually transmitted infections (STIs) and HIV prevalence across typology categories. Binary logistic regression analyses were done to examine the association between category of sex work and HIV, STIs, and condom use.

Results

By combining place of solicitation with place of sex, seven distinct categories of sex work emerged. The largest category were women who usually solicited in a public place and had sex in a rented room or lodge (31.7%, n = 132). One-tenth of participants were HIV positive (10.3%) and 35.4% had at least one STI (reactive syphilis serology, gonorrhoea or chlamydia). FSWs who both solicited and entertained in a rented room or lodge (OR = 13.3; 95% CI 2.2, 81.5) and those who solicited by phone and had sex in a rented room or lodge (OR = 6.3; 95% CI 1.0, 38.0) were more likely to be HIV positive compared to home-based FSWs. Women who both solicited and entertained in public (OR = 6.7; 95% CI 1.6, 28.0) and who solicited in public and entertained in a rented room or lodge (OR = 2.5; 95% CI 1.1, 6.0) were more likely to test positive for an STI compared to home-based FSWs.

Conclusion

The results indicate that different categories of sex work are associated with different HIV and STI risk profiles. Local contextual understanding of the different types of sex work and the associated levels of risk assist NGOs to target their interventions more effectively and efficiently in order to reduce STI and HIV prevalence among FSWs and their clients.

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

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

Exploring the population-level impact of antiretroviral treatment: the influence of baseline intervention context

OBJECTIVE

To compare the potential population-level impact of expanding antiretroviral treatment (ART) in HIV epidemics concentrated among female sex workers (FSWs) and clients, with and without existing condom-based FSW interventions.

DESIGN

Mathematical model of heterosexual HIV transmission in south India.

METHODS

We simulated HIV epidemics in three districts to assess the 10-year impact of existing ART programs (ART eligibility at CD4 cell count ≤350) beyond that achieved with high condom use, and the incremental benefit of expanding ART by either increasing ART eligibility, improving access to care, or prioritizing ART expansion to FSWs/clients. Impact was estimated in the total population (including FSWs and clients).

RESULTS

In the presence of existing condom-based interventions, existing ART programs (medium-to-good coverage) were predicted to avert 11-28% of remaining HIV infections between 2014 and 2024. Increasing eligibility to all risk groups prevented an incremental 1-15% over existing ART programs, compared with 29-53% when maximizing access to all risk groups. If there was no condom-based intervention, and only poor ART coverage, then expanding ART prevented a larger absolute number but a smaller relative fraction of HIV infections for every additional person-year of ART. Across districts and baseline interventions, for every additional person-year of treatment, prioritizing access to FSWs was most efficient (and resource saving), followed by prioritizing access to FSWs and clients.

CONCLUSION

The relative and absolute benefit of ART expansion depends on baseline condom use, ART coverage, and epidemic size. In south India, maximizing FSWs' access to care, followed by maximizing clients' access are the most efficient ways to expand ART for HIV prevention, across baseline intervention context.

Circumstances, experiences and processes surrounding women's entry into sex work in India

Evidence suggests that in India, the early stages of a woman's career as a sex worker may be an important period to target for HIV and sexually transmitted infection prevention. Before such an intervention is designed and implemented, it is necessary to first understand the life circumstances of women at the start of their sex work careers. We performed a review to bring together available literature pertaining to entry into sex work in India and to highlight knowledge gaps. We found that historical traditions of dedication into sex work, financial insecurity, family discord, violence and coercion, and desire for financial independence are commonly reported reasons for entering into sex work. We also found that families and the broader sex worker community play an important role in the early stages of a woman's sex work career. We suggest that HIV-prevention programmes in India would substantially benefit from a deeper understanding of the life circumstances of new and young women sex workers. Further research should be conducted focusing on family and community involvement in women's entry into sex work, and on the important period of time after a woman's first commercial sex encounter, but before self-identification as a sex worker.

Factors associated with risky sexual practices among female sex workers in Karnataka, India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.