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He J, Wang Y, Du Z, Liao J, He N, Hao Y. Peer education for HIV prevention among high-risk groups: a systematic review and meta-analysis. BMC Infect Dis 2020; 20:338. [PMID: 32398032 PMCID: PMC7218508 DOI: 10.1186/s12879-020-05003-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 03/30/2020] [Indexed: 12/23/2022] Open
Abstract
Background Peer education has become a strategy for health promotion among high-risk groups for HIV infection worldwide. However, the extent to which peer education could have an impact on HIV prevention or the long-term effect of this impact is still unknown. This study thus quantifies the impact of peer education over time among high-risk HIV groups globally. Method Following the PRISMA guidelines, a systematic review and meta-analysis was used to assess the effects and duration of peer education. A thorough literature search of PubMed, Web of Science, Embase and Cochrane Library was performed, and studies about peer education on high-risk HIV groups were reviewed. Pooled effects were calculated and the sources of heterogeneity were explored using meta-regression and subgroup analysis. Results A total of 60 articles with 96,484 subjects were identified, and peer education was associated with 36% decreased rates of HIV infection among overall high risk groups (OR: 0.64; 95%CI: 0.47–0.87). Peer education can promote HIV testing (OR = 3.19; 95%CI:2.13,4.79) and condom use (OR = 2.66, 95% CI: 2.11–3.36) while reduce equipment sharing (OR = 0.50; 95%CI:0.33,0.75) and unprotected sex (OR = 0.82; 95%CI: 0.72–0.94). Time trend analysis revealed that peer education had a consistent effect on behavior change for over 24 months and the different follow-up times were a source of heterogeneity. Conclusion Our study shows that peer education is an effective tool with long-term impact for behavior change among high-risk HIV groups worldwide. Low and middle-income countries are encouraged to conduct large-scale peer education.
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Affiliation(s)
- Jiayu He
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China.,Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, China.,The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, 200032, China
| | - Ying Wang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China
| | - Zhicheng Du
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China
| | - Jing Liao
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China
| | - Na He
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, China.,The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, 200032, China
| | - Yuantao Hao
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong Province, China.
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Patel SK, Mukherjee S, Mahapatra B, Battala M, Jayaram M, Kumta S, Atmavilas Y, Saggurti N. Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey. PLoS One 2019; 14:e0223961. [PMID: 31639161 PMCID: PMC6804955 DOI: 10.1371/journal.pone.0223961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/02/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India. Data and methods This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment. Results There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5–4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs. Conclusions Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.
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Affiliation(s)
| | | | | | | | | | - Sameer Kumta
- Bill & Melinda Gates Foundation, New Delhi, India
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3
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Misra G, Sahu D, Reddy US, Nair S. Correlates of HIV prevalence among female sex workers in four north and east Indian states: findings of a national bio-behavioural survey. Int J STD AIDS 2018; 30:120-130. [PMID: 30236041 DOI: 10.1177/0956462418799018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The socio-demographic, sex work characteristics and the factors affecting HIV prevalence among female sex workers (FSWs) are not well known in low prevalence states showing rising trends within the HIV epidemic. This paper studies these attributes among FSWs in three north (Punjab, Rajasthan and Uttar Pradesh) and one east Indian states (Jharkhand). Integrated Biological and Behavioural Surveillance (IBBS) data, collected from 4491 FSWs in the study states, were analysed, with HIV status as the dependent variable and several socio-demographic, sex work, knowledge and agency characteristics as independent variables. Multivariate analysis found a number of factors such as age above 25 years (adjusted odds ratio [AOR] 5.0, 95% confidence interval [CI] 1.4-18.1), client solicitation in rented rooms (AOR 2.8, 95% CI 1.2-6.4) and the use of mobile phones for client solicitation (AOR 5.1, 95% CI 1.6-16.0) to be significantly associated with HIV risk. The study found low levels of HIV programme services uptake and HIV/AIDS knowledge among FSWs in the study states. There is an urgent need to focus on these risk factors for improving the effectiveness of the ongoing HIV prevention efforts and attaining the 'Sustainable Development Goals' goal of 'Ending the AIDS epidemic' by 2030.
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Affiliation(s)
- Gunjika Misra
- 1 School of Medicine and Para-Medical Health Sciences, Guru Gobind Singh Indraprastha University, New Delhi, India
| | - Damodar Sahu
- 2 ICMR-National Institute of Medical Statistics, Indian Council of Medical Research (ICMR), New Delhi, India
| | - Umenthala S Reddy
- 2 ICMR-National Institute of Medical Statistics, Indian Council of Medical Research (ICMR), New Delhi, India
| | - Saritha Nair
- 2 ICMR-National Institute of Medical Statistics, Indian Council of Medical Research (ICMR), New Delhi, India
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4
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Musyoki H, Bhattacharjee P, Blanchard AK, Kioko J, Kaosa S, Anthony J, Javalkar P, Musimbi J, Malaba SJ, Olwande C, Blanchard JF, Sirengo M, Isac S, Moses S. Changes in HIV prevention programme outcomes among key populations in Kenya: Data from periodic surveys. PLoS One 2018; 13:e0203784. [PMID: 30231072 PMCID: PMC6145580 DOI: 10.1371/journal.pone.0203784] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/27/2018] [Indexed: 11/28/2022] Open
Abstract
The Kenya National AIDS and STI Control Programme (NASCOP) conducted annual polling booth surveys (PBS) in 2014 and 2015 to measure outcomes from the national HIV prevention programme for key populations (KPs), comprising behavioural, biomedical and structural interventions. KPs included female sex workers (FSWs), men who have sex with men (MSM) and people who inject drugs (PWID). We compared survey results from the first and second rounds. Comparing the second to the first round, significantly more FSWs (93% vs. 88%, p<0.001) and MSM (77% vs. 58%, p<0.001) reported condom use at last sex with a paying client, and at last anal sex among MSM (80% vs. 77%, p<0.05) and PWID (48% vs. 27%, p<0.01). However, condom use with regular partners remained low, at less than 53% for FSWs and 69% for MSM. Among PWID, there was a significant increase in use of new needles and syringes at last injection (93% vs. 88%, p<0.001), and a significant decrease in reported non-availability of clean needles (23% vs. 36%, p<0.001). The number of overdoses in the past six months reduced significantly but remained high (40% vs. 51%, p<0.001). FSWs and MSM reported significantly higher HIV testing, and in all KP groups, over 93% reported ever having been tested for HIV. Among the respondents self-reporting to have tested HIV positive (24% of FSW, 22% of MSM and 19% of PWID), 80% of FSWs, 70% of MSM, and 73% of PWID reported currently taking antiretroviral therapy (ART). While the experience of forced intercourse by partners declined among FSWs (18% vs. 22%, p<0.01) and MSM (13% vs. 17%, p<0.01), more FSWs reported violence by law enforcement personnel (49% vs. 44%, p<0.001). These findings provide valuable information on the programme's progress, and a signpost for the integrated behavioural, biomedical and structural interventions to achieve their HIV prevention targets.
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Affiliation(s)
- Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Parinita Bhattacharjee
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Andrea K. Blanchard
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Japheth Kioko
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Shem Kaosa
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - John Anthony
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | - Janet Musimbi
- Partners for Health and Development in Africa, Nairobi, Kenya
| | | | - Carol Olwande
- National AIDS and STI Control Programme, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - James F. Blanchard
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Martin Sirengo
- National AIDS and STI Control Programme, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Shajy Isac
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Stephen Moses
- Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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5
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Mamulwar M, Godbole S, Bembalkar S, Kamble P, Dulhani N, Yadav R, Kadu C, Kumar P, Lalikar S, Acharya S, Gangakhedkar R, Risbud A, Venkatesh S. Differing HIV vulnerability among female sex workers in a high HIV burden Indian state. PLoS One 2018; 13:e0192130. [PMID: 29420577 PMCID: PMC5805240 DOI: 10.1371/journal.pone.0192130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/18/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction The HIV sentinel surveillance [HSS] conducted in 2010–11 among female sex workers [FSW] in the state of Maharashtra, India provided an opportunity to assess characteristics of different types of FSWs and their HIV risk. It is important for India’s National AIDS Control Program, to understand the differences in vulnerability among these FSW, in order to define more specific and effective risk reduction intervention strategies. Therefore, we analyzed data from HSS with the objective of understanding the HIV vulnerability among different types of FSW in Maharashtra. Material and methods Cross sectional data collected as a part of HSS among FSWs in year 2010–11 from 21 sentinel sites in the state of Maharashtra were analyzed to understand the vulnerability and characteristics of different types of female sex workers based on their place of solicitation using multinomial logistic regression. Results While the HIV prevalence was 6.6% among all FSWs, it was 9.9% among brothel based [BB], 9% among street based [SB] and 3.1% and 3.7% among home based [HB], and bar based [Bar-B] sex workers respectively. SB FSWs were least likely to be located in HIV low burden districts [ANC] [ARRR: 0.61[95% CI: 0.49, 0.77]], but were 6 times more likely to be recently [<1 year] involved in sex work [ARRR: 6.15 [95% CI: 3.15, 12.0]]. The number of clients of SB FSWs in the preceding week were lower than 11% [ARRR: 0.89 [95%CI: 0.87, 0.90]] as compared to the BB FSWs denoting lesser client load. The duration since last paid sex was shorter [ARRR: 0.94[95%CI: 0.91, 0.96]] as compared to the BB FSWs. Conclusion Street based FSWs have emerged as one of the most vulnerable types of FSW with a high HIV prevalence similar to BB FSWs. Our study reveals that they have more frequent sex acts despite lower client loads, and are more likely to be located in districts highly affected by HIV (ANC prevalence >1%). We identify them as a group to be focused on for prevention interventions and it is likely that they would be easily amenable to novel interventions due to their higher literacy rate as compared to other typologies.
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Affiliation(s)
- Megha Mamulwar
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Sheela Godbole
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Shilpa Bembalkar
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Pranil Kamble
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Nisha Dulhani
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Rajesh Yadav
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Chitra Kadu
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Pradeep Kumar
- National Program Officer (Surveillance) National AIDS Control Organization, Strategic Information Management Unit [SIMU], Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Shivraj Lalikar
- Joint Director STI, Monitoring &Evaluation, Maharashtra State AIDS Control Society, Mumbai, Maharashtra India
| | - Shrikala Acharya
- Additional Project Director, Mumbai District AIDS Control Society, Mumbai, Maharashtra India
| | - Raman Gangakhedkar
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Arun Risbud
- National AIDS Research Institute [Indian Council of Medical Research], Pune, Maharashtra, India
| | - Srinivas Venkatesh
- Deputy Director General, National AIDS Control Organization, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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6
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Williams JD, Vijayaraman A, Krishnaswamy P, Saggurti N, Ramesh S, Ganju D. Impact of an HIV Prevention Intervention on HIV Risk Behavior and Sexually Transmitted Infection among Female Sex Workers in Tamil Nadu, India. WORLD JOURNAL OF AIDS 2017; 7:166-178. [PMID: 33552672 PMCID: PMC7797626 DOI: 10.4236/wja.2017.73014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 11/20/2022]
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7
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Firestone R, Rowe CJ, Modi SN, Sievers D. The effectiveness of social marketing in global health: a systematic review. Health Policy Plan 2016; 32:110-124. [DOI: 10.1093/heapol/czw088] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2016] [Indexed: 12/30/2022] Open
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8
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Bradley J, Rajaram SP, Isac S, Gurav K, Ramesh BM, Gowda C, Moses S, Alary M. Pornography, Sexual Enhancement Products, and Sexual Risk of Female Sex Workers and their Clients in Southern India. ARCHIVES OF SEXUAL BEHAVIOR 2016; 45:945-954. [PMID: 25905909 DOI: 10.1007/s10508-015-0486-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 01/13/2015] [Accepted: 01/16/2015] [Indexed: 06/04/2023]
Abstract
Despite their large numbers, and important role in the HIV epidemic in India, male clients of female sex workers (FSWs) are a difficult to reach population and little is known about their sexual behaviors. Using data from an integrated behavioral and biological assessment of 684 clients in Bangalore in 2012, we examined factors associated with their reports of having sex with three or more different female sex workers in the last month, and anal sex with sex workers. We included sociodemographic and sexual behavior factors and, for the first time in client studies in India, included data on the use of pornography and sexual enhancement products (SEPs) such as pills, oils, and sprays, in our multivariable analyses of client risk. Seventy-eight percent of clients had seen pornographic material and 8% reported ever having used SEPs. The profiles of men practicing the two risk behaviors examined were quite different. Travel in the past year, drunkenness in the past month, young age at first commercial sex, non-use of condoms at last sex, and finding sex workers in public places (but not use of pornography and SEPs) were independently associated with multiple partnering. Sex with a man or transsexual, being a white collar worker, seeking out FSWs at home, pornography and SEP use, and condom use at last FSW sex, were all independently associated with anal sex with an FSW. More research is needed to better understand the links between pornography and SEPs, and HIV risk behaviors, and HIV prevention programs need to be cognizant of the importance of ensuring that condom use is adequately promoted and supported in the context of anal sex in female sex worker-client interactions.
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Affiliation(s)
- Janet Bradley
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec, Hôpital du Saint-Sacrement, Quebec City, PQ, Canada.
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 McDermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB, R3E 0T6, Canada.
| | - Subramanian Potty Rajaram
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec, Hôpital du Saint-Sacrement, Quebec City, PQ, Canada
- CHARME-India Project, Bangalore, India
- India KHPT Office, Bangalore, India
| | | | | | | | | | - Stephen Moses
- Centre for Global Public Health, Faculty of Medicine, University of Manitoba, 771 McDermot Avenue, Medical Rehabilitation Building, Room R070, Winnipeg, MB, R3E 0T6, Canada
| | - Michel Alary
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec, Hôpital du Saint-Sacrement, Quebec City, PQ, Canada
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Bandewar SVS, Bharat S, Kongelf A, Pisal H, Collumbien M. Considering risk contexts in explaining the paradoxical HIV increase among female sex workers in Mumbai and Thane, India. BMC Public Health 2016; 16:85. [PMID: 26822805 PMCID: PMC4730760 DOI: 10.1186/s12889-016-2737-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 01/14/2016] [Indexed: 11/17/2022] Open
Abstract
Background The period 2006–2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers’ risk environment is needed to explain this paradox. Methods In this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012. Results Dramatic changes in Mumbai’s urban landscape dominated participants’ accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women’s decisions to compromise on condom use. Surveys monitoring HIV prevalence among ‘visible’ street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction. Conclusions Targeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building ‘dark logic’ models to predict potential harms.
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Affiliation(s)
- Sunita V S Bandewar
- Independent Senior Research Professional in Bioethics, Global Health, and Program Evaluation, Pune, MH, 411 008, India.
| | - Shalini Bharat
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, MH, India.
| | - Anine Kongelf
- Present address: Norwegian Red Cross, Vestlia 4, Jessheim, Norway.
| | - Hemlata Pisal
- Independent Senior Research Professional, Pune, MH, India.
| | - Martine Collumbien
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK.
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10
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Pettifor A, Lippman SA, Selin AM, Peacock D, Gottert A, Maman S, Rebombo D, Suchindran CM, Twine R, Lancaster K, Daniel T, Gómez-Olivé FX, Kahn K, MacPhail C. A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention. BMC Public Health 2015; 15:752. [PMID: 26245910 PMCID: PMC4527273 DOI: 10.1186/s12889-015-2048-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/10/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Community mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa. METHODS Community Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18-35 years at baseline and endline about two years later. CONCLUSIONS This is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective. TRIAL REGISTRATION ClinicalTrials.gov NCT02129530.
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Affiliation(s)
- Audrey Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
- Honorary appointments at MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and Wits Reproductive Health and HIV Institute (WHRI), University of the Witwatersrand, Johannesburg, South Africa.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sheri A Lippman
- Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Amanda M Selin
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ann Gottert
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - Chirayath M Suchindran
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Lancaster
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine MacPhail
- Honorary appointments at MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and Wits Reproductive Health and HIV Institute (WHRI), University of the Witwatersrand, Johannesburg, South Africa
- CRN for Mental Health and Wellbeing, University of New England, Armidale, NSW, Australia
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11
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Thamattoor U, Thomas T, Banandur P, S R, Duchesne T, Abdous B, Washington R, B M R, Moses S, Alary M. Multilevel Analysis of the Predictors of HIV Prevalence among Pregnant Women Enrolled in Annual HIV Sentinel Surveillance in Four States in Southern India. PLoS One 2015; 10:e0131629. [PMID: 26147208 PMCID: PMC4492681 DOI: 10.1371/journal.pone.0131629] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 06/04/2015] [Indexed: 11/19/2022] Open
Abstract
Background Heterogeneity of the HIV epidemic across districts of south India is reflected in HIV positivity among antenatal clinic (ANC) attendees. Along with individual factors, contextual factors also need consideration for effective HIV interventions. Thus, identifying district and individual level factors that influence ANC HIV positivity assumes importance to intervene effectively. Methods Data on HIV sentinel surveillance among the ANC population were obtained from the National AIDS Control Organization (NACO) between years 2004 and 2007. Data from serial cross-sectional studies among female sex workers (FSWs) conducted during this time period in 24 districts were used to generate district level variables corresponding to parameters concerning this high risk population. Other district level data were obtained from various official/governmental agencies. Multilevel logistic regression was used to identify individual and district level factors associated with ANC-HIV positivity. Results The average ANC-HIV prevalence from 2004 to 2007 in the 24 integrated biological and behavioural assessments (IBBA) districts ranged from 0.25 to 3.25%. HIV positivity was significantly higher among ANC women with age≥25 years [adjusted odds ratio (AOR):1.49; 95% confidence interval (95%CI):1.27 to 1.76] compared to those with age<25 years; illiterate (AOR:1.62; 95%CI:1.03 to 2.54) compared to literate; employed in agriculture (AOR:1.34; 95%CI:1.11 to 1.62) or with occupations like driver/helper/industry/factory workers/hotel staff (AOR:1.59; 95%CI:1.26 to 2.01) compared to unemployed. District level HIV prevalence among FSWs (AOR:1.03; 95%CI:1.0 to 1.05) and percentage women marrying under 18 years were significantly associated with ANC-HIV positivity (AOR:1.02; 95%CI:1.00 to 1.04). Conclusion Illiteracy of the woman, higher HIV prevalence among FSWs and early marriage were associated with HIV positivity among pregnant women in southern India. In addition to targeted HIV preventive interventions among FSWs, studying and changing the behavior of FSW clients and addressing structural drivers of the epidemic might indirectly help reduce HIV infection among women in southern India.
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Affiliation(s)
- Usha Thamattoor
- St John’s Research Institute, Bangalore, 560034, India
- CHARME II Project, Bangalore, 560044, India
- * E-mail:
| | - Tinku Thomas
- St John’s Research Institute, Bangalore, 560034, India
- CHARME II Project, Bangalore, 560044, India
| | - Pradeep Banandur
- CHARME II Project, Bangalore, 560044, India
- Department of Epidemiology, National Institute of Medical Sciences (NIMHANS), Bangalore, 560029, India
| | - Rajaram S
- CHARME II Project, Bangalore, 560044, India
- Karnataka Health Promotion Trust, Bangalore, 560044, India
| | - Thierry Duchesne
- Centre de recherche du CHU de Québec, Québec, Canada
- Département de mathématiques et de statistique, Université Laval, Québec, Canada
| | - Belkacem Abdous
- Centre de recherche du CHU de Québec, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Reynold Washington
- St John’s Research Institute, Bangalore, 560034, India
- Karnataka Health Promotion Trust, Bangalore, 560044, India
| | - Ramesh B M
- CHARME II Project, Bangalore, 560044, India
- Karnataka Health Promotion Trust, Bangalore, 560044, India
| | - Stephen Moses
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Michel Alary
- CHARME II Project, Bangalore, 560044, India
- Centre de recherche du CHU de Québec, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
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12
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Giguère K, Alary M. Targeting core groups for gonorrhoea control: feasibility and impact. Sex Transm Infect 2015; 91:241-4. [PMID: 25926404 DOI: 10.1136/sextrans-2014-051732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/02/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE We aimed to outline why core groups should be targeted in Neisseria gonorrhoeae control and suggest several important and timely interventions to target core groups while highly resistant strains are spreading. METHODS Core group definition, feasibility and impact of gonorrhoea core group interventions as well as gonorrhoea resistance development have been reviewed in the paper. RESULTS Core group interventions have proven effective in gonorrhoea control in the past but are compromised by the spread of highly resistant strains. CONCLUSIONS Worldwide functional Gonorrhoea Antimicrobial Surveillance Program, better screening and better treatment programmes are needed. Prevention through condom promotion aimed at core groups remains essential. More specific treatment guidance for low-income and middle-income countries without resistance data is required in the meantime to achieve a better use of antibiotics.
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Affiliation(s)
- Katia Giguère
- Centre de recherche du CHU de Québec, Québec, Canada Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Michel Alary
- Centre de recherche du CHU de Québec, Québec, Canada Département de médecine sociale et préventive, Université Laval, Québec, Canada Institut national de santé publique du Québec, Québec, Canada
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13
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Kongelf A, Bandewar SVS, Bharat S, Collumbien M. Is scale-up of community mobilisation among sex workers really possible in complex urban environments? The case of Mumbai, India. PLoS One 2015; 10:e0121014. [PMID: 25811484 PMCID: PMC4374852 DOI: 10.1371/journal.pone.0121014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the last decade, community mobilisation (CM) interventions targeting female sex workers (FSWs) have been scaled-up in India's national response to the HIV epidemic. This included the Bill and Melinda Gates Foundation's Avahan programme which adopted a business approach to plan and manage implementation at scale. With the focus of evaluation efforts on measuring effectiveness and health impacts there has been little analysis thus far of the interaction of the CM interventions with the sex work industry in complex urban environments. METHODS AND FINDINGS Between March and July 2012 semi-structured, in-depth interviews and focus group discussions were conducted with 63 HIV intervention implementers, to explore challenges of HIV prevention among FSWs in Mumbai. A thematic analysis identified contextual factors that impact CM implementation. Large-scale interventions are not only impacted by, but were shown to shape the dynamic social context. Registration practices and programme monitoring were experienced as stigmatising, reflected in shifting client preferences towards women not disclosing as 'sex workers'. This combined with urban redevelopment and gentrification of traditional red light areas, forcing dispersal and more 'hidden' ways of solicitation, further challenging outreach and collectivisation. Participants reported that brothel owners and 'pimps' continued to restrict access to sex workers and the heterogeneous 'community' of FSWs remains fragmented with high levels of mobility. Stakeholder engagement was poor and mobilising around HIV prevention not compelling. Interventions largely failed to respond to community needs as strong target-orientation skewed activities towards those most easily measured and reported. CONCLUSION Large-scale interventions have been impacted by and contributed to an increasingly complex sex work environment in Mumbai, challenging outreach and mobilisation efforts. Sex workers remain a vulnerable and disempowered group needing continued support and more comprehensive services.
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Affiliation(s)
- Anine Kongelf
- London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London United Kingdom
| | - Sunita V. S. Bandewar
- Independent Senior Researcher in Global Health, Bioethics and Program Evaluation, C-5, Mantri Avenue—I, Panchavati, Pashan Rd, Pune, India
| | - Shalini Bharat
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Martine Collumbien
- London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London United Kingdom
- * E-mail:
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14
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Increased HIV prevention program coverage and decline in HIV prevalence among female sex workers in south India. Sex Transm Dis 2015; 41:380-7. [PMID: 24825335 PMCID: PMC4047305 DOI: 10.1097/olq.0000000000000138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As one way of assessing the impact of Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation, we examined the association between HIV prevention program indicators and changes in HIV prevalence among female sex workers (FSWs) between 2005 and 2009. METHODS We conducted a secondary data analysis from 2 large cross-sectional surveys (2005-2006 and 2008-2009) across 24 districts in south India (n = 11,000 per round). A random-effect multilevel logistic regression analysis was performed using HIV as the outcome, with individual independent variables (from both surveys) at level 1 and district-level FSW-specific program indicators and contextual variables at level 2. Program indicators included their 2006 value, the difference in their values between 2008 and 2006, and the interaction between this difference and study round. RESULTS HIV prevalence among FSWs decreased from 17.0% to 14.2% (P < 0.001). This decline varied significantly (P = 0.006) across levels of difference in program coverage (% of FSWs contacted by the program in a given year). Odds ratios comparing HIV prevalence between rounds changed with the level of increase in coverage and were statistically significant with coverage increase ≥ quartile (Q) 1: odds ratio, 0.85 at Q1; 0.78 at Q2; 0.66 at Q3; and 0.51 at Q4. CONCLUSIONS These findings suggest that increased program coverage was associated with declining HIV prevalence among FSWs covered by the Avahan program. The triangulation of our results with those from other approaches used in evaluating Avahan suggests a major impact of this intervention on the HIV epidemic in southern India.
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15
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Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, McFall A, Fonner VA, Butler J. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet 2015; 385:172-85. [PMID: 25059938 PMCID: PMC7394498 DOI: 10.1016/s0140-6736(14)60973-9] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.
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Affiliation(s)
- Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | - Peninah Mwangi
- Bar Hostess Empowerment and Support Program, Nairobi, Kenya
| | - Kay Thi Win
- Asia Pacific Network of Sex Workers (APNSW), Bangkok, Thailand
| | - Allison McFall
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, Reza-Paul S, Lau J, Deering K, Pickles MR, Boily MC. Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet 2015; 385:55-71. [PMID: 25059947 PMCID: PMC4297548 DOI: 10.1016/s0140-6736(14)60931-4] [Citation(s) in RCA: 535] [Impact Index Per Article: 59.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.
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Affiliation(s)
- Kate Shannon
- Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada.
| | | | - Shira M Goldenberg
- Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
| | - Putu Duff
- Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
| | - Peninah Mwangi
- Bar Hostesses Empowerment and Support Program, African Sex Workers Alliance, Nairobi, Kenya
| | | | | | | | - Kathleen Deering
- Gender and Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
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Sharma V, Saggurti N, Bharat S. Association Between System Reach and Exposure to Interventions and Characteristics of Mobile Female Sex Workers in Four High HIV Prevalence States in India. Glob J Health Sci 2015; 7:83-95. [PMID: 25946932 PMCID: PMC4802063 DOI: 10.5539/gjhs.v7n4p83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/25/2014] [Accepted: 11/11/2014] [Indexed: 11/12/2022] Open
Abstract
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.
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18
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Ogbe AE, Sagay AS, Imade GE, Musa J, Pam VC, Egah D, Onwuliri V, Short R. DECLINING PREVALENCE OF HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS AMONG FEMALE SEX WORKERS IN JOS, NORTH-CENTRAL NIGERIA. AFRICAN JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2014; 43:5-13. [PMID: 29578211 PMCID: PMC4682905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Female Sex Workers (FSWs) are key reservoirs of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) from which transmission to the general population fuels epidemics. STIs amplify HIV infectiousness and susceptibility. We determined the status of HIV and STIs among brothel-based FSWs in Jos as part of an ongoing prevention intervention. METHOD Between January and May 2012, consenting consecutive brothel-based FSWs were recruited from previously designated brothels across Jos. HIV counseling and testing as well as screening for gonorrhoea, syphilis, trichomonasis, candidasis and Bacteria vaginosis (BV) were performed. Positive cases were provided free treatment and follow-up at Solat Women Hospital, Jos. Ethical clearance was obtained from Jos University Teaching Hospital (JUTH) ethical committee. RESULT Two hundred FSWs aged 27.6 ± 4.6 years (range 15-55 years) were recruited and of these, 47 (23.5%) were HIV Positive, 20 (10.0%) had syphilis, 9 (4.5%) had Neisseria gonorrhea, 3 (1.5%) had Trichomonas vaginalis and 86 (43.0%) had BV. The association between HIV and bacterial vaginosis was statistically significant (OR of 2.2, 95% CI of 1.1-4.2, P-value=0.02). In comparison to similar prevalence in 2006, the current findings represent 51.5% decline in HIV prevalence, 40.8% decline for syphilis and over 83.3% decline in prevalence for Trichomonas vaginalis. There was no significant change in the prevalence of Neisseria gonorrhoea and BV. CONCLUSION The prevalence of HIV and STIs among brothel-based FSWs in Jos remain unacceptably high, although, there is a declining trend. A comprehensive HIV prevention program targeting these women is required to block transmission to the general population.
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Affiliation(s)
- AE Ogbe
- Departments of Obstetrics and Gynaecology, University of Jos /Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - AS Sagay
- Departments of Obstetrics and Gynaecology, University of Jos /Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - GE Imade
- Departments of Obstetrics and Gynaecology, University of Jos /Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - J Musa
- Departments of Obstetrics and Gynaecology, University of Jos /Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - VC Pam
- Departments of Obstetrics and Gynaecology, University of Jos /Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - D Egah
- Medical Microbiology, University of Jos, Jos, Plateau State, Nigeria
| | - V Onwuliri
- Biochemistry, Faculty of Medical Sciences, University of Jos, Jos, Plateau State, Nigeria
| | - R Short
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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Ramanathan S, Deshpande S, Gautam A, Pardeshi DB, Ramakrishnan L, Goswami P, Adhikary R, George B, Paranjape RS, Mainkar MM. Increase in condom use and decline in prevalence of sexually transmitted infections among high-risk men who have sex with men and transgender persons in Maharashtra, India: Avahan, the India AIDS Initiative. BMC Public Health 2014; 14:784. [PMID: 25086742 PMCID: PMC4131028 DOI: 10.1186/1471-2458-14-784] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 07/23/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Kumar GA, Dandona R, Alary M, Dandona L. Predictors of HIV prevalence among street-based female sex workers in Andhra Pradesh state of India: a district-level analysis. BMC WOMENS HEALTH 2014; 14:65. [PMID: 24885786 PMCID: PMC4017706 DOI: 10.1186/1472-6874-14-65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/25/2014] [Indexed: 11/22/2022]
Abstract
Background A decline in HIV prevalence among female sex workers (FSWs) has been reported from the Indian state of Andhra Pradesh between the two rounds of integrated biological and behavioural assessment (IBBA) surveys in 2005–06 and 2009, the first of these around the time of start of the Avahan HIV prevention intervention. In order to facilitate further planning of FSW interventions, we report the factors associated with HIV prevalence among street-based FSWs. Methods Behavioural data from the two rounds of IBBA surveys, district-level FSW HIV prevention program data, and urbanisation data from the Census of India were utilized. A multilevel logistic model was used to investigate factors associated with inter-district variations in HIV positivity among street-based FSWs in the districts by fitting a two-level model. Results The estimated HIV prevalence among street-based FSWs changed from 16% (95% confidence interval [CI] 14.2 – 17.7%) to 12.9% (95% CI 11.5 – 14.2%) from 2005–06 to 2009. HIV positivity was significantly higher in districts with a high proportion of FSWs registered with targeted interventions (odds ratio [OR] 2.02; 95% CI 1.18-3.45), and in districts with medium (OR 2.54; 95% CI 1.58-4.08) or high (OR 1.55; 95% CI 1.05-2.29) proportion of urban population. Districts which had met the condom requirement targets for FSWs had significantly lower HIV positivity (OR 0.50; 95% CI 0.26-0.97). In round 2 survey, the districts with medium level urbanisation had significantly higher proportion of FSWs registered with HIV intervention programmes and also reported higher consistent condom use with regular partner (p < 0.001). Conclusions Variations in HIV positivity among street-based FSWs were seen at the district level in relation to HIV intervention programs and the degree of urbanization. These findings could be used to enhance program planning to further reduce HIV transmission in this population.
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Affiliation(s)
| | - Rakhi Dandona
- Public Health Foundation of India, ISID Campus, 4 Institutional Area, Vasant Kunj, New Delhi 110 070, India.
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Rukewe A, Fatiregun A, Adebayo K. Anaesthesia for caesarean deliveries and maternal complications in a Nigerian teaching hospital. AFRICAN JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2014; 43:5-10. [PMID: 25335372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The aim of this audit was to evaluate the frequency of caesarean delivery, anaesthetic techniques employed, investigate potential trends and the rate of maternal complications associated with general or regional anaesthesia in our institution. METHODS We reviewed data collected on all deliveries from patients' medical records, anaesthetic charts and relevant surgical notes from 1 January 2008 to 31 December 2010. RESULTS A total of 10,911 deliveries were conducted during the study period and there were 3389 caesarean sections, giving a rate of 31.1%; which showed an upward trend from 27.8% in the first year to 34% in the third year. Our data showed a predominant use of regional anaesthesia for caesarean section generally (86.2%) and 83.8% for emergency caesarean deliveries in line with global trends. The overall complication rate was 10.5%. However, 34.5% of parturients who had general anaesthesia in contrast with 6.7% who had regional techniques had anaesthesia-related complications, postoperative intensive care unit admission rather than recovery room care, intra-operative cardiac arrest and haemorrhage exceeding 1200 ml (p = 0.001). Haemodynamic fluctuations were the most common anaesthesia-related complication. Our data revealed that general anaesthesia was a significant risk factor for maternal complications. CONCLUSION Obstetric general anaesthesia is low in our hospital. Our result showed that general anaesthesia was a significant risk factor for maternal complications during caesarean section.
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Fonner VA, Kerrigan D, Mnisi Z, Ketende S, Kennedy CE, Baral S. Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland. PLoS One 2014; 9:e87527. [PMID: 24498125 PMCID: PMC3909117 DOI: 10.1371/journal.pone.0087527] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 12/29/2013] [Indexed: 11/18/2022] Open
Abstract
Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR] = 2.25, 95% confidence interval [CI]: 1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.
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Affiliation(s)
- Virginia A. Fonner
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, Maryland, United States of America
| | | | - Sosthenes Ketende
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Caitlin E. Kennedy
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
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Lippman SA, Maman S, MacPhail C, Twine R, Peacock D, Kahn K, Pettifor A. Conceptualizing community mobilization for HIV prevention: implications for HIV prevention programming in the African context. PLoS One 2013; 8:e78208. [PMID: 24147121 PMCID: PMC3795620 DOI: 10.1371/journal.pone.0078208] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 09/17/2013] [Indexed: 01/15/2023] Open
Abstract
Introduction Community mobilizing strategies are essential to health promotion and uptake of HIV prevention. However, there has been little conceptual work conducted to establish the core components of community mobilization, which are needed to guide HIV prevention programming and evaluation. Objectives We aimed to identify the key domains of community mobilization (CM) essential to change health outcomes or behaviors, and to determine whether these hypothesized CM domains were relevant to a rural South African setting. Method We studied social movements and community capacity, empowerment and development literatures, assessing common elements needed to operationalize HIV programs at a community level. After synthesizing these elements into six essential CM domains, we explored the salience of these CM domains qualitatively, through analysis of 10 key informant in-depth-interviews and seven focus groups in three villages in Bushbuckridge. Results CM domains include: 1) shared concerns, 2) critical consciousness, 3) organizational structures/networks, 4) leadership (individual and/or institutional), 5) collective activities/actions, and 6) social cohesion. Qualitative data indicated that the proposed domains tapped into theoretically consistent constructs comprising aspects of CM processes. Some domains, extracted from largely Western theory, required little adaptation for the South African context; others translated less effortlessly. For example, critical consciousness to collectively question and resolve community challenges functioned as expected. However, organizations/networks, while essential, operated differently than originally hypothesized - not through formal organizations, but through diffuse family networks. Conclusions To date, few community mobilizing efforts in HIV prevention have clearly defined the meaning and domains of CM prior to intervention design. We distilled six CM domains from the literature; all were pertinent to mobilization in rural South Africa. While some adaptation of specific domains is required, they provide an extremely valuable organizational tool to guide CM programming and evaluation of critically needed mobilizing initiatives in Southern Africa.
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Affiliation(s)
- Sheri A. Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Suzanne Maman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Catherine MacPhail
- Wits Reproductive Health and HIV Institute (WRHI), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Collaborative Research Network, University of New England, Armidale, New South Wales, Australia
| | - Rhian Twine
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dean Peacock
- Sonke Gender Justice Network, Cape Town, South Africa
| | - Kathleen Kahn
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Wits Reproductive Health and HIV Institute (WRHI), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Suryawanshi D, Bhatnagar T, Deshpande S, Zhou W, Singh P, Collumbien M. Diversity among clients of female sex workers in India: comparing risk profiles and intervention impact by site of solicitation. implications for the vulnerability of less visible female sex workers. PLoS One 2013; 8:e73470. [PMID: 24023877 PMCID: PMC3759393 DOI: 10.1371/journal.pone.0073470] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/22/2013] [Indexed: 12/05/2022] Open
Abstract
Background It seems generally accepted that targeted interventions in India have been successful in raising condom use between female sex workers (FSWs) and their clients. Data from clients of FSWs have been under-utilised to analyse the risk environments and vulnerability of both partners. Methods The 2009 Integrated Biological and Behavioural Assessment survey sampled clients of FSWs at hotspots in Andhra Pradesh, Maharashtra and Tamil Nadu (n=5040). The risk profile of clients in terms of sexual networking and condom use are compared across usual pick-up place. We used propensity score matching (PSM) to estimate the average treatment effect on treated (ATT) of intervention messages on clients’ consistent condom use with FSW. Results Clients of the more hidden sex workers who solicit from home or via phone or agents had more extensive sexual networks, reporting casual female partners as well as anal intercourse with male partners and FSW. Clients of brothel-based sex workers, who were the least educated, reported the fewest number/categories of partners, least anal sex, and lowest condom use (41%). Consistent condom use varied widely by state: 65% in Andhra Pradesh, 36% in Maharashtra and 29% in Tamil Nadu. Exposure to intervention messages on sexually transmitted infections was lowest among men frequenting brothels (58%), and highest among men soliciting less visible sex workers (70%). Exposure had significant impact on consistent condom use, including among clients of home-based sex workers (ATT 21%; p=0.001) and among men soliciting other more hidden FSW (ATT 17%; p=0.001). In Tamil Nadu no impact could be demonstrated. Conclusion Commercial sex happens between two partners and both need to be, and can be, reached by intervention messages. Commercial sex is still largely unprotected and as the sex industry gets more diffuse a greater focus on reaching clients of sex workers seems important given their extensive sexual networks.
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Affiliation(s)
| | | | | | - Weiwei Zhou
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pankaj Singh
- Tata Institute of Social Sciences, Mumbai, India
| | - Martine Collumbien
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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Arora P, Nagelkerke NJD, Moineddin R, Bhattacharya M, Jha P. Female sex work interventions and changes in HIV and syphilis infection risks from 2003 to 2008 in India: a repeated cross-sectional study. BMJ Open 2013; 3:bmjopen-2013-002724. [PMID: 23794571 PMCID: PMC3686231 DOI: 10.1136/bmjopen-2013-002724] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES We examined if increased spending and coverage of female sex worker (FSW) interventions were associated with declines in HIV or syphilis risk among young pregnant women (as a proxy for new infections in the general population) in the high-burden southern states of India. DESIGN Repeated cross-sectional analysis. SETTING We used logistic regression to relate district-level spending, number of sexually transmitted infections (STIs) treated, FSWs reached or condoms distributed to the declines in the annual risk of HIV and syphilis from 2003 to 2008 among prenatal clinic attendees in the four high-HIV burden states of Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu. PARTICIPANTS 386 961 pregnant women aged 15-24 years (as a proxy for incident infections in the adult population). INTERVENTIONS We examined National AIDS Control Organisation (NACO) data on 868 FSW intervention projects implemented between 1995 and 2008. PRIMARY AND SECONDARY OUTCOME MEASURES HIV or syphilis infection. RESULTS HIV and syphilis prevalence declined substantially among young pregnant women. Each additional STI treated (per 1000 people) reduced the annual risk of HIV infection by -1.7% (95% CI -3.3 to -0.1) and reduced the annual risk of syphilis infection by -10.9% (95%CI -15.9 to -5.8). Spending, FSWs reached or condoms distributed did not reduce HIV risk, but each was significantly associated with reduced annual risk of syphilis infection. There were no major differences between the NACO-funded and Avahan-funded districts in the annual risk of either STI. CONCLUSIONS Targeted FSW interventions are associated with reductions in syphilis risk and STI treatment is associated with reduced HIV risk. Both more and less costly FSW interventions have comparable effectiveness.
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Affiliation(s)
- Paul Arora
- Division of Epidemiology, Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nico J D Nagelkerke
- Department of Community Medicine, UAE University, Al Ain, United Arab Emirates
| | - Rahim Moineddin
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Madhulekha Bhattacharya
- Department of Community Health Administration, National Institute of Health and Family Welfare, New Delhi, India
| | - Prabhat Jha
- Division of Epidemiology, Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Armstrong G, Medhi GK, Kermode M, Mahanta J, Goswami P, Paranjape R. Exposure to HIV prevention programmes associated with improved condom use and uptake of HIV testing by female sex workers in Nagaland, Northeast India. BMC Public Health 2013; 13:476. [PMID: 23675685 PMCID: PMC3658933 DOI: 10.1186/1471-2458-13-476] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 05/10/2013] [Indexed: 11/28/2022] Open
Abstract
Background There a concentrated HIV epidemic among female sex workers (FSWs) in the state of Nagaland, located in the north-east of India. Local non-government organisations (NGOs) are supported by the National State AIDS Control Society (NSACS) and the Avahan-funded Project ORCHID (Avahan is the India AIDS initiative of Bill & Melinda Gates Foundation in India) to deliver a range of interventions to FSWs including safe sex promotion, condom distribution, and testing and treatment of sexually transmitted infections (STIs). The commercial hub of Nagaland, Dimapur, is an important transportation node, and hosts a concentration of FSWs. This paper reports on comparative analysis of Integrated Behavioural and Biological Assessment (IBBA) data collected from FSWs in Dimapur in 2006 and 2009 to assess changes in condom use, HIV testing, and exposure to interventions. Methods Two IBBA cross-sectional surveys were undertaken among FSWs in Dimapur in 2006 (Round 1) and 2009 (Round 2) using an interviewer-administered questionnaire and the collection of blood and urine samples. Respondent-driven sampling (RDS), a sampling technique for use among hidden populations, was used to recruit the samples. Results When round 1 is compared with round 2, there was a marked and statistically significant improvement in the use of condoms at last sex with both occasional (35.2% to 72.4%) and regular (25.8% to 57.7%) clients, and an increase in the proportion having ever had an HIV test (8.9% to 29.1%). There was no evidence of an improvement in the proportional coverage of the HIV prevention services delivered to FSWs in Dimapur between round 1 and round 2. In round 2, FSWs exposed to the programme were more than twice (OR=2.27) as likely to consistently use condoms with occasional clients, four times (OR: 4.11) more likely to use condoms consistently with regular clients and nine times (OR: 9.08) more likely to have ever had an HIV test. Conclusions We found evidence of an increase in condom use and HIV testing, and a strong and consistent association between programme exposure and condom use and HIV testing indicating that NGO HIV prevention programmes have been making a substantial contribution to HIV prevention among FSWs in Dimapur. However, there was no evidence of improved coverage of HIV prevention services, and there is a clear need to expand the reach of services in order for them to have an impact on a larger pool of FSWs.
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Affiliation(s)
- Gregory Armstrong
- Nossal Institute for Global Health, University of Melbourne, Victoria, Australia.
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Dandona L, Benotsch EG. Evaluation of the Avahan HIV prevention initiative in India. BMC Public Health 2011; 11 Suppl 6:I1. [PMID: 22376043 PMCID: PMC3287546 DOI: 10.1186/1471-2458-11-s6-i1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Rachakulla HK, Kodavalla V, Rajkumar H, Prasad SPV, Kallam S, Goswami P, Dale J, Adhikary R, Paranjape R, Brahmam GNV. Condom use and prevalence of syphilis and HIV among female sex workers in Andhra Pradesh, India - following a large-scale HIV prevention intervention. BMC Public Health 2011; 11 Suppl 6:S1. [PMID: 22376071 PMCID: PMC3287547 DOI: 10.1186/1471-2458-11-s6-s1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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<0.001) and occasional clients (70.8% to 83.7%; AOR=2.20; p<0.001). The prevalence of lifetime syphilis decreased (10.8% to 6.1%; AOR=0.39; p<0.001) and HIV prevalence decreased in all districts combined (17.7% to 13.2%; AOR 0.68; p<0.01). Prevalence of HIV among younger FSWs (aged 18 to 20 years) decreased (17.7% to 8.2%, p=0.008). A significant increase in condom use at last sex with occasional and regular clients and consistent condom use with occasional clients was observed among FSWs exposed to the Avahan program. There was no association between exposure and HIV or STIs, although numbers were small. 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.
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Affiliation(s)
- Hari Kumar Rachakulla
- Division of Community Studies, National Institute of Nutrition (NIN), Hyderabad, India
| | - Venkaiah Kodavalla
- Department of Bio-statistics, National Institute of Nutrition (NIN), Hyderabad, India
| | - Hemalatha Rajkumar
- Department of Micro-Biology, National Institute of Nutrition (NIN), Hyderabad, India
| | - SPV Prasad
- Division of Community Studies, National Institute of Nutrition (NIN), Hyderabad, India
| | | | | | - Jayesh Dale
- National AIDS Research Institute (NARI), Pune, India
| | | | | | - GNV Brahmam
- Division of Community Studies, National Institute of Nutrition (NIN), Hyderabad, India
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