Awareness of and willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs and men who have sex with men in India: Results from a multi-city cross-sectional survey

Introduction

Pre-exposure prophylaxis (PrEP) is effective in reducing HIV transmission among key populations. In India, where PrEP is not currently part of the national HIV program, little is known about PrEP awareness, willingness to use PrEP, and barriers to uptake among people who inject drugs (PWID) and men who have sex with men (MSM).

Methods

We used respondent-driven sampling to accrue PWID and MSM in 22 sites from August 2016 to May 2017. Participants were asked about awareness of PrEP, willingness to use PrEP (following a brief description) and reasons why they might not be willing to use PrEP. Participants were also queried on preferences for PrEP delivery modality (oral vs. injectable). Multi-level logistic regression models were used to determine participant correlates of willingness to use PrEP. Estimates were weighted for the sampling method.

Results

A total of 10,538 PWID and 8,621 MSM who self-reported being HIV-negative were included in the analysis. Only 6.1% (95% confidence interval [CI]: 5.9, 6.3) of PWID and 8.0% of MSM (95% CI: 7.7, 8.4) were aware of PrEP. However, willingness to use PrEP was substantially higher in both groups: 52.4% of PWID and 67.6% of MSM. Participants commonly cited a perceived low risk for acquiring HIV infection, being perceived by others as being HIV-positive, and side effects as reasons why they would be unwilling to use PrEP. Among PWID, sharing needles and hazardous alcohol use were associated with increased willingness to use PrEP. Among MSM, having a main male partner and injection drug use were associated with increased willingness to use PrEP. Preference for daily oral or monthly injectable PrEP was similar among MSM (39.6%% vs. 41.7%,), while PWID were more likely to prefer oral to injectable administration routes (56.3% vs. 31.1%).

Conclusions

As India plans to roll-out of PrEP in the public sector, our multi-city survey of PWID and MSM highlights the need for key population-focused education campaigns about PrEP and self-assessment of risk.

Diversity of hepatitis C virus infection among HIV-infected people who inject drugs in India

The availability of generic direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has prompted many low-and-middle-income countries to launch HCV elimination programs. Because the efficacy of some of these generic DAAs varies by HCV viral subtype, information on subtype distribution can contribute important information to these elimination programs. We conducted a cross-sectional serosurvey to characterize HCV subtype diversity among HIV positive people who inject drugs (PWID) across 14 cities in India. Of 801 HIV positive PWID sampled, 639 tested HCV antibody positive (78.9%). Among 105 samples sequenced, genotype 3 (58.1%) was the most commonly observed followed by genotype 1 (36.2%) and genotype 6 (5.7%). Of the genotype 3 infections, 65% were subtype 3a and 35% were subtype 3b. Of the genotype 1 infections, 94% were subtype 1a and 6% were subtype 1b. All genotype 6 samples were subtype 6n. There was some variability in genotype diversity depending on geographic region and PWID epidemic stage with greater diversity observed in older PWID epidemics. One sequence, HY018, did not cluster with any known reference sequences in phylogenetic analysis. Nearly 80% of HIV infected PWID across India are co-infected with HCV, and subtype prevalence and genetic diversity varied by region and PWID epidemic stage. HCV elimination programs in India will need to consider HCV subtype.

Alcohol Use and Experiences of Partner Violence Among Female Sex Workers in Coastal Andhra Pradesh, India

This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW's defiance. In multivariate logistic regressions, frequency of FSW's alcohol use was associated with abuse by clients and primary partner, whereas partner's alcohol use was only significant for abuse by primary partner, not clients.

Directly observed therapy of sofosbuvir/ribavirin +/- peginterferon with minimal monitoring for the treatment of chronic hepatitis C in people with a history of drug use in Chennai, India (C-DOT)

We assessed the feasibility of field-based directly observed therapy (DOT) with minimal monitoring to deliver HCV treatment to people with a history of drug use in Chennai, India. Fifty participants were randomized 1:1 to sofosbuvir+peginterferon alfa 2a+ribavirin (SOF+PR) for 12 weeks (Arm 1) vs sofosbuvir+ribavirin (SOF+R) for 24 weeks (Arm 2). SOF+R was delivered daily at participant chosen venues and weekly peginterferon injections at the study clinic. HCV RNA testing was performed to confirm active HCV infection and sustained virologic response 12 weeks after treatment completion (SVR12). No baseline genotyping or on-treatment viral loads were performed. Median age was 46 years. All were male and 20% had significant fibrosis/cirrhosis. All self-reported history of injection drug use, 18% recent noninjection drug use and 38% alcohol dependence. Six discontinued treatment (88% completed treatment in each arm). Of 22 who completed SOF+PR, all achieved SVR12 (22/25=88%); 15 of 22 who completed SOF+R achieved SVR12 (15/25=60%; P=.05). Among those completing SOF+R, SVR12 was significantly less common in participants reporting ongoing substance use (36% vs 100%) and missed doses. Active substance use and missed doses did not impact SVR with SOF+PR. Field-based DOT of HCV therapy without real-time HCV RNA monitoring was feasible; however, achieving 100% adherence was challenging. SOF+PR appeared superior to SOF+R in achieving SVR12, even when doses were missed with no discontinuations due to side effects. Further exploration of short duration treatment with peginterferon plus direct-acting antivirals is warranted.

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India

Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.

Mobile phones and sex work in South India: the emerging role of mobile phones in condom use by female sex workers in two Indian states

The aim of this study was to examine female sex workers' solicitation of clients using mobile phones and the association between this and condom use with clients. Cross-sectional data were utilised to address the study's aim, drawing on data collected from female sex workers in Calicut, Kerala, and Chirala, Andhra Pradesh. Use of mobile phone solicitation was reported by 46.3% (n = 255) of Kerala participants and 78.7% (n = 464) of those in Andhra Pradesh. Kerala participants reporting exclusive solicitation using mobile phones demonstrated 1.67 times higher odds (95% CI: 1.01-2.79) of inconsistent condom use than those reporting non-use of mobile phones for solicitation. However, those reporting exclusive solicitation through mobile phones in Andhra Pradesh reported lower odds of inconsistent condom use (OR: 0.03; 95% CI: 0.01-0.26) than those not using mobile phones for solicitation. Findings indicate that solicitation of clients using mobile phones facilitates or hampers consistency in condom use with clients depending on the context, and how mobile phones are incorporated into solicitation practices. Variations in sex work environments, including economic dependence on sex work or lack thereof may partially account for the different effects found.

Measurement of self, experienced, and perceived HIV/AIDS stigma using parallel scales in Chennai, India

HIV/AIDS stigma can severely compromise the quality of life of people living with HIV/AIDS (PLHA) by reducing access and quality of care, adherence to therapy, and disclosure of HIV status, thereby potentially increasing transmission. The objective of this study was to develop and psychometrically test three parallel scales measuring self, experienced, and perceived stigma among PLHA (n=188) in Chennai, India. Exploratory factor analysis (EFA), which was used to facilitate item reduction and assess construct validity, confirmed the presence of three underlying theoretical domains. The final number of items and Cronbach's Alpha for each scale were: 8 items, Alpha of 0.84, for self stigma; 7 items, Alpha of 0.86, for experienced stigma; and 7 items, Alpha of 0.83, for perceived stigma. External validity was ascertained by confirming a significant positive association between the measure of each type of stigma and depression (measured using CES-D), using structural equation modeling (SEM). Therefore, scales were parsimonious, reliable, and were found to be valid measures of HIV/AIDS stigma. Using these validated scales, researchers can accurately collect data to inform the design of stigma reduction programs and interventions and enable subsequent evaluation of their effectiveness.

Measuring perceived stigma in female sex workers in Chennai, India

Although sex work is highly stigmatized throughout the world, a limited body of research has examined stigma among female sex workers (FSWs). We developed a Sex Worker Stigma (SWS) Index to measure perceived stigma among 150 FSWs in Chennai, India. These women were at a median age of 35 years and reported, on average, having engaged in sex work for nine out of the previous 12 months. The two-factor structure of the index was verified in both exploratory and confirmatory factor analyses with acceptable goodness of fit. The final 10-item index comprises of two domains of perceived stigma from the community and perceived stigma from one's family. Cronbach's α coefficients were 0.87 and 0.88 for each domain, respectively. In regression analysis, we found that income from jobs other than sex work was correlated with decreased levels of perceived stigma from both the community (β = - 0.16; 95% CI: -0.30 and -0.02) and the family (β = - 0.24; 95% CI: -0.40 and -0.07); prior experience of accessing health care system increased perceived stigma from the community while heavier financial responsibility for the family was associated with lower perceived stigma from women's family. With the proposed SWS Index, we have a valid and reliable metric to document and track levels of perceived stigma among FSWs to assess the impact of stigma reduction interventions.

Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery

The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January and April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when enrolling into care. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.

Acceptability of a microenterprise intervention among female sex workers in Chennai, India

Female sex workers have been central in India's HIV epidemic since it was first diagnosed among them in 1989. Female sex workers' risk of HIV is primarily economically motivated. The Pi pilot study examined the feasibility and association of a microenterprise intervention, the tailoring of canvas bags, on sexual risk behaviors among female sex workers (N = 100) in Chennai. Women were randomized to an intervention or control arm. Between-group comparisons at baseline and at six-month follow-up were performed. Multivariate linear regression with bootstrapping was conducted to estimate the intervention effect. At baseline, women were a median of 35 years old, 61% were married and they had an average of two children. Intervention participants reported a significantly lower number of sex partners and significant increases in income at the 6-month follow-up compared to control participants. In a multivariate model, intervention participants had a significantly lower number of paying clients per month at follow-up compared to control participants. By graduation, 75% of intervention arm participants had made at least one sellable canvas bag and 6 months after the study's end, 60% have continued involvement in bag production. The pilot study demonstrated that microenterprise interventions are successful in both providing FSWs with licit income opportunities and was associated with reductions in HIV risk behaviors.

A descriptive profile of abused female sex workers in India

This descriptive study presents the profiles of abused female sex workers (FSWs) in Chennai, India. Of 100 abused FSWs surveyed using a structured questionnaire, severe forms of violence by intimate partners were reported by most (98%) respondents. Of the total sample, 76% experienced violence by clients. Sexual coercion experiences of the FSWs included verbal threats (77%) and physical force (87%) by intimate partners and forced unwanted sexual acts (73%) by clients. While 39% of the women consumed alcohol before meeting a client, 26% reported that their drunkenness was a trigger for violence by clients. The findings suggest that there is an urgent need to integrate services, along with public-health interventions among FSWs to protect them from violence. Recognition of multiple identities of women in the contexts of intimate relationships versus sex work is vital in helping women to stay safe from adverse effects on health.

The profile of injection drug users in Chennai, India: identification of risk behaviours and implications for interventions

We characterize the demographics, injection practices and risk behaviours of 1,158 injection drug users (IDUs) in Chennai, the capital of Tamil Nadu in southern India, who were recruited during 2005-2006 by community outreach. The median age was 35 years; the majority of IDUs were male, of Tamil ethnicity and married, and earning less than US$75 per month. Most (76%) had injected in the prior month. The median age at first injection was 25 years; the most common drug injected was heroin (80%) followed by buprenorphine. High risk behaviours were common and included needle-sharing, unsafe disposal, and inappropriate cleaning of needles as well as limited condom use. IDUs in India need to be educated on harm reduction and safe-injection practices; Pharmacies could serve as potential venues for HIV prevention interventions among IDUs in India, as most IDUs obtain their needles from pharmacies without prescription.

Couples at risk for HIV infection in Southern India: characteristics of HIV-infected patients in concordant and discordant heterosexual relationships

The aim of the article is to compare the clinical and behavioural characteristics of HIV-infected South Indian patients in concordant and discordant heterosexual relationships. A cross-sectional analysis of married couples in concordant and discordant relationships was carried out. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were assessed. A total of 839 concordant patients and 996 discordant patients were included in this analysis. Significantly more men were in discordant than concordant relationships (97% versus 59%; P = 0.002). More discordant patients had never initiated highly active antiretroviral treatment (HAART) than concordant patients (14.1% versus 8.5%; P = 0.004). Concordant patients had significantly higher CD4 cell counts than discordant patients at the time of enrolling to care (205 versus 139 cells/μL; P = 0.001). Discordant patients had significantly higher plasma viral loads than concordant patients (100,000 copies/mL versus 89,154 copies/mL; P = 0.002). Discordant patients were more likely to use condoms with their spouses than concordant patients (49% versus 28.8%; P = 0.01).

In conclusion, couples-based interventions and the provision of HAART could substantially decrease behavioural and clinical correlates of HIV transmission among discordant South Indian married couples. The spouses of HIV-infected index patients are at increased risk for HIV infection, and further preventive measures are needed.

Risk factors for HIV transmission among heterosexual discordant couples in South India

OBJECTIVE

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care.

METHODS

A nested matched case-control study of serodiscordant couples in which the HIV-infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were measured at enrollment and longitudinally over 12 months of follow-up. The study included 70 cases who seroconverted during study follow-up and 167 matched controls who remained persistently serodiscordant.

RESULTS

The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person-years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P<0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P<0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL >100,000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1-2.8], non-disclosure of HIV status (OR: 5.5; 95% CI: 4.3-6.2) and not using condoms (OR: 2.8; 95% CI: 2.4-3.6).

CONCLUSIONS

Couples-based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

Associations between social capital and HIV stigma in Chennai, India: considerations for prevention intervention design

Stigma against persons living with HIV/AIDS (PLHA) is a barrier to seeking prevention education, HIV testing, and care. Social capital has been reported as an important factor influencing HIV prevention and social support upon infection. In the study, we explored the associations between social capital and stigma among men and women who are patrons of wine shops or community-based alcohol outlets in Chennai. We found that reports of social capital indicators were associated with reduced fear of transmission of HIV/AIDS, lower levels of feelings of shame, blame and judgment, lower levels of personal support and perceived community support for discriminatory actions against PLHA. Specifically, when participants reported membership in formal groups, perception of high levels of collective action toward community goals, high norms of reciprocity between neighbors and residents in daily life, and presence of trusted sexually transmitted disease care providers, all levels of measures of stigma were lower. Although we defined social capital rather narrowly in this study, our findings suggest that seeking partnerships with existing organizations and involving health care providers in future interventions may be explored as a strategy in community-based prevention interventions.

Expansion of HIV laboratory diagnostic services in Chennai, India 2001-2006: is the growth commensurate with the need?

OBJECTIVE

To describe the changes in HIV services provided and the patient population utilizing voluntary counseling and testing (VCT) services at private testing laboratories in Chennai, India in 2001 and 2006.

METHODS

In 2001, a cross-sectional descriptive survey was conducted to assess the services provided and client population of 1,031 private laboratories. A subset of labs (9%) that had been surveyed in 2001 were also studied in 2006.

RESULTS

In 2001, significantly more high volume labs (>10 HIV tests per month) offered HIV diagnostic tests than low volume labs (<10 HIV test per month) (p<0.001). More high volume labs (20.0%) provided pre-test counseling as part of HIV testing than low volume labs (11.1%) (p = 0.003). Between 2001 and 2006, the number of labs that provided HIV diagnostic tests significantly increased, including ELISA (87.8% vs. 40.0%), Western Blot (84.4% vs. 13.3%), and Tridot (98.9% vs. 72.2%) (p<0.001). Also the number of labs that reported greater than 10 women seeking HIV testing per month significantly increased from 14.5% to 79.0% (p = 0.006). More labs provided pre-test counseling in 2006 (34.4%) than in 2001 (21.1%) (p = 0.046).

CONCLUSIONS

Though HIV diagnostic testing services have increasingly become available, counseling services have not expanded commensurately. Further outreach and education is necessary to expand comprehensive HIV VCT services in both urban and rural India.

HIV/AIDS stigma: reliability and validity of a new measurement instrument in Chennai, India

HIV/AIDS stigma is a frequently cited barrier to HIV prevention, including voluntary counseling and testing. A reliable and valid measurement instrument is critical to empirically assess the extent and effects of HIV/AIDS stigma. The paper reports the development and psychometric testing of an HIV/AIDS stigma scale among 200 men in India. The resulting 24-item scale and the four subscales had good internal consistency (Cronbach's alpha overall was 0.81; subscales were 0.86, 0.73, 0.72 and 0.76, respectively). The scale and distinct subscales suggest a valid and reliable measure for HIV/AIDS stigma in a setting with highly prevalent HIV risk behaviors.

Geographic prevalence and multilevel determination of community-level factors associated with herpes simplex virus type 2 infection in Chennai, India

Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections, and it increases the risk of transmission of human immunodeficiency virus type 1 at least twofold. Individual-level factors are insufficient to explain geographic and population variation in HSV-2, suggesting the need to identify ecologic factors. The authors sought to determine the geographic prevalence and community-level factors associated with HSV-2 after controlling for individual-level factors among slums in Chennai, India. From March to June 2001, participants aged 18-40 years voluntarily completed a survey and were tested for HSV-2. Community characteristics were assessed through interviews with key informants and other secondary data sources. Multilevel nonlinear analysis was conducted. Eighty-five percent of eligible persons completed the survey; of these, 98% underwent HSV-2 testing, producing a final sample of 1,275. Participants were of Tamil ethnicity, were predominantly female and married, and were on average 30 years old. Fifteen percent were infected with HSV-2, and there was significant variation in HSV-2 prevalence among communities. After controlling for individual-level factors, the authors identified community-level factors, including socioeconomic status and the presence of injection drug users, that were independently associated with HSV-2 and explained 11% of the variance in prevalence. Future studies are needed to test mechanisms through which these community-level factors may be operating.

Comorbidities among HIV-infected injection drug users in Chennai, India

BACKGROUND & OBJECTIVE

HIV-infected injection drugs users (IDUs) are known to have high rates of co-infections. A few reports exist on comorbidities among HIV-infected IDUs in India. We carried out a retrospective study to analyse data on comorbidities in India and treatment challenges faced when treating HIV-infected IDUs in India.

METHODS

A retrospective chart review of 118 HIV-infected IDUs who accessed care at the YRG Centre for Substance Abuse-Related Research, Chennai, between August 2005 and February 2006 was done. Demographic, laboratory and clinical information was extracted from medical records. Descriptive demographic and clinical characteristics and distributions of comorbidities across CD4 cell count strata were analysed.

RESULTS

All IDUs were male with a median age of 35.5 yr. The majority were married with average monthly income less than INR 3000 per month. The prevalence of hepatitis B and C infections were 11.9 and 94.1 per cent, respectively. Other common co-morbidities included oral candidiasis (43.2%), tuberculosis (33.9%), anaemia (22.9%), lower respiratory tract infections (16.1%), cellulitis (6.8%), herpes zoster (9.3%) and herpes simplex (9.3%). Among participants with CD4+ < 200 cells/microl, the prevalence of TB was 60 per cent.

INTERPRETATION & CONCLUSION

IDUs in Chennai were commonly co-infected with HBV, HCV and tuberculosis, complicating use of antiretroviral and anti-tuberculous therapy. The current regimens available for the management of HIV and TB in India may need to be re-assessed for IDUs given the potential for increased rates of hepatotoxicity.

Intimate partner violence is as important as client violence in increasing street-based female sex workers' vulnerability to HIV in India

OBJECTIVES

There are no studies that examine street-based female sex workers' vulnerability to HIV from both clients and intimate partners. This study documents street-based female sex workers' experiences of client and intimate partners, examines the intersections of violence, alcohol use in condom use, and highlights survival strategies used to avert harm.

METHODS

Ethnographic data were collected from 49 female sex workers through focus group discussions and in-depth interviews.

RESULTS

Female sex workers experienced multifarious forms of severe client and intimate partner violence. Sexual coercion and forced group sex in the context of alcohol use posed formidable barriers for condom use negotiation. Further, traditional gender norms dictated women's inabilities to negotiate condom-use with intimate partners. However, there was evidence of adoption of successful survival strategies in the face of danger and women's positive evaluations of the benefits of sex work and their contributions to family well-being.

CONCLUSIONS

Harm reduction efforts with female sex workers need to account for their vulnerability to HIV from intimate partners in addition to clients. HIV prevention programmes need to include male clients in order to reduce harm among street-based female sex workers. There is an urgent need to build on sex workers' strengths and involve them in designing individual level, community, and structural interventions that could help in reducing women's vulnerability to intimate partner violence and HIV in India.

Challenges of expansion of voluntary counselling and testing in India

Voluntary counselling and testing (VCT) has been recognised as an integral element of any effective HIV public health primary prevention and care program. In India, it is currently estimated that 2.0–3.1 million individuals are living with HIV. As low-cost antiretroviral therapy has increasingly become available in India, VCT could be an important link connecting individuals to treatment and care. Major barriers remain for scaling-up of VCT services, including location of VCT centres, HIV-associated stigma, and lack of perception of HIV risk. Future national expansions of VCT services must engage the Indian private sector, which is likely to remain the largest provider of healthcare for the foreseeable future, through scaling-up personnel in these facilities to provide accurate testing and culturally-relevant counselling.

Exploring "wine shops" as a venue for HIV prevention interventions in urban India

Addressing male heterosexual risk is a high priority for HIV prevention efforts in India. Particularly in urban India, which draws men for employment opportunities, these efforts are gaining momentum with a focus on understanding possible risk facilitators such as alcohol use. However, little is known about venues where such efforts might be targeted. In this paper, we explore community-based alcohol outlets or "wine shops" in Chennai, India, as potential venues. We conducted ethnographic research with wine shop staff and clients to understand alcohol use and sexual behaviors. We then surveyed 118 wine shop patrons to quantify these risk behaviors and plan an appropriate intervention. Our results show that wine shops are a venue where social and sexual networks converge. Reports and observations of regular and heavy drinking were frequent. Over 50% of patrons surveyed reported three or more sexual partners in the past 3 months, and 71% of all patrons reported a history of exchanging sex for money. Condom use history was low overall but, in the adjusted analyses, was significantly higher (OR = 20.1) among those who reported that their most recent partner was a sex worker and lower (OR = 0.28) among those who reported they drank to feel disinhibited. The data suggest that wine shops may be an appropriate location to target men for HIV prevention interventions. We discuss how these findings helped design such an intervention in Chennai.

A social cognitive model of health for HIV-positive adults receiving care in India

In-depth interviews were conducted with 50 HIV-positive adults (23 women, 27 men) with access to care at a non-governmental organization in Chennai, India to gain a broad understanding of how they managed their HIV infection. Using a Social Cognitive Model of Health, we identified factors within the model's three domains--Personal, Environmental, and Behavioral--that are applicable to this socio-cultural context. The Personal domain's factors were a positive self-concept, family-focused goals, and treatment optimism; the Environmental domain comprised family-based support, treatment availability, access and quality, and HIV stigma and discrimination; and the Behavior domain's factors were medication adherence and health habits, sexual behavior, and social relationships and emotional well-being. Significant differences for many of the factors within the three domains were observed across married men and women, widowed women, unmarried men, and female sex workers. Implications for an enhanced intervention for HIV-infected individuals in similar treatment settings are discussed.

Risk Reduction Counseling Is Associated With Decreased HIV Transmission-Associated Behaviors in High-Risk Indian Heterosexuals

OBJECTIVE

To estimate the incidence of HIV and study the impact of risk-reduction counseling (RRC) in a cohort of people with high-risk behavior for HIV transmission in Chennai, India.

DESIGN

Prospective cohort follow-up of 500 HIV-negative people (250 men and 250 women) at increased risk for HIV acquisition in Chennai, India for a maximum of 1 year was conducted. They received RRC at 0, 6, and 12 months. Generalized estimating equation methodology was used to determine the statistical significance of differences reported in behavior between baseline, 6 months, and 12 months.

RESULTS

The overall HIV incidence in this cohort was 0.44 per 100 person-years (95% confidence interval: 0.05-1.60). In the course of the study, both male and female participants reported statistically significant decreases in the number of different sexual partners, the number of new partners, and the proportion of sexual encounters with nonprimary partners. Participants who had more than 3 different partners at baseline and/or exchanged money for sex in the 6 months before enrollment demonstrated the greatest reductions in the number of different sexual partners.

CONCLUSIONS

Individualized sexual RRC seems to be a useful intervention to reduce risk-taking behavior among at-risk heterosexuals in India.

Gender differences in the prevalence of sexually transmitted infections and genital symptoms in an urban setting in southern India

OBJECTIVES

To examine gender differences in sexual behaviour, the prevalence of laboratory-detected sexually transmitted infections (STIs) and self-reported genital symptoms in urban Chennai, Tamil Nadu, India.

STUDY DESIGN

The data were based on a cross-sectional survey (n = 1649) of residents from low-income communities in Chennai. Data were collected during community-wide health camps comprising physical examinations, interviews and laboratory testing between March and June 2001.

RESULTS

The population was young, sexually active, with a low prevalence of STI. The most commonly detected STI was Herpes simplex virus type 2 (HSV2; 13.2%). Women had a higher prevalence of HSV2, but were more likely than men to be asymptomatic. Most of the self-reported genital symptoms could not be linked to a laboratory-detected STI. >10% of the cohort had a history of an ulcerative STI and >5% had an inflammatory STI.

CONCLUSIONS

Given a high prevalence of HSV2 in the study population, interventions targeting HSV2 transmission may be particularly relevant for this population.

Sexual health promotion in Chennai, India: key role of communication among social networks

Communication about sex and sexual health is an important facilitator in gaining accurate knowledge about prevention of sexually transmitted diseases (STDs) and promotion of sexual health. Understanding how and with whom communication about sex occurs and the nature of the information exchanged is valuable in designing sexual risk prevention interventions. In this study of low-income communities residents in Chennai, India, our aim was to understand the composition of personal communication networks, the nature of information related to sex and sexual health that is exchanged in these networks and the value of communication among members of these networks. We conducted in-depth open-ended interviews using a structured interview guide with 43 individuals. We also conducted 12 focus group discussions. Individuals were selected using snowball sampling. Our results indicate that information about sex and sexual health is exchanged within and between four groups: married women, married men, unmarried men and unmarried women. Communication leads to an expansion of sexual networks among unmarried men and treatment seeking behaviour for STDs in all groups. Unmarried men offer immense potential for intervention given the range of topics related to sex and sexual health that are discussed and the risky sexual behaviours practiced. Spousal communication about sexual behaviour or sexual health is minimal and shifting norms for prevention would be difficult. Interventions identifying communication networks and influencing the natural communication patterns in these networks may be a viable HIV prevention strategy in the study area.

When HIV-prevention messages and gender norms clash: the impact of domestic violence on women's HIV risk in slums of Chennai, India

This paper examines how marital violence affects women's ability to protect themselves from HIV/AIDS. In-depth interviews (n = 48) and focus groups (n = 84, 3-7 per group) were conducted among men and women in two randomly selected slums of Chennai, India. The study showed that community gender norms tacitly sanction domestic violence that interferes with adopting HIV-preventive behaviors. Given the choice between the immediate threat of violence and the relatively hypothetical specter of HIV, women often resign themselves to sexual demands and indiscretions that may increase their risk of HIV acquisition. In conclusion, AIDS-prevention interventions must incorporate gender-related social contexts in settings where husbands strictly enforce their locus of control. HIV-prevention messages targeting men may effectively reduce women's exposure to HIV/AIDS.