Declining trends in risk behaviors and HIV/ STIs among Clients of FSWs in India: findings from large scale bio-behavioral surveys from three high prevalent Southern states
There is increasing recognition of the importance of
clients of FSW as bridge group to HIV transmission. However, there is paucity
of evidence that establishes the HIV vulnerabilities or risk among clients in
India. The current analysis examines the changes in risk behaviors (condom
use), prevalence of HIV and STIs, and the factors associated with condom use
behaviors among clients of sex workers in three Indian states using data from a
large scale cross-sectional bio-behavioural survey.
Data were derived from two rounds of integrated
behavioural and biological assessments (IBBA) conducted among clients in the
years 2006 and 2009 in Andhra Pradesh, Tamil Nadu and Maharashtra, India. Eligible
clients for the survey included men aged 18 years or older who had bought sex
from a FSW at least once in the previous month.Two
stage probability sampling was used and time location clusters sampling was
applied. Consented participants completed structured interviews to collect
behavioural data and provided blood and urine samples for HIV, Neisseria
gonorrhea, Chlamydia trachomatis, and syphilis testing.
Samples of 4,821 and 4,803 clients were covered in
IBBA rounds 1 and 2, respectively. The majority of the clients were literate,
ever married and worked as a laborer in two consecutive rounds. Over three
fourth of clients had first paid sex before age 25 years. Clients of FSWs had a
higher level of condom use during last sex act (AOR-2.5, 95% CI 1.9-3.3) and
consistent condom use (AOR-3.1, 95% CI-2.1-3.9) with occasional FSWs during
Round 2, compared with Round 1. Clients 24 years or younger (AOR=4.2; 95% CI:
2.9-6.2) were most likely to have reported consistent condom use with FSWs when
compared with clients 40 years or older. Clients who reported having sex with
other men, were less likely to report consistent condom use (AOR=0.63; 95% CI:
0.4-0.8) with FSWs. Clients who had exposure to messages on STIs or condom use
through media advertising were significantly more likely to report consistent
condom use with FSWs (AOR=1.6; 95% CI: 1.1-2.3). Logistic regression analysis
of factors associated with having an STI indicates that clients having sex with
another man have significantly higher likely hood of having an STI (9.1% versus
6.6%; AOR=1.8; 95% CI: 1.1 – 2.9).
The findings strongly suggest improvements in condom
use among the bridge population, which is also confirmed by the non-increase in
HIV and STI prevalence. Exposure to media messages on STIs and condom have
shown to positively influence condom use. These findings have programmatic
implications, in that it increases understanding about the sub-populations of
bridge populations more at risk and who need to be reached with more tailored
[1.] National AIDS Control Organisation MoHFW, Government
of India. Annual Report 2006. 2007.
[2.] Kumar R JP, Arora P, Dhingra N, Rao S HIV-1 trends,
risk factors and growth in India. 2005.
[3.] Nagelkerke NJD JP, de Vlas SJ, Korenromp EL, Moses S,
et al. Modelling HIV/AIDS epidemics in Botswana and India: impact of
interventions to prevent transmission. Bull
World Health Organ 2002;80(2):89-96.
[4.] Venkataramana CB SP. Extent and speed of spread of HIV
infection in India through the commercial sex networks: a perspective. Trop Med Int Health 2001;6(12):1040–1061.
[5.] National AIDS Control Organisation MoHaFW, Government
of India. 2006. New DelhiNational
Behavioural Surveillance Survey (BSS)-Female Sex Workers (FSWs) and their
[6.] Subramanian T, Gupte MD, Paranjape RS, et al. HIV,
sexually transmitted infections and sexual behaviour of male clients of female
sex workers in Andhra Pradesh, Tamil Nadu and Maharashtra, India: results of a
cross-sectional survey. AIDS. . 20081222
DCOM- 20090220 2008 22 ( 5):S69-79. .
[7.] Michelle F. Gaffey SV, Neeraj Dhingra, Ajay Khera,
Rajesh Kumar, Paul Arora, Nico Nagelkerke, Prabhat Jha. Male Use of Female Sex
Work in India: A Nationally Representative Behavioural Survey. PLoS ONE. 2011;6(7).
[8.] Ruxrungtham K BT, Phanuphak P HIV/AIDS in Asia. Lancet. 2004;364(9428):69-82.
[9.] Saidel T, Adhikary R, Mainkar M, et al. Baseline
integrated behavioural and biological assessment among most at-risk populations
in six high-prevalence states of India: design and implementation challenges. AIDS (London, England). 2008;22:S17-S34
[10.] Saidel T LV, Salyuk T, Emmanuel F, Morineau G, Lyerla
R. . Applying current methods in size estimation for high risk groups in the
context of concentrated epidemics: Lessons learned. jHASE 2010:1-24.
[11.] Boerma JT, Weir SS. Integrating demographic and
epidemiological approaches to research on HIV/AIDS: the proximate-determinants
framework. J Infect Dis. Feb 1
2005;191 Suppl 1:S61-67.
[12.] Organization NAC. Natinal behavioral surveillance
survey among general population. 2006.
[13.] Lipovsek V, Mukherjee A, Navin D, Marjara P, Sharma A,
Roy KP. Increases in self-reported consistent condom use among male clients of
female sex workers following exposure to an integrated behaviour change
programme in four states in southern India. Sexually
transmitted infections. 2010;86(1):038497.
[14.] Shaw S, Deering K, Reza-Paul S, et al. Prevalence of
HIV and sexually transmitted infections among clients of female sex workers in
Karnataka, India: a cross-sectional study. BMC
public health. 2011;11(Suppl 6):S4.
[15.] Phillips AE, Lowndes CM, Boily MC, et al. Men who have
sex with men and women in Bangalore, South India, and potential impact on the
HIV epidemic. Sexually Transmitted
Infections. June 1, 2010 2010;86(3):187-192.
[16.] Hernandez AL, Lindan CP, Mathur M, et al. Sexual
behavior among men who have sex with women, men, and Hijras in Mumbai,
India--multiple sexual risks. AIDS Behav.
Jul 2006;10(4 Suppl):S5-16.
[17.] Rajatashuvra Adhikary AG, Satya Ranjan Lenka, Prabuddhagopal
Goswami, Lakshmi Ramakrishnan, Bitra George, Mandar K. Mainkar, S.
Thilakavathi,, Paranjape GNVBRR. Decline in unprotected sex & sexually
transmitted infections (STIs) among female sex workers from repeated
behavioural & biological surveys in three southern States of India. The Indian journal of medical research. 2012;136:5-13.
[18.] Ramesh BM, Moses S, Washington R, et al. Determinants
of HIV prevalence among female sex workers in four south Indian states:
analysis of cross-sectional surveys in twenty-three districts. AIDS (London, England). 2008;22(5).
[19.] Mainkar M, Pardeshi D, Dale J, et al. Targeted
interventions of the Avahan program and their association with intermediate
outcomes among female sex workers in Maharashtra, India. BMC public health. 2011;11(Suppl 6):S2.
[20.] Rachakulla HK, Kodavalla V, Rajkumar H, et al. 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.
[21.] 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(9):e73470.
[22.] Michael D Sweat JD, Caitlin Kennedy, Virginia Tedrow
& Kevin O'Reilly Effects of condom social marketing on condom use in
developing countries: a systematic review and meta-analysis, 1990–2010. Bulletin of the World Health Organization 2012;90:613-622A.
[23.] Piot B, Mukherjee A, Navin D, et al. Lot quality
assurance sampling for monitoring coverage and quality of a targeted condom
social marketing programme in traditional and non-traditional outlets in India.
Sexually transmitted infections. February
1, 2010 2010;86(Suppl 1):i56-i61.
[24.] Gomes do Espirito Santo ME, Etheredge GD. Male clients
of brothel prostitutes as a bridge for HIV infection between high risk and low
risk groups of women in Senegal. Sexually
transmitted infections. 2005;81(4):342-344.
[25.] Vuylsteke BL, Ghys PD, Traore M, et al. HIV prevalence
and risk behavior among clients of female sex workers in Abidjan, Cote
d'Ivoire. AIDS (London, England). 2003;17(11):1691-1694.
[26.] Espirito Santo ME, Etheredge GD. How to reach clients
of female sex workers: a survey by surprise in brothels in Dakar, Senegal. Bull World Health Organ. 2002;80(9):709-713.