Abstract
IntroductionRole of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.MethodsData for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.ResultsEver having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.ConclusionPractice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.
Highlights
Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood
Programs implemented by National AIDS Control Organization of India promoting safe sex have resulted in reduction of prevalence of HIV among Female Sex Workers (FSWs) from 5.06% in 2007 to 2.67% in 2011. [1,2] Global data suggest that at least 10% women in heterosexual relationships practice anal sex. [4,5,6,7,8] But very little attention has been given to the role of heterosexual anal sex (HAS) in transmission of HIV to women even though evidence through systematic review shows that HIV risk associated with receptive anal intercourse is almost eight times higher even if the infected partner is receiving HAART. [4,9,10,11] Meta-analysis of studies from developed countries has shown that probability of HIV transmission is higher per act of receptive anal sex (1.7%) as compared to peno-vaginal sex (0.8%)
[13] Associated risk behaviors innate to sex trade such as substance use and multiple partners augment the risk of anal sex. [14,15] Motivation for engaging in unprotected HAS in FSWs could be more related to their occupation instead of factors such as intimacy, physical pleasure, experimentation, etc. cited by other heterosexual couples. [14,16,17,18] Studies have documented that several high-risk behaviors such as sex work, multi-partner sex, anal sex and substance abuse occur together
Summary
Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. [4,5,6,7,8] But very little attention has been given to the role of heterosexual anal sex (HAS) in transmission of HIV to women even though evidence through systematic review shows that HIV risk associated with receptive anal intercourse is almost eight times higher even if the infected partner is receiving HAART. [10,20] Available data from recent studies report high prevalence and lack of condom use during anal sex. [3,14] there is lack of information on HIV transmission risk due to unprotected heterosexual anal sex in high-risk populations in India. Anal sex offered by FSWs in India might be contributing significantly to HIV transmission, but its role needs to be investigated. It is important to identify risk factors associated with HAS and implement appropriate preventive strategies through the national program
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