Large-scale HIV Prevention Program Research Articles

Using prevention cascades to investigate coverage of contraception services among young women enrolled in a large-scale combination HIV prevention program in South Africa

ObjectivesWe investigated the coverage of contraception services (excluding condoms) to prevent unintended pregnancy among young women and girls aged 15 to 24 years who were beneficiaries of one of the two largest combination HIV and pregnancy prevention program in South Africa. Study designWe invited 2160 randomly sampled beneficiaries who were living in six of the 12 program districts across six provinces to participate in a telephone survey. We created pregnancy prevention coverage cascades and conducted univariate and multivariable analyses to identify key barriers and facilitators associated with each step of the cascade. ResultsWe achieved a response rate of 23.8%, resulting in 515 respondents, of whom 303 had sex in the 6 months before the survey. Of this subsample, 80.4% had access to contraception services, 60.6% had access and motivation to use contraceptives, and 21.9% had access to, motivation to use, and effectively used contraceptives. Distance to travel to services and not ever being offered contraceptives by health workers were access barriers, while low pregnancy risk perception was a barrier to motivation. ConclusionsMost respondents had access to and were motivated to use contraceptives other than condoms but were not effectively using them. Having been offered contraceptives facilitated better access, while distance to the services was a barrier, suggesting the importance of improving supply-side interventions, such as increasing the number and accessibility of spaces where Sexual and Reproductive Health (SRH) services are offered. We recommend longitudinal behavioral counseling for young people, especially adolescents, as well as risk reduction and information-tailored interventions. ImplicationsPregnancy prevention cascades are a promising tool to monitor progress toward universal access to contraception services and to identify barriers that need to be addressed to achieve the effective use of contraceptives.

Impact of an HIV Prevention Intervention on HIV Risk Behavior and Sexually Transmitted Infection among Female Sex Workers in Tamil Nadu, India.

BackgroundIn 2003 a large-scale HIV prevention program was launched for key populations in six high HIV prevalence states of India. This paper assesses the effect of exposure to the intervention on condom use with commercial clients and experiences of sexually transmitted infection (STI) among female sex workers (FSWs) in Tamilnadu, a southern Indian state, between 2006 and 2009.MethodsData were drawn from two rounds of cross-sectional surveys conducted in 2006 (N = 2010) and 2009 (N = 2500) among FSWs in Tamilnadu, recruited through probability-based sampling. A series of multivariate logistic regression models were constructed to examine the association between exposure to the intervention and change over time with condom use and self-reported STI. All the analyses were performed using STATA 11.1.ResultsOverall, 48% of FSWs in 2006 and 90% in 2009 reported exposure to the intervention. Compared to 2006, there was a considerable increase in the proportion of FSWs reporting consistent condom use with regular and occasional clients at follow-up (2009). Further, the increase in consistent condom use over time with occasional (adjusted OR = 3.53, 95% CI: 2.47 - 5.05) and regular clients (adjusted OR = 4.97, 95% CI: 3.43 - 7.16) was significantly higher among FSWs exposed to the intervention than those not exposed. Additionally, a significant decline was observed in self-reported STI overtime among FSWs exposed to the intervention compared to their counterparts (adjusted OR = 0.39, 95% CI: 0.26 - 0.59).ConclusionThe HIV prevention program in Tamilnadu resulted in increased consistent condom use and a decrease in self-reported STI among FSWs exposed to intervention. These findings suggest that HIV prevention programs should aim to saturate coverage among key populations to sustain the gains achieved.

"From me to HIV": a case study of the community experience of donor transition of health programs.

BackgroundAvahan, a large-scale HIV prevention program in India, transitioned over 130 intervention sites from donor funding and management to government ownership in three rounds. This paper examines the transition experience from the perspective of the communities targeted by these interventions.MethodsFifteen qualitative longitudinal case studies were conducted across all three rounds of transition, including 83 in-depth interviews and 45 focus group discussions. Data collection took place between 2010 and 2013 in four states: Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu.ResultsWe find that communication about transition was difficult at first but improved over time, while issues related to employment of peer educators were challenging throughout the transition. Clinical services were shifted to government providers resulting in mixed experiences depending on the population being targeted. Lastly, the loss of activities aimed at community ownership and mobilization negatively affected the beneficiaries’ view of transition.ConclusionsWhile some programmatic changes resulted in improvements, additional opportunity costs for beneficiaries may pose barriers to accessing HIV prevention services. Communicating and engaging community stakeholders early on in future such transitions may mitigate negative feelings and lead to more constructive relationships and dialogue.

Consistent condom use with regular, paying, and casual male partners and associated factors among men who have sex with men in Tamil Nadu, India: findings from an assessment of a large-scale HIV prevention program

BackgroundMen who have sex with men (MSM) are a marginalized population at high risk for HIV infection. Promoting consistent condom use (CCU) during anal sex is a key risk reduction strategy for HIV prevention among MSM. To inform effective HIV prevention interventions, we examined the factors associated with CCU among MSM with their regular, paying, and casual partners, as well as with all three types of partners combined.MethodsData for this analysis were from a large-scale bio-behavioural survey conducted during 2009–2010 in Tamil Nadu, India. MSM aged 18 years or older were recruited for the survey using time-location cluster sampling at cruising sites in four districts of Tamil Nadu. Binary logistic regression analyses were conducted to assess the association of CCU with selected socio-demographic characteristics and other contextual factors.ResultsAmong 1618 MSM interviewed, CCU during anal sex with regular, paying, and a casual male partner was 45.3%, 50.8% and 57.9%, respectively. CCU with all three types of partners combined was 52.6%. Characteristics associated with increased odds for CCU with MSM having all three types of partners combined were frequent receptive anal sex acts with regular partners (adjusted odds ratio [AOR] 2.17, 95% confidence interval [CI] 1.01-4.65), fewer number of casual partners (AOR 3.41, 95% CI 1.50-7.73) and membership in a community-based organization (CBO) for MSM (AOR 3.54, 95% CI 1.62-7.74). CCU with regular partners was associated with membership in a CBO (AOR 1.96, 95% CI 1.23-3.11), whereas CCU with paying, and casual male partners was associated with perceived higher risk of acquiring HIV (AOR 1.92, 95% CI 1.22-3.01) and exposure to any HIV prevention intervention (AOR 3.62, 95% CI 1.31-10.0), respectively. Being aged 26 years or older, being in debt, and alcohol use were factors associated with inconsistent condom use across partner types.ConclusionHIV interventions among MSM need to promote CCU with all types (regular, paying, and causal) of male partners, and need to reach MSM across all age groups. In addition to enhancing interventions that focus on individual level risk reduction, it is important to undertake structural interventions that promote social acceptance of same-sex sexuality and address contextual barriers to condom use such as alcohol use.

P6.038 Technical Support For Clinical Services of a Large Scale HIV Prevention Programme For Key Populations in India

BackgroundAvahan was a focused HIV prevention programme implemented across six states in India by seven lead agencies through 129 local NGOs, providing services to 321,000 individuals from key populations. Clinical...

P6.053 Evaluation of Cost & Efficiency of Alternative Service Delivery Models For Providing STI Services to High Risk Individuals in India

BackgroundAvahan, a large-scale HIV prevention programme, provides STI services to over 300,000 high risk individuals (HRIs) in six states of India through six different service delivery models varying by provision...

Integrating syphilis screening in a large-scale HIV prevention program for key populations: the Avahan experience from India

Documented experiences from India on the implementation of syphilis screening in large-scale HIV prevention programs for "key populations at higher risk" (KPs) are limited. Avahan is a large-scale HIV prevention program providing services to more than 300,000 KPs in six high HIV prevalence states of India since 2004. Avahan clinics provide a sexually transmitted infection service package which includes bi-annual syphilis screening. The trends in the coverage of syphilis screening among Avahan clinic attendees were studied retrospectively. Screening was performed using either the Rapid Plasma Reagin (RPR) test or point-of-care immunochromatographic strip test (ICST). Clinic records from 2005 to 2009 were collated in an individual tracking database and analyzed with STATA-10. Initially the coverage of syphilis screening (2.6% in 2005) was constrained by the availability and operational complexity of the RPR test. After its introduction in 2007, the use of ICST for screening increased from 7.4% to 77.0% and the proportion of clinic attendees screened increased from 9.0% to 21.6% during 2007-2009. The RPR reactivity rates declined from 6.6% (2006) to 4.4% (2009). The data showed improved rates of screening of clinic attendees and declining trends in sero-reactivity over time. The introduction of point-of-care syphilis tests may have contributed to the improved coverage of syphilis screening. The ICST may be considered for initial syphilis screening at other resource-constrained primary care sites in India such as ante-natal clinics and other KP interventions.

Changes in the size of high-risk populations in India: results from two rounds of size estimations

BackgroundEstimating the size of a high-risk population group is always challenging and is a requisite for planning and policy development. In India, the Bill & Melinda Gates Foundation implemented Avahan, a large-scale HIV prevention programme. As part of Avahan's overall evaluation strategy, two rounds of large-scale cross-sectional integrated behaviour and biological assessment (IBBA) surveys were carried out in 2006 (round 1) and 2009 (round 2) in selected districts in three states. MethodsTwo rounds of IBBA covered 23 female sex worker (FSW) and ten men who have sex with men (MSM) groups across 29 districts in three states. Sizes were estimated using three different methods: capture-recapture (CR), multiplier method (MM), and reverse tracking method (RTM), a technique mathematically similar to the Hansen-Hurwitz method. FindingsAmong the three methods, RTM was applied consistently in all groups in both the rounds. MM and CR were applied in the selected districts owing to the implementation issues and experiences in round 1 of the survey. The results from RTM showed that in Andhra Pradesh, the sizes of the FSW and MSM populations increased between rounds. In Maharashtra, FSW groups showed a decline from round 1 (13 459, 95% CI 13 431–13 487) to round 2 (8955, 8945–8964), whereas the MSM groups in Maharashtra showed an overall increase from round 1 (1498, 1480–1516) to round 2 (2667, 2605–2729). Tamil Nadu had mixed results in both FSW and MSM groups. The results from RTM were much more reliable and accurate compared with those obtained from CR and MM. Estimates from RTM also tended to be close to programme data. InterpretationChanges in high-risk population sizes captured through RTM were much more accurate and tended to be closer to the programme data. Also, in large-scale surveys where the sampling frame is exhaustive, using the RTM method for size estimation seems to be better than other indirect methods. FundingBill & Melinda Gates Foundation.

Positive impact of a large-scale HIV prevention programme among female sex workers and clients in South India

Objective:Estimate the potential impact of Avahan, the India AIDS Initiative, among female sex workers (FSWs) and their clients in five districts of Karnataka state, south India.Design:Examination of time trends in sexually transmitted infection (STI)/HIV prevalence from serial cross-sectional surveys, combined with mathematical modelling.Methods:Survey data from each district were used to monitor changes in FSW STI/HIV prevalence during Avahan. A deterministic model, parameterized with district-specific survey data, was used to simulate HIV/HSV-2/syphilis transmission among high-risk groups in each district. Latin hypercube sampling was used to obtain multiple parameter sets that reproduced district-specific HIV prevalence trends. A Bayesian framework tested whether self-reported increases in consistent condom use (CCU) during Avahan were more compatible with FSW HIV prevalence trends than assuming no or slow (preintervention rates) CCU increases, and were used to estimate HIV incidence and infections averted.Results:Declines in FSW HIV prevalence occurred over 5 years in all districts, and were statistically significant in three. Self-reported increases in CCU were more consistent with observed declines in HIV prevalence in three districts. In all five districts, an estimated 25–64% (32–70%) HIV infections were averted among FSWs (clients) over 5 years. This corresponded to 142–2092 FSW infections averted depending on the district (two-fold to nine-fold more among clients).Conclusion:Empirical HIV prevalence trends combined with Bayesian modelling have provided plausible evidence that Avahan has reduced HIV transmission among FSWs and their clients. If current CCU levels are sustained, FSW HIV prevalence could decline to low levels by 2015, with many more infections averted.

An assessment of a large-scale HIV prevention programme for high-risk men who have sex with men and transgenders in Andhra Pradesh, India: using data from routine programme monitoring and repeated cross-sectional surveys

ObjectivesTo assess a large-scale intervention, the Avahan intervention, using an evaluation framework that included programme coverage, condom use and changes in sexually transmitted infection (STI) and HIV prevalence among high-risk...

P5-S7.03 Syphilis screening for high-risk groups in a large-scale HIV prevention program in India: uptake and trends

BackgroundAvahan, a large-scale HIV prevention program in India, provides syphilis screening as a part of its service package for high-risk groups (HRGs) including female sex workers, men who have sex with men (MSM) and injecting drug users through its targeted intervention clinics. The objective of this retrospective study was to understand the uptake and trends in reactivity patterns of syphilis screening tests at Avahan clinics from 2005 to 2009.MethodsSyphilis screening was done with either Rapid Plasma Reagin (RPR test, provided on-site or through referrals to local laboratories) or a point-of-care immunochromatographic strip test (ICST) using whole blood. ICST was introduced to the program in 2007. The clinical records of the HRGs attending Avahan clinics in six high HIV prevalence states in India from January 2005 to December 2009 were collated in an “individual tracking sheet” database and analysed with STATA software version 10.ResultsThe overall proportion of clinic attendees screened for syphilis increased consistently during the study period from 2.6% in 2005 to 21% in 2009. The increasing trend in uptake and actual proportions were similar in all risk groups. The use of ICST as a screening test increased from 8% in 2007 to 70% in 2009 thus becoming the predominant screening method. During this period, the uptake of syphilis screening also increased from 9% in 2007 to 21% in 2009 see Abstract P5-S7.03 table 1. A declining trend was found with the overall syphilis sero-reactivity rates (ICST and RPR), from 7% in 2006 to 4% in 2009 and this decreasing trend was found in all risk groups. The proportion of active high-titre syphilis (>1:8) to all reactive RPR tests (any titre) declined from 61% in 2005 to 30% in 2009.Abstract P5-S7.03 Table 1Uptake of syphilis screening by RPR and ICSTYearTotal individuals attending clinics# Screened for syphilis (%)Proportion screened with RPR (%)Proportion screened with ICST (%)200543 3941112 (2.6%)10002006108 8365700 (5.2%)10002007169 61215 179 (8.9%)91.88.22008220 87728 502 (12.9%)60.139.92009286 99160 412 (21.1%)30.869.2ConclusionsThe improved uptake of syphilis screening has lead to improved detection and appropriate management of cases of latent syphilis. The results show that introduction of rapid point-of-care tests likely contributed to the improved uptake of syphilis screening. Rapid tests may be considered for syphilis screening at other resource-constrained primary care sites in India such as targeted intervention and ante-natal clinics.

S7.1 Achieving high coverage of HIV prevention services for MARPs: Avahan's experience in six states in India

In 2003, the Bill and Melinda Gates foundation initiated “Avahan” a large scale HIV prevention program in India. The goal was to halt the HIV epidemic in India by rapidly...

O1-S09.01 Increased condom use and decreased HIV & STI prevalence among female sex workers following a targeted HIV prevention program in Karnataka, South India

BackgroundWe assessed the impact of a large-scale, targeted HIV prevention program among female sex workers (FSWs) in Karnataka state, south India.MethodsIn the context of an HIV prevention program involving 18...

P1-S2.12 Improving access to STI care among female sex workers by strengthening service provider networks in Bangalore, South India

BackgroundThe Karnataka Health Promotion Trust, in partnership with non-governmental and community-based organisations, has been implementing a focused HIV prevention project among female sex workers (FSWs) in Bangalore since 2005. Over...

Assessment of the scale, coverage and outcomes of the Avahan HIV prevention program for female sex workers in Tamil Nadu, India: is there evidence of an effect?

BackgroundAvahan, the India AIDS Initiative, a large-scale HIV prevention program, using peer-mediated approaches and STI services, was implemented for high-risk groups for HIV in six states in India. This paper describes the assessment of the program among female sex workers (FSWs) in the southern state of Tamil Nadu.MethodsAn analytical framework based on the Avahan impact evaluation design was used. Routine program monitoring data, two rounds of cross-sectional biological and behavioural surveys among FSWs in 2006 (Round 1) and 2009 (Round 2) and quality assessments of clinical services for sexually transmitted infections (STIs) were used to assess trends in coverage, condom use and prevalence of STIs, HIV and their association with program exposure. Logistic regression analysis was used to examine trends in intermediate outcomes and their associations with intervention exposure.ResultsThe Avahan program in Tamil Nadu was scaled up and achieved monthly reported coverage of 79% within four years of implementation. The cross-sectional survey data showed an increasing proportion of FSWs being reached by Avahan, 54% in Round 1 and 86% in Round 2 [AOR=4.7;p=0.001]. Quality assessments of STI clinical services showed consistent improvement in quality scores (3.0 in 2005 to 4.5 in 2008). Condom distribution by the program rose to cover all estimated commercial sex acts. Reported consistent condom use increased between Round 1 and Round 2 with occasional (72% to 93%; AOR=5.5; p=0.001) and regular clients (68% to 89%; AOR=4.3; p=0.001) while reactive syphilis serology declined significantly (9.7% to 2.2% AOR=0.2; p=0.001). HIV prevalence remained stable at 6.1% between rounds. There was a strong association between Avahan exposure and consistent condom use with commercial clients; however no association was seen with declines in STIs.ConclusionsThe Avahan program in Tamil Nadu achieved high coverage of FSWs, resulting in outcomes of improved condom use, declining syphilis and stabilizing HIV prevalence. These expected outcomes following the program logic model and declining HIV prevalence among general population groups suggest potential impact of high risk group interventions on HIV epidemic in Tamil Nadu.

Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program

BackgroundViolence against female sex workers (FSWs) can impede HIV prevention efforts and contravenes their human rights. We developed a multi-layered violence intervention targeting policy makers, secondary stakeholders (police, lawyers, media), and primary stakeholders (FSWs), as part of wider HIV prevention programming involving >60,000 FSWs in Karnataka state. This study examined if violence against FSWs is associated with reduced condom use and increased STI/HIV risk, and if addressing violence against FSWs within a large-scale HIV prevention program can reduce levels of violence against them.MethodsFSWs were randomly selected to participate in polling booth surveys (PBS 2006-2008; short behavioural questionnaires administered anonymously) and integrated behavioural-biological assessments (IBBAs 2005-2009; administered face-to-face).Results3,852 FSWs participated in the IBBAs and 7,638 FSWs participated in the PBS. Overall, 11.0% of FSWs in the IBBAs and 26.4% of FSWs in the PBS reported being beaten or raped in the past year. FSWs who reported violence in the past year were significantly less likely to report condom use with clients (zero unprotected sex acts in previous month, 55.4% vs. 75.5%, adjusted odds ratio (AOR) 0.4, 95% confidence interval (CI) 0.3 to 0.5, p < 0.001); to have accessed the HIV intervention program (ever contacted by peer educator, 84.9% vs. 89.6%, AOR 0.7, 95% CI 0.4 to 1.0, p = 0.04); or to have ever visited the project sexual health clinic (59.0% vs. 68.1%, AOR 0.7, 95% CI 0.6 to 1.0, p = 0.02); and were significantly more likely to be infected with gonorrhea (5.0% vs. 2.6%, AOR 1.9, 95% CI 1.1 to 3.3, p = 0.02). By the follow-up surveys, significant reductions were seen in the proportions of FSWs reporting violence compared with baseline (IBBA 13.0% vs. 9.0%, AOR 0.7, 95% CI 0.5 to 0.9 p = 0.01; PBS 27.3% vs. 18.9%, crude OR 0.5, 95% CI 0.4 to 0.5, p < 0.001).ConclusionsThis program demonstrates that a structural approach to addressing violence can be effectively delivered at scale. Addressing violence against FSWs is important for the success of HIV prevention programs, and for protecting their basic human rights.

Changes in risk behaviours and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India

ObjectivesTo examine the impact of a large-scale HIV prevention programme for female sex workers (FSW) in Karnataka state, south India, on the prevalence of HIV/sexually transmitted infections (STI), condom use...