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Goswami P.,MandE | Rachakulla H.K.,National Institute of Nutrition NIN | Ramakrishnan L.,MandE | Mathew S.,MandE | And 7 more authors.
BMJ Open | Year: 2013

Objectives: To 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 men who have sex with men/transgender (HR-MSM/TG) in the state of Andhra Pradesh, India. Design: Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis. Setting: Programme monitoring data and crosssectional surveys from Andhra Pradesh, India. Participants: Data from 1218 and 1203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts. Primary and secondary outcomes: (1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention. Results: By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HRMSM/ TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/ TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52). Conclusion: The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HRMSM/ TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.


PubMed | FHI 360, National Institute of Nutrition NIN, National AIDS Research Institute NARI and National Institute of Epidemiology NIE
Type: Journal Article | Journal: BMJ open | Year: 2014

Self-reported anal intercourse by female sex workers (FSWs) documented in recent studies from India range between 11.9% and 22%. However, comparable data on anal intercourse and condom use from male clients of FSWs is lacking. Using data from a bio-behavioural survey (2009-2010), we examined prevalence of anal intercourse, male clients self-reported inconsistent condom use during anal intercourse with FSWs, and correlates of this behaviour in Indias high HIV prevalence southern states (Andhra Pradesh, Maharashtra and Tamil Nadu combined).Using two-stage time location cluster sampling, we recruited 4803 clients of FSWs, ages 18-60years, who had purchased sex from an FSW in the past month. After obtaining informed consent, respondents were interviewed and tested for HIV and sexually transmitted infections (syphilis, gonorrhoea and chlamydia). Logistic regression analysis was used to identify the factors associated with inconsistent condom use during anal intercourse (in the past 6months) with FSWs.Overall, 12.3% clients reported anal intercourse in the past 6months, of whom 48.4% used condoms inconsistently. Clients of FSWs who were ages 26years or older (AOR 2.68, p=0.032); employed as manual labourers (AOR 2.43, p=0.013); consumed alcohol (AOR 2.63, p=0.001); reported five or more sex acts with FSWs in the past month (AOR 2.53, p=0.031); and perceived themselves to be at higher risk for HIV (AOR 4.82, p=0.001) were more likely to inconsistently use condoms during anal intercourse.The results suggest that sex workers and their clients commonly practice anal intercourse, but a relatively high proportion of clients do not consistently use condoms, leading to a greater risk of acquiring HIV and its further transmission to other male and female sexual partners. Given the multidirectional risk, safer sex communication on heterosexual anal intercourse must be incorporated into HIV prevention programmes.


Nagarajan K.,National AIDS Research Institute NARI | Ramakrishnan L.,FHI 360 | Mainkar M.K.,National AIDS Research Institute NARI | Goswami P.,FHI 360 | And 6 more authors.
BMJ Open | Year: 2014

Objectives: Self-reported anal intercourse by female sex workers (FSWs) documented in recent studies from India range between 11.9% and 22%. However, comparable data on anal intercourse and condom use from male clients of FSWs is lacking. Using data from a bio-behavioural survey (2009-2010), we examined prevalence of anal intercourse, male clients' self-reported inconsistent condom use during anal intercourse with FSWs, and correlates of this behaviour in India's high HIV prevalence southern states (Andhra Pradesh, Maharashtra and Tamil Nadu combined).Methods: Using two-stage time location cluster sampling, we recruited 4803 clients of FSWs, ages 18-60 years, who had purchased sex from an FSW in the past month. After obtaining informed consent, respondents were interviewed and tested for HIV and sexually transmitted infections (syphilis, gonorrhoea and chlamydia). Logistic regression analysis was used to identify the factors associated with inconsistent condom use during anal intercourse (in the past 6 months) with FSWs.Results: Overall, 12.3% clients reported anal intercourse in the past 6 months, of whom 48.4% used condoms inconsistently. Clients of FSWs who were ages 26 years or older (AOR 2.68, p=0.032); employed as manual labourers (AOR 2.43, p=0.013); consumed alcohol (AOR 2.63, p=0.001); reported five or more sex acts with FSWs in the past month (AOR 2.53, p=0.031); and perceived themselves to be at higher risk for HIV (AOR 4.82, p=0.001) were more likely to inconsistently use condoms during anal intercourse.Conclusions: The results suggest that sex workers and their clients commonly practice anal intercourse, but a relatively high proportion of clients do not consistently use condoms, leading to a greater risk of acquiring HIV and its further transmission to other male and female sexual partners. Given the multidirectional risk, safer sex communication on heterosexual anal intercourse must be incorporated into HIV prevention programmes.


Barua P.,Regional Medical Research Center | Mahanta J.,Regional Medical Research Center | Medhi G.K.,Regional Medical Research Center | Dale J.,National AIDS Research Institute NARI | And 2 more authors.
Indian Journal of Medical Research, Supplement | Year: 2012

Background & objectives: Female sex workers (FSWs) of north-east India form a unique group as they are exposed to an enormous injecting drug user (IDU) clientele. This association makes them more vulnerable to blood borne viral infections. Over and above some of them also indulge in drug injecting practices along with their partners. The present study was carried out on FSWs to assess the prevalence of hepatitis C virus (HCV) infection and possibility of sexual transmission of HCV and associated risk factors among them. Methods: A sample of 426 FSWs was recruited cross-sectionally using respondent driven sampling methods. Univariate and multivariate logistic regression analysis was carried out to determine the factors associated with HCV infection. Results: The seroprevalence of HCV among 426 FSWs was 9.6 per cent, antibody to HIV was present in 13.4 per cent, 4.9 per cent were co-infected with HIV and HCV. Seroprevalence of HCV among participants without history of injecting drugs use, tattooing or blood transfusion was 7.5 per cent. An increased risk of HCV seropositivity was associated with history of injecting drug use (OR 10.41, CI 4.30-25.22), use of oral drugs (OR 4.7, CI 2.4-9.08), having sexual partners who were injecting drug users (OR 2.9, CI 1.5-5.6), having live-in relationship (OR 7.1, CI 1.59-31.52), HIV seropositivity (OR 10.18, CI 5.05-20.54) and HSV-2 seropositivity (OR 2.86, CI 1.45-5.43) in univariate analysis. In the multivariate analysis, history of injecting drug use, HIV and HSV-2 seropositivity were found to be significantly associated with HCV seropositivity. Interpretation & conclusion: Although acquisition of HCV by sexual route may not be as efficient as parenteral route, yet sexual transmissibility of HCV among FSWs poses high risk to the community.


Murugesan V.,CSIR - Central Electrochemical Research Institute | Makwana N.,National AIDS Research Institute NARI | Suryawanshi R.,National AIDS Research Institute NARI | Saxena R.,CSIR - Central Electrochemical Research Institute | And 4 more authors.
Bioorganic and Medicinal Chemistry | Year: 2014

A series of novel thiazolidin-4-one analogues, characterized by different substitution patterns at positions C-2 and N-3 of the thiazolidin-4-one scaffold for anti-HIV-1 activity has been investigated. Most of the compounds showed anti-HIV-1 activity at micromolar concentrations when tested in TZM-bl cells in vitro. Among the thirty-three compounds tested, compound 16 was the most potent inhibitor of HIV-1 replication against HIV-1IIIB, HIV-1 ADA5, HIV-1UG070 and HIV-1VB59 (EC50 = 0.02, 0.08, 0.08 and 0.08 μM, respectively) with selectivity index (SI = 6940, 1735, 1692 and 1692) against tested viral strains, respectively. The results of the present study suggested that the substitution of the nitro group at 6′ position of the C-2 phenyl ring and 4,6-dimethylpyridin-2-yl at the N-3 position of thiazolidin-4-one had a major impact on the anti-HIV-1 activity and was found to lower cytotoxicity. The substitution of the heteroaryl ring with bromo group and bicyclic heteroaryl ring at N-3 thiazolidin-4-one was found to lower anti-HIV-1 activity and increase cytotoxicity. The undertaken docking studies thus facilitated the identification of crucial interactions between the HIV-1 RT enzyme and thiazolidin-4-one inhibitors, which can be used to design new potential inhibitors. © 2014 Elsevier Ltd. All rights reserved.


Rachakulla H.K.,National Institute of Nutrition NIN | Kodavalla V.,National Institute of Nutrition NIN | Rajkumar H.,National Institute of Nutrition NIN | Prasad S.P.V.,National Institute of Nutrition NIN | And 6 more authors.
BMC Public Health | Year: 2011

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. © 2011 Rachakulla et al; licensee BioMed Central Ltd.


Armstrong G.,University of Melbourne | Medhi G.K.,Regional Medical Research Center | Mahanta J.,Regional Medical Research Center | Paranjape R.S.,National AIDS Research Institute NARI | Kermode M.,University of Melbourne
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2015

Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lifetime rate of HIV testing has been documented amongst PWID in Manipur. Little is known about the extent of undiagnosed HIV in this setting and whether uptake of HIV testing (and knowledge of a positive diagnosis) leads HIV-positive PWID to change their risk behaviours. The cross-sectional data (n = 821) analysed for this paper were collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) using interviewer-administered questionnaires and the collection of de-linked blood and urine samples. Almost one-third (30.7%) of the participants tested HIV positive. The majority knew where to obtain a confidential HIV test (80.7%), however, half of the HIV-positive participants had either never had an HIV test (37.7%), or had undertaken a test without collecting the result (12.7%). Almost one-quarter (23.4%) of the HIV-positive participants and 17.4% of the HIV-negative participants had shared a needle/syringe with at least one other injector during the preceding month. Encouragingly, HIV-positive participants were significantly more likely than HIV-negative participants to use condoms with their regular sexual partners, however, there was still a high proportion of HIV-positive participants who did not use a condom at last sex with their regular (47.2%) or casual (48.0%) partners. Having taken an HIV test and collected the result was associated with a reduction in HIV-risk behaviours among HIV-positive participants, but not among HIVnegative participants. In conclusion, we found that a substantial proportion of the HIV-positive PWID in Manipur were not aware of their positive status, and risky injecting and sexual practices were commonplace. However, HIV-positive PWID appear to reduce their high-risk behaviours when they become aware of their HIV status highlighting the importance of taking HIV testing coverage to scale. © 2014 Taylor & Francis.


Medhi G.K.,Regional Medical Research Center | Mahanta J.,Regional Medical Research Center | Hazarika I.,University of Melbourne | Armstrong G.,University of Melbourne | And 3 more authors.
International Journal of STD and AIDS | Year: 2013

This paper describes the sex work characteristics and factors associated with syphilis among female sex workers (FSWs) in Dimapur district of high HIV prevalence Indian state, Nagaland. The study recruited 426 FSWs in 2006 using respondentdriven sampling. The prevalence of syphilis was 21.1% and HIV prevalence was 11.7%. Approximately half were under 25 years of age. Clients were solicited mainly in public places (32.7%), while hotels/lodges/rented rooms were the most common places of entertainment (57.2%). Condom use during the last sex was 36.5% with occasional and 27% with regular clients. Being married, being widowed/divorced/separated, being illiterate or having a history of drug use increased the likelihood of syphilis infection. Entertaining clients in bars/booze joints decreased the probability of syphilis. FSWs who moved between soliciting in public places or bars/booze joints and then entertaining in hotels/lodges/rented rooms had a higher vulnerability to syphilis. In summary, we found that the vulnerability to syphilis among mostly young FSWs in Dimapur varied according to their sex work characteristics, marital and educational status and drug use habits. They may be more vulnerable to HIV and sexually transmitted infections (HIV/STIs) due to the low rate of condom use. The findings have direct implications for HIV/STI prevention programmes in Northeast India.


Armstrong G.,University of Melbourne | Medhi G.K.,Regional Medical Research Center | Kermode M.,University of Melbourne | Mahanta J.,Regional Medical Research Center | And 2 more authors.
BMC Public Health | Year: 2013

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. © 2013 Armstrong et al.; licensee BioMed Central Ltd.


Medhi G.K.,Regional Medical Research Center | Mahanta J.,Regional Medical Research Center | Kermode M.,University of Melbourne | Paranjape R.S.,National AIDS Research Institute NARI | And 3 more authors.
BMC Public Health | Year: 2012

Background: The intersection between illicit drug use and female commercial sex work has been identified as an important factor responsible for rising HIV prevalence among female sex workers (FSW) in several northeastern states of India. But, little is know about the factors associated with the use of drugs among FSWs in this region. The objective of the paper was to describe the factors associated with history of drug use among FSWs in Dimapur, an important commercial hub of Nagaland, which is a high HIV prevalence state of India. Methods: FSWs were recruited using respondent driven sampling (RDS), and were interviewed to collect data on socio-demographic characteristics and HIV risk behaviours. Biological samples were tested for HIV, syphilis gonorrhea and Chlamydia. Logistic regression analysis was performed to identify factors associated with drug use. Results: Among the 426 FSWs in the study, about 25% (n = 107) reported having ever used illicit drugs. Among 107 illicit drug users, 83 (77.6%) were non-injecting and 24 (22.4%) were injecting drug users. Drug-using FSWs were significantly more likely to test positive for one or more STIs (59% vs. 33.5%), active syphilis (27.1% vs. 11.4%) and Chlamydia infection (30% vs. 19.9%) compared to their non-drug using peers. Drug-using FSWs were also significantly more likely to be currently married, widowed or separated compared with non-drug-using FSWs. In multiple logistic regression analysis, being an alcohol user, being married, having a larger volume of clients, and having sexual partners who have ever used or shared injecting drugs were found to be independently associated with illicit drug use. Conclusions: Drug-using FSWs were more vulnerable to STIs including HIV compared to their non-drug using peers. Several important factors associated with being an FSW who uses drugs were identified in this study and this knowledge can be used to plan more effectively targeted harm reduction strategies and programs. © 2012 Medhi et al.

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