Improving HIV testing in targeted populations in India

At the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, staff from FHI 360’s India office will present a poster on a study that shows improved HIV testing among clients of female sex workers. The study contributes to evidence about what works to strengthen HIV prevention.

Why focus research on the clients of female sex workers?

Recent studies from India suggest that the purchase of sex from female sex workers is most predominant in higher HIV-prevalence states, such as Andhra Pradesh, Maharashtra and Tamil Nadu. In India, there is a growing recognition of the importance of considering clients when looking to stop HIV transmission, and a number of prevention efforts under the national program have targeted these clients, most of whom are men.

Conducting surveys among clients of sex workers is challenging, because clients do not like to be identified. There is also little evidence that establishes clients’ risk of contracting HIV in India. To bridge this gap and to provide invaluable information on HIV trends and risk behavior, FHI 360 designed and managed the largest integrated biological and behavioral assessment (IBBA) for most-at-risk populations in India.

Collecting evidence to inform HIV programming

Conducted in 2006 and 2009, this cross-sectional survey interviewed approximately 10,000 clients of sex workers as part of Avahan (the India AIDS initiative). This program, funded by the Bill & Melinda Gates Foundation, gathered evidence to inform future HIV prevention programs in India. The IBBA survey was implemented by the institutes of the Indian Council of Medical Research, and technical support was provided by FHI 360.
Data was collected from three high HIV-prevalence states (Andhra Pradesh, Maharashtra and Tamil Nadu). Eligible clients for the survey included men ages 18 years or older who had bought sex from female sex workers at least once in the previous month. The recruitment process was unique, because it looked beyond venue-based settings, such as brothels and bars, to any public place where female sex workers solicit clients. After obtaining informed consent from participants, researchers collected behavioral information using a structured questionnaire. Biological samples, including blood and urine, were collected to facilitate testing for HIV and other sexually transmitted infections (STIs).

Among clients of female sex workers, the Avahan initiative focused on condom promotion and the treatment of STIs through social marketing, STI clinics and mass media campaigns.

Results reveal an impressive increase in HIV testing

Sample results showed that over a period of three years, HIV testing among clients of female sex workers increased from 13.5 percent to 30.7 percent. The proportion of clients who collected their HIV test results increased from 73 percent to 91 percent. In addition, a high proportion of clients who were tested for HIV were older than 25 years, never married, reported consistent condom use with both occasional and regular contact with female sex workers and had reactive syphilis serologic tests. Seventy-two percent of clients who had seen or heard messages on STIs in the six months prior were tested for HIV. After controlling for variables such as age, education and occupation, researchers found that HIV testing among clients was associated with condom use during the last sexual encounter with a casual partner and after having seen media messages about STIs.

This evidenced-based study establishes that risk perception, coupled with exposure to media messages on STIs, positively impacts the uptake of HIV testing services among clients of sex workers. It reinforces the importance of targeted media campaigns for clients of sex workers in attracting this group to HIV testing and other HIV services.

As the world comes together to discuss the challenges facing the HIV epidemic at AIDS 2014, FHI 360 is pleased to be able to add to the body of evidence in HIV prevention strategies.

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