Background This paper examines the association between degree of confidence in collective efficacy and self-efficacy for condom use and empowerment among heterogeneous female sex workers (FSWs) in two metropolitan Indian cities with high HIV prevalence. Methods The study utilises data from the Behavioural Tracking Survey, a cross-sectional behavioural study with 2106 FSWs recruited from 411 intervention sites in Mumbai and Thane. The key independent measures used determine the degree of confidence in collective efficacy (belief in the power to achieve goals and address problems together) and outcome measures included: self-efficacy for condom use with occasional clients and condom use with regular partners, self-confidence in handling a crisis situation and public speaking ability. Univariate and multivariate statistical methods were used to examine the study objectives.Results Of the analytical sample of 2106 FSWs, 532 (25.3%) reported high degree of collective efficacy for achieving certain goals and 1534 (72.8%) reported collective efficacy for addressing specific problems. FSWs reporting a higher collective efficacy as compared with those reporting lower collective efficacy were as follows: more likely to negotiate condom use with occasional clients (60.3% vs 19.7%; adjusted OR (AOR) ¼6.3, 95% CI 4.8 to 8.4) as well as regular partners (62.8% vs 20.2%; AOR ¼6.4, 95% CI 4.9 to 8.4); confident in facing troublesome stakeholders (73.5% vs 38.8%; AOR ¼4.3, 95% CI 3.3 to 5.6), confident in supporting fellow FSWs in a crisis (76.1% vs 49.6%; AOR ¼2.9, 95% CI 2.2 to 3.7), received help from other FSWs when a client or partner was violent (73.9% vs 46.3%; AOR ¼3.5, 95% CI 2.7 to 4.5) and had stood up to the police or madams/brokers to help fellow FSWs in the past 1 year (5.8% vs 3.3%; AOR ¼2.7, 95% CI 1.5 to 4.9). Conclusion The results suggest that the strategy of collectivisation in HIV prevention programme has much broader benefits than merely the promotion of safer sex practices. Future HIV prevention interventions in India and elsewhere may include collectivisation as the core strategy within HIV prevention programmes.

BackgroundIt is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility, and literacy, for effective human immunodeficiency virus (HIV) prevention. This paper describes and examines the association of the Aastha HIV/sexually transmitted infection (STI) prevention project in Mumbai and Thane, India, on the relationship between vulnerability and behavioral outcomes.Materials and methodsData were drawn from the Behavioural Tracking Survey, a cross-sectional behavioral study conducted in 2010 with 2,431 FSWs recruited in Mumbai and Thane. The key independent measures used were program exposure and “vulnerability index”, a composite index of literacy, factors of dependence (alternative livelihood options, current debt, and children), and aspects of sex work (mobility and duration in sex work). Dependent measures included service uptake, self-confidence, self-identity, and individual agency. Logistic regression analysis was used to examine the study objectives.ResultsOf the analytical sample of 2,431 FSWs, 1,295 (53.3%) were categorized as highly vulnerable. Highly vulnerable FSWs who were associated with the Aastha program for more than a year were more likely to have accessed crisis-response services in the past 6 months (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.4–3.6; P<0.001), to have visited a clinic to get a checkup for STI symptoms (AOR 2.4, 95% CI 1.2–4.8; P<0.015), not to be ashamed to disclose identity as an FSW to health workers (AOR 2.1, 95% CI 1.2–3.5; P<0.008), and to be confident in supporting a fellow FSW in crisis (AOR 1.7, 95% CI 1.0–2.8, P<0.033) compared to those less vulnerable with similar exposure to the Aastha program.ConclusionIt is critical for HIV/STI interventions to consider vulnerabilities of FSWs at project inception and address them with focused strategies, including a segmented service-delivery model and community involvement, in order to strengthen the structural response to HIV prevention.

BackgroundThe objectives of this paper are: (1) to study the feasibility and relative benefits of integrating the prevention of parent-to-child transmission (PPTCT) component of the National AIDS Control Program with the maternal and child health component of the National Rural Health Mission (NRHM) by offering HIV screening at the primary healthcare level; and (2) to estimate the incremental cost-effectiveness ratio to understand whether the costs are commensurate with the benefits.MethodsThe intervention included advocacy with political, administrative/health heads, and capacity building of health staff in Satara district, Maharashtra, India. The intervention also conducted biannual outreach activities at primary health centers (PHCs)/sub-centers (SCs); initiated facility-based integrated counseling and testing centers (FICTCs) at all round-the-clock PHCs; made the existing FICTCs functional and trained PHC nurses in HIV screening. All “functional” FICTCs were equipped to screen for HIV and trained staff provided counseling and conducted HIV testing as per the national protocol. Data were collected pre- and post- integration on the number of pregnant women screened for HIV, the number of functional FICTCs and intervention costs. Trend analyses on various outcome measures were conducted. Further, the incremental cost-effectiveness ratio per pregnant woman screened was calculated.ResultsAn additional 27% of HIV-infected women were detected during the intervention period as the annual HIV screening increased from pre- to post-intervention (55% to 79%, p < 0.001) among antenatal care (ANC) attendees under the NRHM. A greater increase in HIV screening was observed in PHCs/SCs. The proportions of functional FICTCs increased from 47% to 97% (p < 0.001). Additionally, 93% of HIV-infected pregnant women were linked to anti-retroviral therapy centers; 92% of mother-baby pairs received Nevirapine; and 89% of exposed babies were enrolled for early infant diagnosis. The incremental cost-effectiveness ratio was estimated at INR 44 (less than 1 US$) per pregnant woman tested.ConclusionsIntegrating HIV screening with the broader Rural Health Mission is a promising opportunity to scale up the PPTCT program. However, advocacy, sensitization, capacity building and the judicious utilization of available resources are key to widening the reach of the PPTCT program in India and elsewhere.

Background: To demonstrate that customized demand generation leads to increased voluntary HIV counseling and testing (VCT) among Sex Workers (SWs). Methods: FHI 360 Aastha implemented Vivek intervention among SWs in Mumbai and Thane, India using customized demand generation through outreach services for VCT. Program monitoring data and integrated counseling and testing center tracking sheets were used to assess the intervention effect. Results: Higher proportion of registered SWs tested during: 1) Vivek months than other months (17% vs. 5%, p < 0.001); 2) Post-initiation non-Vivek months than pre-Vivek months (4.7%, vs. 1.5% p < 0.001). Conclusions: Customized demand generation approach is successful in increasing HIV testing.

examined. Multivariable logistic regression models were used to analyse the socio-demographic, sexual behaviour and sex-work related characteristics related to the prevalence of each pathogen. Sampling weights and appropriate survey methods were utilised in regression models to account for a complex sampling design. Results The total sample size was 2745. The average age of clients was 30.4 years (SEd0.3). Across the total sample, the prevalences of HIV, HSV-2, syphilis and CT/GC were 5.6%, 28.4%, 3.6% and 2.2%, respectively. The prevalence of HIV/STIs varied substantially across districts, reaching statistical significance for HIV (p<0.0001) and CT/GC (p¼0.005). In multivariable models, duration of paying for commercial sex was associated with increased risk for HIV and HSV-2 (both AORsd1.1; 95% CI 1.0 to 1.1, p<0.0001). Clients using brothels as a main FSW solicitation site were associated with increased risk of HIV (AORd2.4; 95% CI 1.2 to 4.7, p¼0.001), while those frequenting lodges were at increased risk for CT/GC (AORd6.3; 95% CI 1.9 to 20.6, p¼0.03). Clients with HSV-2 infection were at substantially higher risk of being HIV-positive (AORd10.4; 95% CI 6.1 to 17.7, p<0.0001). Conclusions This study fills in important gaps in knowledge regarding clients of FSWs in Southern India. FSW clients clearly constitute an important bridging population between FSWs and their other sexual partners in the population. It is important to design and implement effective prevention and care programs for this well-hidden population.

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