Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis

Pickles, Michael; Boily, Marie‐Claude; Vickerman, Peter; Lowndes, Catherine M; Moses, Stephen; Blanchard, James; Deering, Kathleen; Bradley, MA Janet; Ramesh, Banadakoppa M; Washington, Reynold; Adhikary, Rajatashuvra; Mainkar, M K; Paranjape, Ramesh; Alary, Michel

doi:10.1016/s2214-109x(13)70083-4

Cited by 65 publications

(59 citation statements)

References 40 publications

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“…We calibrated the models and analysed them within a Bayesian framework with available data to define plausible uniform ranges around model parameters. 109 We used many sets of fitting parameters to reproduce the reported HIV prevalence in each setting to predict the effect of single and combined structural changes on the course of HIV epidemics from 2014 to 2021, through both immediate and sustained effect on condom use.…”

Section: Modelling Hiv Epidemics In Female Sex Workmentioning

confidence: 99%

Global epidemiology of HIV among female sex workers: influence of structural determinants

et al. 2015

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SUMMARY Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1–31) and 20% in Canada (95% UI 3–39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25–42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8–36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33–46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

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Section: Modelling Hiv Epidemics In Female Sex Workmentioning

confidence: 99%

Global epidemiology of HIV among female sex workers: influence of structural determinants

et al. 2015

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“…An increase in consistent condom use with clients of FSWs between 2005–06 and 2009 has also been reported from the IBBA states [10,12,13]. A beneficial effect in reducing HIV prevalence at the population level over 5 years of Avahan program implementation in some of the states including Andhra Pradesh has also been reported [15,16]. …”

Section: Introductionmentioning

confidence: 87%

Predictors of HIV prevalence among street-based female sex workers in Andhra Pradesh state of India: a district-level analysis

et al. 2014

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BackgroundA decline in HIV prevalence among female sex workers (FSWs) has been reported from the Indian state of Andhra Pradesh between the two rounds of integrated biological and behavioural assessment (IBBA) surveys in 2005–06 and 2009, the first of these around the time of start of the Avahan HIV prevention intervention. In order to facilitate further planning of FSW interventions, we report the factors associated with HIV prevalence among street-based FSWs.MethodsBehavioural data from the two rounds of IBBA surveys, district-level FSW HIV prevention program data, and urbanisation data from the Census of India were utilized. A multilevel logistic model was used to investigate factors associated with inter-district variations in HIV positivity among street-based FSWs in the districts by fitting a two-level model.ResultsThe estimated HIV prevalence among street-based FSWs changed from 16% (95% confidence interval [CI] 14.2 – 17.7%) to 12.9% (95% CI 11.5 – 14.2%) from 2005–06 to 2009. HIV positivity was significantly higher in districts with a high proportion of FSWs registered with targeted interventions (odds ratio [OR] 2.02; 95% CI 1.18-3.45), and in districts with medium (OR 2.54; 95% CI 1.58-4.08) or high (OR 1.55; 95% CI 1.05-2.29) proportion of urban population. Districts which had met the condom requirement targets for FSWs had significantly lower HIV positivity (OR 0.50; 95% CI 0.26-0.97). In round 2 survey, the districts with medium level urbanisation had significantly higher proportion of FSWs registered with HIV intervention programmes and also reported higher consistent condom use with regular partner (p < 0.001).ConclusionsVariations in HIV positivity among street-based FSWs were seen at the district level in relation to HIV intervention programs and the degree of urbanization. These findings could be used to enhance program planning to further reduce HIV transmission in this population.

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“…In some cases, sound analysis of an HIV epidemic within a country has been undertaken and has led to investment in HIV reduction programs for sex workers. For example, in India a sound epidemic analysis has led to appropriate investments in HIV reduction interventions targeted towards sex work [27,36–38]—India recognized that its epidemic was driven by sex workers in four high burden southern and western states and focused its HIV prevention investments on sex worker HIV prevention programs in these high burden states. In short, the investments followed the epidemic and reflected HIV transmission patterns [38].…”

Section: Recommendationsmentioning

confidence: 99%

“…Implementation science is “the study of methods to promote the integration of research findings and evidence into healthcare policy and practice” [51]. The Avahan project shows how implementation science may increase the scope, intensity, and impact of sex worker HIV prevention programs [29,38,52–55]. Avahan used private sector capacity and business models to improve the delivery of a public health service—and specifically to rapidly deliver a large-scale sex worker HIV prevention program in India’s highest burden South Indian states (including Maharastra).…”

Section: Recommendationsmentioning

confidence: 99%

HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs

Wilson

2015

PLoS Med

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There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection “Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers” highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.

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Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis

Abstract: Bill & Melinda Gates Foundation.

Cited by 65 publications

References 40 publications

Global epidemiology of HIV among female sex workers: influence of structural determinants

Global epidemiology of HIV among female sex workers: influence of structural determinants

Predictors of HIV prevalence among street-based female sex workers in Andhra Pradesh state of India: a district-level analysis

HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs

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