Targeted interventions of the Avahan program and their association with intermediate outcomes among female sex workers in Maharashtra, India

Abstract

BackgroundAvahan, the India AIDS Initiative has been a partner supporting targeted interventions of high risk populations under India’s National AIDS Control Organisation (NACO) since 2004 in the state of Maharashtra. This paper presents an assessment of the Avahan program among female sex workers (FSWs) in Maharashtra, its coverage, outcomes achieved and their association with Avahan program.MethodsAn analytical framework based on the Avahan evaluation design was used, addressing assessment questions on program implementation, intermediate outcomes and association of outcomes with Avahan. Data from routine program monitoring, two rounds of cross-sectional Integrated Behavioural and Biological Assessments (IBBAs) conducted in 2006 (Round 1- R1) and 2009 (Round 2 – R2) and quality assessments of program clinics were used. Bi-variate and multivariate analysis were conducted using the complex samples module in SPSS 15® (IBM, Somers NY).ResultsThe Avahan program achieved coverage of over 66% of FSWs within four years of implementation. The IBBA data showed increased contact by peers in R2 compared to R1 (AOR:2.34; p=0.001). Reported condom use with clients increased in R2 and number of FSWs reporting zero unprotected sex acts increased from 76.2% (R1) to 94.6% (R2) [AOR: 5.1, p=0.001].Significant declines were observed in prevalence of syphilis (RPR) (15.8% to 10.8%; AOR:0.54; p=0.001), chlamydia (8% to 6.2%; AOR:.0.65; p=0.010) and gonorrohoea (7.4% to 3.9; AOR:.0.60; p=0.026) between R1 and R2. HIV prevalence increased (25.8% to 27.5%; AOR:1.29; p=0.04). District-wise analysis showed decline in three districts and increase in Mumbai and Thane districts.FSWs exposed to Avahan had higher consistent condom use with occasional (94.3% vs. 90.6%; AOR: 1.55; p=0.04) and regular clients (92.5% vs. 86.0%; AOR: 1.95, p=0.001) compared to FSWs unexposed to Avahan. Decline in high titre syphilis was associated with Avahan exposure.ConclusionThe Avahan program was scaled up and achieved high coverage of FSWs in Maharashtra amidst multiple intervention players. Avahan coverage of FSWs was associated with improved safe sexual practices and declines in STIs. Prevalence of HIV increased requiring more detailed understanding of the data and, if confirmed, new approaches for HIV control.

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

“…Similarly, we noted that condom access (not just coverage) is a key issue, including availability of free or subsidised condoms in the workplace, the ability to carry condoms, and access to sex worker outreach distribution 25, 30, 39, 40, 44, 47, 68, 70, 79, 82, 84, 87, 93, 95, 97, 98, 99, 102, 103, 104, 105, 106, 107. In Kenya, where condoms are available in less than a third of bars and lodges, 105 sex worker-led outreach models are critical, alongside supportive venue-based policies on and practices in condom use.…”

“…Aside from a few reports from China, 32 Kenya, 44 and Latin America, 45, 46 gaps in data for community empowerment up to now can be attributed in large part to scarcity of resources to assess grassroots sex worker efforts and macrostructural constraints of criminalisation and stigma that restrict the ability of FSWs to organise. Community organisation has been considered both as a broad process or intervention of community empowerment, as exemplified by Songachi and Avahan models in India, 25, 39, 47 or as a specific component of community organisation (eg, sex work drop-in spaces or social cohesion). For example, substantial increases in condom use (and decreased STI prevalence) were noted after the Ashodaya sex work collective intervention in Mysore, India, which combined community mobilisation, sex worker-led outreach, sex worker advocacy to police and local government, and improved sexual health services tailored to sex workers.…”

“…Where FSWs report adequate access to condoms, sexual health care (eg, STI testing and contraceptives) and HIV care (eg, HIV testing, ART, and sex worker-tailored clinics), increases are noted in condom use and reduced condom breakage, 39, 40, 32, 44, 47, 67, 79, 95, 96, 97, 98, 99 and lower HIV prevalence. 100, 101 Condom coverage must include condom access (eg, free or subsidised condoms at the workplace, the ability to carry condoms while working, and contact with peer condom distribution), availability and affordability, linked to reduced HIV acquisition and transmission among FSWs 25, 30, 39, 40, 44, 47, 68, 70, 79, 82, 84, 87, 93, 95, 97, 98, 99, 102, 103, 104, 105, 106, 107…”

Targeting core groups for gonorrhoea control: feasibility and impact

“…Likewise, a syndromic approach combined with the promotion of condom use among FSWs in India with the Avahan programme18 19 and the preventive periodic treatment for FSWs in high-prevalence settings in Kenya20 and South Africa21 were also shown to decrease gonorrhoea prevalence.…”

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

“…An overall declining trend in HIV prevalence among FSWs is reported from the state of Andhra Pradesh as part of the Avahan program [10]. 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].…”