STI Levels Decline Among Sex Workers in India After Program Implementation
Levels of HIV and other STIs declined, and condom use increased, among female sex workers in southern India in the three years following the initiation of a large-scale HIV- prevention program.1 Compared with female sex workers surveyed 7–19 months after the start of the program, those surveyed 28–37 months after the intervention began were less likely to test positive for HIV (odds ratio, 0.8), high-titer syphilis (0.5) and either chlamydia or gonorrhea (0.7). They were also more likely to report having not engaged in any unprotected sex acts with clients in the past month (2.4) and having used condoms the last time they had sex with a repeat client (2.0). Longer durations of exposure to the program were generally associated with higher levels of condom use.
The program, implemented by the Karnataka Health Promotion Trust in January 2004–April 2005, serves 60,000 female sex workers in Karnataka state; it provides sexual health services, promotes condom use through peer outreach, mobilizes communities around HIV prevention and empowers the sex work community. Seven to 19 months after implementation, the researchers interviewed a probability-based sample of 2,312 female sex workers in five districts (Bangalore Urban, Belgaum, Bellary, Mysore and Shimoga). The sample included street-based sex workers, as well as those who worked at home, brothels or other sites. A follow-up survey was conducted with 2,400 women 28–37 months after the program started; about 17% of respondents in the first survey also took part in the follow-up survey. In both surveys, the researchers collected data on women's social and demographic characteristics, age at sexual debut, age at initiation of sex work, primary place of solicitation, earnings from sex work, number of clients per week and condom use with clients and regular partners. They also asked women to report their exposure to five program components: having been visited by a peer educator, having visited a drop-in center, having visited the program's sexual health clinic, having received a pack for treating chlamydia and gonorrhea, and having witnessed a condom demonstration. In addition, respondents were tested for HIV, syphilis, chlamydia, gonorrhea and (in Mysore only) trichomonas at the time of the survey.
Respondents had a median age of 30; on average, they had been 15 years old when they first had sex and 25 when they began sex work. Some 33–46% of women from the initial and follow-up surveys were married, and 36–44% were separated, divorced, widowed or abandoned. Two-thirds were illiterate. The majority (54–55%) solicited customers in public places. The proportion earning more than 1,500 rupees per week (roughly US$30) from sex work increased from 31% to 52% between surveys.
At the time of the first survey, 20% of respondents tested positive for HIV, with prevalence ranging from 10% in Shimoga to 34% in Belgaum. Brothel-based sex workers were more likely than home- or street-based workers to be infected with HIV (33% vs. 14–21%) or either chlamydia or gonorrhea (12% vs. 6–10%), while those who solicited clients in public places were more likely than other workers to have high-titer syphilis (9% vs. 2–3%).
Between the first and follow-up surveys, exposure to most program components increased; for example, the proportion of respondents who had ever been visited by a peer educator rose from 83% to 95%, and increases occurred for visits to the drop-in center (from 32% to 77%) and sexual health clinic (from 68% to 85%). In some instances, changes in exposure varied by women's place of solicitation; for example, receipt of the chlamydia and gonorrhea treatment pack increased among home-based respondents, declined among brothel-based sex workers and did not change among street-based workers. Moreover, by the follow-up survey, brothel-based workers were less likely than others to have visited the drop-in center (62% vs. 74–81%) or the sexual health clinic (75% vs. 85–87%), or to have received a treatment pack (55% vs. 59–68%).
Condom use at last sex with a repeat client was reported by 66% of respondents at the initial survey and 84% at follow-up, a significant increase between surveys (odds ratio, 2.0). The odds of having had no unprotected sex acts in the past month also increased over time (2.4). Increases in condom use at last sex with an occasional client and with a regular partner were smaller and were not significant after adjustment for demographic and other variables. However, the odds of condom use with occasional clients, repeat clients and regular partners were all positively associated with greater duration of exposure to the program. Condom breakage was reported by significantly fewer women at follow-up than at the first survey (14% vs. 17%; odds ratio, 0.8).
Finally, STI prevalence was generally lower at follow-up than at the initial survey. The proportion of respondents who tested positive for HIV fell from 20% to 16% (odds ratio, 0.8); the proportion with high-titer syphilis decreased from 6% to 3% (0.5); and the proportion with either chlamydia or gonorrhea declined from 9% to 7% (0.7). In Mysore, the prevalence of trichomonas infection dropped from 33% to 14% (0.3). The proportion of sex workers infected with either chlamydia or gonorrhea was negatively associated with length of program exposure—it ranged from 13% among women who had not been exposed to the program to 3% among those exposed for more than 33 months—but there was no correlation between length of exposure and infection with other STIs.
The declines in STI prevalence among female sex workers in Karnataka suggest that "sexual health promotion programmes and services are now starting to reach this population, and safer sex practices are being adopted," the researchers conclude. They attribute the lack of gains in condom use between surveys to the high levels of use achieved in the months between program initiation and the first survey, and posit that community mobilization and the creation of a less hostile environment may have contributed to improvements in sex workers' sexual health practices and outcomes. However, because some sex workers (e.g., those based in brothels) received fewer program services and experienced higher levels of certain STIs than other workers did, the researchers stress that "concerted efforts that target the most vulnerable women must continue and be strengthened."—H. Ball.
1. Ramesh BM et al., Changes in risk behaviors and prevalence of sexually transmitted infections following HIV preventive interventions among female sex workers in five districts in Karnataka state, south India, Sexually Transmitted Infections, 2010, 86(Suppl. 1):i17–i24.