RESUMEN
BACKGROUND: The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India's concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. METHODS: Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. RESULTS: Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. CONCLUSION: This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.
Asunto(s)
Condones/estadística & datos numéricos , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Promoción de la Salud/métodos , Sexo Seguro/estadística & datos numéricos , Trabajadores Sexuales/estadística & datos numéricos , Adulto , Estudios Transversales , Femenino , Humanos , India/epidemiología , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: The present study describes an assessment of a large-scale intervention, "Avahan", using an evaluation framework that assesses the program coverage, changes in injection patterns, condom use, and STI and HIV prevalence among People Who Inject Drugs (PWID) in two states of India - Manipur and Nagaland. METHODS: Program monitoring data and results from two rounds of a cross sectional biological and behavioural surveys in 2006 (Round 1) and 2009 (Round 2) were used. The sample included 839 and 860 PWIDs from Manipur and 821 and 829 PWIDs from Nagaland in Round 1 and Round 2 respectively for current analysis. Bivariate and multivariate analyses were done to measure the changes in behavioural and biological outcomes between the two rounds and to examine the association between programme exposure and behavioural outcomes. RESULTS: In Manipur, about 77% of the PWIDs were contacted by the peer educators/outreach workers every month and about 18% of the PWIDs visited the clinic every month by March 2010. In Nagaland, however, the proportion of PWIDs visiting the clinic monthly remained low (11% in March 2010). PWIDs in both states were more likely to report 'consistent safe injection practice in the last six months' in Round 2 compared to Round 1 (Manipur: adjusted odds ratio (aOR): 1.88, 95% confidence intervals (CI): 1.46-2.43; Nagaland: aOR: 2.35, 95% CI: 1.86-2.80) PWIDs were also more likely to report consistent condom use with regular partners in Round 2. The prevalence of Hepatitis B virus (HBV) increased in Round 2 in Manipur (11% vs 6%, p<0.001) and Nagaland (8% vs 6%, p=0.05). The prevalence of Hepatitis C virus (HCV) was high and did not change, either in Manipur (67.3% vs 69.9%, p=0.42) and Nagaland (14.7% vs 15.1%, p=0.82). Similarly, the prevalence of HIV did not change significantly between the two Rounds either in Manipur (27.8% in Round 1 vs 29.2% in Round 2, p=0.59) or in Nagaland (1.2% in Round 1 and 1.6% in Round 2 of the IBBA, p=0.82). CONCLUSION: Improvements in safe injection practices and consistent condom use with regular partners suggest effectiveness of prevention efforts. However, increase in HBV prevalence and non-decline in HCV and HIV prevalence in both the states also underscore the need to continue and intensify targeted interventions (such as Hepatitis B vaccination, needle exchange programmes, condom distribution) for long term risk reduction among PWID population.
Asunto(s)
Condones/estadística & datos numéricos , Infecciones por VIH/prevención & control , Enfermedades de Transmisión Sexual/epidemiología , Abuso de Sustancias por Vía Intravenosa/epidemiología , Adolescente , Adulto , Estudios Transversales , Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Hepatitis B/epidemiología , Hepatitis C/epidemiología , Humanos , India/epidemiología , Masculino , Análisis Multivariante , Programas de Intercambio de Agujas/organización & administración , Prevalencia , Asunción de Riesgos , Conducta Sexual/estadística & datos numéricos , Parejas Sexuales , Adulto JovenRESUMEN
OBJECTIVES: To assess a large-scale intervention, the Avahan intervention, using an evaluation framework that included programme coverage, condom use and changes in sexually transmitted infection (STI) and HIV prevalence among high-risk men who have sex with men/transgender (HR-MSM/TG) in the state of Andhra Pradesh, India. DESIGN: Programme monitoring data and results from two rounds of cross-sectional integrated biological and behavioural assessment (IBBA) in 2006 (Round 1) and 2009 (Round 2) were used for current analysis. SETTING: Programme monitoring data and cross-sectional surveys from Andhra Pradesh, India. PARTICIPANTS: Data from 1218 and 1203 participants in Rounds 1 and 2 of the IBBA, respectively, and field level programme monitoring data from the intervention districts. PRIMARY AND SECONDARY OUTCOMES: (1) Assess the reach of intervention in the HR-MSM/TG population; (2) evaluate the association between intervention and the intermediate outcomes (such as condom use and STIs) and (3) assess the association between HIV/STIs and the intervention. RESULTS: By July 2008, the intervention contacted 83% of the estimated HR-MSM/TG population monthly and 16% were attending the STI clinic monthly. HR-MSM/TG exposed to the intervention were significantly more likely to use condom consistently with a regular male partner (adjusted OR 4.62, 95% CI 1.40 to 15.22). Consistent condom use with all types of male partners increased significantly in survey Round 2 compared with Round 1. The proportion of HR-MSM/TG who tested positive for HIV-1 antibodies was similar in both rounds (15.5% in Round 1 vs 17.3% in Round 2, p=0.52). CONCLUSION: The Avahan intervention achieved a good population coverage, and delivered high-intensity peer and STI clinical services in Andhra Pradesh in the highly mobile target population of HR-MSM/TG; this also resulted in positive behavioural outcomes including increased condom use. However, the high prevalence of HIV in this group is an important public health priority.