A comprehensive HIV prevention programme targeted at female sex workers and men who have sex with men in India has had a major impact on reported condom use and incidence of sexually transmitted infections, according to the evaluation results presented by Alvaro Bernejo of the International HIV/AIDS Alliance at the International AIDS Conference in Mexico City on August 6th.
The programme was part of the International HIV/AIDS Alliance’s Frontiers Prevention Project, which focuses on low prevalence countries in which the epidemic is not yet generalised, but is concentrated in groups such as sex workers and men who have sex with men. Frontiers aims to support local partner organisations to develop HIV prevention programmes that provide a comprehensive package of interventions including both scale-up of services and community empowerment. Interventions focus on those population groups most vulnerable to HIV, and are intensively provided to ensure ‘saturation coverage’ so that the vast majority of targeted population groups can access the services provided.
The programme was provided in Andhra Pradesh, the most populous state in southern India and one of the six Indian states with the highest prevalence of HIV. It consisted of:
- Individually focussed health promotion
- Large-scale expansion of targeted services – 60 new sexual health clinics, condom provision, treatment for people with HIV
- Community mobilisation – involvement in planning of programme, involvement in delivery of services, outreach workers from the communities promoting access to services
- Structural and environmental interventions to create an enabling environment – for example, creation of drop-in centres
- Capacity strengthening of local NGOs
It was also a ‘model programme’ in the sense that significant resources were devoted to external evaluation. Quantitative data were collected from 2182 female sex workers (FSW) and 2929 men who have sex with men (MSM) at baseline in late 2003 and early 2004. Following implementation, further data were collected in 2007 from 2374 FSW and 2014 MSM in 24 sites.
However the initial plan was to conduct the evaluation both in the areas targeted by the intervention and in a series of ‘control’ areas which did not receive the intervention. However, real life proved less easy to control, as another agency, AVAHAN began implementing a similar range of activities in those districts where Frontiers was not working. For this reason, the results below relate only to the districts where Frontiers was provided, and compare results at baseline and four years later.
The evaluation looked at outcomes for self-reported use of condoms and for infection with syphilis and the herpes virus HSV-2 (tests were conducted at the interview). The programme planners believe that increases in condom use and decreases in sexually transmitted infections (STIs) will lead to decreases in HIV incidence.
There was a massive increase in condom use by MSM with their last male partner – from 58% at baseline to 91%. For FSW, their use of condoms with their last client increased from 70% to 98%.
Many of the MSM were married, and condom use with last female partner increased from 15% to 41%. This is a steep increase, although the majority of MSM continued not to use condoms with their female partners.
Similarly, female sex workers’ use of condoms with regular partners (as opposed to clients) was limited. It increased from 6% to 22%.
Although self-reported condom use can be subject to problems with reliability, Alvaro Bernejo indicated that there was a correlation between respondents reported use of condoms and numbers of STIs.
There were also dramatic reductions in STIs. Rates of syphilis in MSM dropped from 26% to 9%, and for FSW, the drop was from 23% to 10%.
Rates of HSV-2 dropped from 37% to 13% in MSM, and from 50% to 23% in FSW.
Bernejo ascribed the success of the programme to the saturation coverage, and suggested that there is a “tipping point” at which behavioural interventions start to make a real impact. Moreover, he pointed out that the implementation of the programme was subject to a demanding level of management and accountability, which may be necessary for effective roll-out of prevention programmes.