title: Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study.
abstract: BACKGROUND
  In 2005, Pakistan was first labeled as a country with concentrated epidemic of Human Immunodeficiency Virus (HIV). This was revealed through second generation surveillance conducted by HIV/AIDS Surveillance Project (HASP). While injection drug users (IDUs) were driving the epidemic, subsequent surveys showed that Hijra (transgender) sex workers (HSWs) were emerging as the second most vulnerable group with an average national prevalence of 6.4%. An exceptionally high prevalence (27.6%) was found in Larkana, which is a small town on the right bank of river Indus near the ruins of Mohenjo-Daro in the province of Sindh. This paper presents the risk factors associated with high prevalence of HIV among HSWs in Larkana as compared to other cities of the country.
  
  
  METHODS
  Data were extracted for secondary analysis from 2008 Integrated behavioral and biological survey (IBBS) to compare HSWs living in Larkana with those living in other cities including Karachi and Hyderabad in Sindh; Lahore and Faisalabad in Punjab; and Peshawar in Khyber Pakhtunkhwa provinces. After descriptive analysis, univariate and multivariate analyses were performed to identify risk factors. P value of 0.25 or less was used to include factors in multivariate analysis.
  
  
  RESULTS
  We compared 199 HSWs from Larkana with 420 HSWs from other cities. The average age of HSWs in Larkana was 26.42 (±5.4) years. Majority were Sindhi speaking (80%), uneducated (68%) and unmarried (97%). In univariate analysis, factors associated with higher prevalence of HIV in Larkana included younger age i.e. 20-24 years (OR: 5.8, CI: 2.809-12.15), being unmarried (OR: 2.4, CI: 1.0-5.7), sex work as the only mode of income (OR: 5.5, CI: 3.70-8.2) and longer duration of being involved in sex work 5-10 years (OR: 3.3, CI: 1.7-6.12). In multivariate logistic regression the HSWs from Larkana were more likely to lack knowledge regarding preventive measures against HIV (OR 11.9, CI: 3.4-41.08) and were more prone to use of alcohol during anal intercourse (OR: 6.3, CI: 2.77-17.797).
  
  
  CONCLUSIONS
  Outreach programs focusing on safer sexual practices and VCT are urgently needed to address the upsurge of HIV among HSWs in Larkana.
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan.
authors.forename: Arshad
authors.initials: A
authors.lastname: Altaf
authors.forename: Aysha
authors.initials: A
authors.lastname: Zahidie
authors.forename: Ajmal
authors.initials: A
authors.lastname: Agha
mesh_terms: D000328:Adult; D002947:Cities; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000635:transmission*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D010154:Pakistan / Q000453:epidemiology; D015995:Prevalence; D012307:Risk Factors; D012309:Risk-Taking; D060386:Sex Workers / Q000523:psychology* / Q000706:statistics & numerical data; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D014504:Urban Health / Q000706:statistics & numerical data*; D055815:Young Adult