title: Increasing condom use and declining STI prevalence in high-risk MSM and TGs: evaluation of a large-scale prevention program in Tamil Nadu, India.
abstract: BACKGROUND
  This paper presents an evaluation of Avahan, a large scale HIV prevention program that was implemented using peer-mediated strategies, condom distribution and sexually transmitted infection (STI) clinical services among high-risk men who have sex with men (HR-MSM) and male to female transgender persons (TGs) in six high-prevalence state of Tamil Nadu, in southern India.
  
  
  METHODS
  Two rounds of large scale cross-sectional bio-behavioural surveys among HR-MSM and TGs and routine program monitoring data were used to assess changes in program coverage, condom use and prevalence of STIs (including HIV) and their association to program exposure.
  
  
  RESULTS
  The Avahan program for HR-MSM and TGs in Tamil Nadu was significantly scaled up and contacts by peer educators reached 77 percent of the estimated denominator by the end of the program's fourth year. Exposure to the program increased between the two rounds of surveys for both HR-MSM (from 66 percent to 90 percent; AOR = 4.6; p < 0.001) and TGs (from 74.5 percent to 83 percent; AOR = 1.82; p < 0.06). There was an increase in consistent condom use by HR-MSM with their regular male partners (from 33 percent to 46 percent; AOR = 1.9; p < 0.01). Last time condom use with paying male partners (up from 81 percent to 94 percent; AOR = 3.6; p < 0.001) also showed an increase. Among TGs, the increase in condom use with casual male partners (18 percent to 52 percent; AOR = 1.8; p < 0.27) was not significant, and last time condom use declined significantly with paying male partners (93 percent to 80 percent; AOR = 0.32; p < 0.015). Syphilis declined significantly among both HR-MSM (14.3 percent to 6.8 percent; AOR = 0.37; p < 0.001) and TGs (16.6 percent to 4.2 percent; AOR = 0.34; p < 0.012), while change in HIV prevalence was not found to be significant for HR-MSM (9.7 percent to 10.9 percent) and TGs (12 percent to 9.8 percent). For both groups, change in condom use with commercial and non-commercial partners was found to be strongly linked with exposure to the Avahan program.
  
  
  CONCLUSIONS
  The Avahan program for HR-MSM and TGs in Tamil Nadu achieved a high coverage, resulting in improved condom use by HR-MSM with their regular and commercial male partners. Declining STI prevalence and stable HIV prevalence reflect the positive effects of the prevention strategy. Outcomes from the program logic model indiacte the effectiveness of the program for HR-MSM and TGs in Tamil Nadu.
authors.affiliation: National Institute of Epidemiology, ICMR, Chennai, India. thilakavathi_s@rediffmail.com.
authors.forename: Thilakavathi
authors.initials: T
authors.lastname: Subramanian
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Ramakrishnan
authors.forename: Santhakumar
authors.initials: S
authors.lastname: Aridoss
authors.forename: Prabuddhagopal
authors.initials: P
authors.lastname: Goswami
authors.forename: Boopathi
authors.initials: B
authors.lastname: Kanguswami
authors.forename: Mathew
authors.initials: M
authors.lastname: Shajan
authors.forename: Rajat
authors.initials: R
authors.lastname: Adhikary
authors.forename: Girish Kumar Chethrapilly
authors.initials: GK
authors.lastname: Purushothaman
authors.forename: Senthil Kumar
authors.initials: SK
authors.lastname: Ramamoorthy
authors.forename: Eswaramurthy
authors.initials: E
authors.lastname: Chinnaswamy
authors.forename: Ilaya Bharathy
authors.initials: IB
authors.lastname: Veeramani
authors.forename: Ramesh Shivram
authors.initials: RS
authors.lastname: Paranjape
mesh_terms: D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data* / Q000600:supply & distribution; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D006293:Health Promotion / Q000379:methods; D018451:Homosexuality, Male / Q000706:statistics & numerical data; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D015995:Prevalence; D015397:Program Evaluation; D021841:Safe Sex / Q000706:statistics & numerical data; D060386:Sex Workers / Q000706:statistics & numerical data; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000517:prevention & control*; D063106:Transgender Persons / Q000706:statistics & numerical data
references.citation: J Acquir Immune Defic Syndr. 2004 Mar 1;35(3):314-9
references.pmid: 15076248
references.citation: BMJ. 2008 Sep 29;337:a1655
references.pmid: 18824488
references.citation: Lancet. 2011 Jan 1;377(9759):85-95
references.pmid: 20619886
references.citation: J Int AIDS Soc. 2010 Jun 23;13 Suppl 2:S7
references.pmid: 20573289
references.citation: Sex Transm Infect. 2010 Feb;86 Suppl 1:i83-8
references.pmid: 20167739
references.citation: Sex Transm Infect. 2010 Feb;86 Suppl 1:i25-32
references.pmid: 20167727
references.citation: Sex Transm Infect. 2010 Feb;86 Suppl 1:i76-82
references.pmid: 20167737
references.citation: Indian J Dermatol Venereol Leprol. 2009 Jan-Feb;75(1):41-6
references.pmid: 19172030
references.citation: Soc Sci Med. 2001 Mar;52(5):707-21
references.pmid: 11218175
references.citation: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001230
references.pmid: 18646068
references.citation: AIDS. 2008 Dec;22 Suppl 5:S1-15
references.pmid: 19098469
references.citation: Reprod Health Matters. 2003 Nov;11(22):74-90
references.pmid: 14708399
references.citation: AIDS. 2008 Dec;22 Suppl 5:S17-34
references.pmid: 19098477
references.citation: BMC Public Health. 2011 Dec 29;11 Suppl 6:S1
references.pmid: 22376071
references.citation: Indian J Dermatol Venereol Leprol. 2006 Nov-Dec;72(6):425-31
references.pmid: 17179617
references.citation: Sex Transm Infect. 2010 Feb;86 Suppl 1:i56-61
references.pmid: 20167732
references.citation: J Infect Dis. 2005 Feb 1;191 Suppl 1:S61-7
references.pmid: 15627232
references.citation: Health Aff (Millwood). 2008 Jul-Aug;27(4):1091-102
references.pmid: 18607044
references.citation: Indian J Med Res. 2010 Sep;132:256-9
references.pmid: 20847370
references.citation: Int J Epidemiol. 1999 Feb;28(1):10-8
references.pmid: 10195658
references.citation: AIDS Behav. 2010 Oct;14(5):1001-10
references.pmid: 20467890
references.citation: BMC Public Health. 2011 Dec 29;11 Suppl 6:S10
references.pmid: 22970436
references.citation: AIDS. 2005 Mar 24;19(6):611-9
references.pmid: 15802980
references.citation: AIDS Behav. 2006 Jul;10(4 Suppl):S5-16
references.pmid: 16832600
references.citation: J LGBT Health Res. 2008;4(2-3):51-70
references.pmid: 19856739
references.citation: J Acquir Immune Defic Syndr. 2012 Jan 1;59(1):72-8
references.pmid: 21937924