title: Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention.
abstract: BACKGROUND
  Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.
  
  
  METHODS
  Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.
  
  
  RESULTS
  Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%-12.6%). Typology (AOR 2.20, 95% CI 1.64-2.95) and literacy (AOR 1.28, 95% CI 1.10-1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44-1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47-2.15), alcohol consumption (AOR 1.21, 95% CI 1.03-1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28-1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25-1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13-1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.
  
  
  CONCLUSIONS
  Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.
authors.affiliation: Clinical Trials Unit, National AIDS Research Institute, Pune, Maharashtra, India.
authors.forename: Mallika
authors.initials: M
authors.lastname: Alexander
authors.affiliation: Clinical Trials Unit, National AIDS Research Institute, Pune, Maharashtra, India.
authors.forename: Mandar
authors.initials: M
authors.lastname: Mainkar
authors.affiliation: Integrated Behavioural and Biological Assessment Project, National AIDS Research Institute, Pune, Maharashtra, India.
authors.forename: Sucheta
authors.initials: S
authors.lastname: Deshpande
authors.affiliation: Clinical Trials Unit, National AIDS Research Institute, Pune, Maharashtra, India.
authors.forename: Shweta
authors.initials: S
authors.lastname: Chidrawar
authors.affiliation: Department of Biostatistics and Epidemiology, National AIDS Research Institute, Pune, Maharashtra, India.
authors.forename: Suvarna
authors.initials: S
authors.lastname: Sane
authors.affiliation: National Institute of Epidemiology, Chennai, Tamil Nadu, India.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mehendale
mesh_terms: D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D007194:India / Q000453:epidemiology; D012044:Regression Analysis; D012307:Risk Factors; D060386:Sex Workers / Q000706:statistics & numerical data*; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D012749:Sexually Transmitted Diseases / Q000175:diagnosis; D011795:Surveys and Questionnaires