Increased HIV prevention program coverage and decline in HIV prevalence among female sex workers in south India.
BACKGROUND
As one way of assessing the impact of Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation, we examined the association between HIV prevention program indicators and changes in HIV prevalence among female sex workers (FSWs) between 2005 and 2009.


METHODS
We conducted a secondary data analysis from 2 large cross-sectional surveys (2005-2006 and 2008-2009) across 24 districts in south India (n = 11,000 per round). A random-effect multilevel logistic regression analysis was performed using HIV as the outcome, with individual independent variables (from both surveys) at level 1 and district-level FSW-specific program indicators and contextual variables at level 2. Program indicators included their 2006 value, the difference in their values between 2008 and 2006, and the interaction between this difference and study round.


RESULTS
HIV prevalence among FSWs decreased from 17.0% to 14.2% (P < 0.001). This decline varied significantly (P = 0.006) across levels of difference in program coverage (% of FSWs contacted by the program in a given year). Odds ratios comparing HIV prevalence between rounds changed with the level of increase in coverage and were statistically significant with coverage increase ≥ quartile (Q) 1: odds ratio, 0.85 at Q1; 0.78 at Q2; 0.66 at Q3; and 0.51 at Q4.


CONCLUSIONS
These findings suggest that increased program coverage was associated with declining HIV prevalence among FSWs covered by the Avahan program. The triangulation of our results with those from other approaches used in evaluating Avahan suggests a major impact of this intervention on the HIV epidemic in southern India.
From the *Centre de recherche du CHU de Québec, Québec, Canada; †Département de médecine sociale et préventive, Université Laval, Québec, Canada; ‡CHARME-India II Project, Bangalore, India; §Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bangalore, India; ¶Karnataka Health Promotion Trust, Bangalore, India; ∥St John's Research Institute, Bangalore, India; **National AIDS Research Institute, Pune, India; ††FHI 360, Washington, DC; ‡‡Département de mathématiques et statistique, Université Laval, Québec, Canada; and §§Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
Michel
M
Alary
Pradeep
P
Banandur
Subramanian Potty
SP
Rajaram
Usha K
UK
Thamattoor
Mandar K
MK
Mainkar
Ramesh
R
Paranjape
Rajatashurva
R
Adhikary
Thierry
T
Duchesne
Shajy
S
Isac
Stephen
S
Moses
D000293:Adolescent; D000328:Adult; D002690:Chlamydia Infections / Q000453:epidemiology / Q000517:prevention & control*; D017280:Condoms / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D006069:Gonorrhea / Q000453:epidemiology / Q000517:prevention & control*; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D007194:India / Q000453:epidemiology; D016015:Logistic Models; D015995:Prevalence; D015397:Program Evaluation; D021841:Safe Sex; D060386:Sex Workers / Q000523:psychology / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013587:Syphilis / Q000453:epidemiology / Q000517:prevention & control*