title: Inconsistent condom use by male clients during anal intercourse with occasional and regular female sex workers (FSWs): survey findings from southern states of India.
abstract: OBJECTIVE
  Self-reported anal intercourse by female sex workers (FSWs) documented in recent studies from India range between 11.9% and 22%. However, comparable data on anal intercourse and condom use from male clients of FSWs is lacking. Using data from a bio-behavioural survey (2009-2010), we examined prevalence of anal intercourse, male clients' self-reported inconsistent condom use during anal intercourse with FSWs, and correlates of this behaviour in India's high HIV prevalence southern states (Andhra Pradesh, Maharashtra and Tamil Nadu combined).
  
  
  METHODS
  Using two-stage time location cluster sampling, we recruited 4803 clients of FSWs, ages 18-60 years, who had purchased sex from an FSW in the past month. After obtaining informed consent, respondents were interviewed and tested for HIV and sexually transmitted infections (syphilis, gonorrhoea and chlamydia). Logistic regression analysis was used to identify the factors associated with inconsistent condom use during anal intercourse (in the past 6 months) with FSWs.
  
  
  RESULTS
  Overall, 12.3% clients reported anal intercourse in the past 6 months, of whom 48.4% used condoms inconsistently. Clients of FSWs who were ages 26 years or older (AOR 2.68, p=0.032); employed as manual labourers (AOR 2.43, p=0.013); consumed alcohol (AOR 2.63, p=0.001); reported five or more sex acts with FSWs in the past month (AOR 2.53, p=0.031); and perceived themselves to be at higher risk for HIV (AOR 4.82, p=0.001) were more likely to inconsistently use condoms during anal intercourse.
  
  
  CONCLUSIONS
  The results suggest that sex workers and their clients commonly practice anal intercourse, but a relatively high proportion of clients do not consistently use condoms, leading to a greater risk of acquiring HIV and its further transmission to other male and female sexual partners. Given the multidirectional risk, safer sex communication on heterosexual anal intercourse must be incorporated into HIV prevention programmes.
authors.affiliation: Department of M&E, Knowledge Network, DAKSH, FHI 360, New Delhi, India.
authors.forename: Shreena
authors.initials: S
authors.lastname: Ramanathan
authors.affiliation: National AIDS Research Institute (NARI), Pune, Maharashtra, India.
authors.forename: Karikalan
authors.initials: K
authors.lastname: Nagarajan
authors.affiliation: FHI 360, New Delhi, India.
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Ramakrishnan
authors.affiliation: National AIDS Research Institute (NARI), Pune, Maharashtra, India.
authors.forename: Mandar K
authors.initials: MK
authors.lastname: Mainkar
authors.affiliation: FHI 360, New Delhi, India.
authors.forename: Prabuddhagopal
authors.initials: P
authors.lastname: Goswami
authors.affiliation: FHI 360, New Delhi, India.
authors.forename: Diwakar
authors.initials: D
authors.lastname: Yadav
authors.affiliation: FHI 360, New Delhi, India.
authors.forename: Shrabanti
authors.initials: S
authors.lastname: Sen
authors.affiliation: FHI 360, New Delhi, India.
authors.forename: Bitra
authors.initials: B
authors.lastname: George
authors.affiliation: National Institute of Nutrition (NIN), Hyderabad, Andhra Pradesh, India.
authors.forename: Harikumar
authors.initials: H
authors.lastname: Rachakulla
authors.affiliation: National Institute of Epidemiology (NIE), Chennai, Tamil Nadu, India.
authors.forename: Thilakavathi
authors.initials: T
authors.lastname: Subramanian
authors.affiliation: National AIDS Research Institute (NARI), Pune, Maharashtra, India.
authors.forename: Ramesh S
authors.initials: RS
authors.lastname: Paranjape
mesh_terms: D000293:Adolescent; D000328:Adult; D016000:Cluster Analysis; D017280:Condoms / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D015438:Health Behavior; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011477:Sex Work / Q000706:statistics & numerical data; D060386:Sex Workers / Q000706:statistics & numerical data*; D012725:Sexual Behavior / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: EPIDEMIOLOGY