Background
Methods
Data sources
Evaluation question | Indicator | Data source |
---|---|---|
1. Is coverage of Avahan adequate?
|
A. Scale
| |
a. Geographical coverage- Description of rollout in number of districts and change in number of implementing NGOs over time | Central monitoring information system (CMIS) | |
b. Proportion of HR-MSM ever contacted and ever visited clinic- Number of HR-MSM ever contacted by Avahan peer educators or ever visited Avahan program STI clinics divided by the estimated size of HR-MSM as of March 2009 | CMIS | |
c. Proportion of HR-MSM c
ontacted monthly by peer educators or visited program STI clinics for STI consultations – Number of HR-MSM contacted every month by peer educators or visited program STI clinics monthly, divided by the estimated denominator/size of HR-MSM as of March 2009 | CMIS | |
d. Proportion of HR-MSM/TGs contacted in last month- Percentage of HR-MSM from IBBA who reported that they had been contacted by Avahan peer educators in the month preceding survey | IBBA | |
B. Intensity
| ||
a. Number of peer educator/outreach worker and ratio of MSM to peer educators- The total number of active outreach workers and peer educators in the Avahan intervention areas across implementation districts in Tamil Nadu; number of estimated MSM/TG covered per peer educator in the coverage area | CMIS | |
b. Condom distribution and availability
| CMIS and condom social marketing data (CSM) | |
1. Absolute number of free condoms distributed by the Avahan program annually and condom sales from project-supported condom social marketing by program from 2005 to 2008. | ||
2. Condom needs analysis- Ratio of average monthly condoms available per MSM; total condoms distributed by Avahan and made available through project-supported condom social marketing sales, divided by the estimated number of MSM in the area covered by Avahan; and ratio of number of condoms distributed to monthly commercial sex acts per MSM/TG, where sex acts are calculated based on number of sex acts with paying and paid male partners per month multiplied by total estimated number of MSMs covered by Avahan multiplied by four to get monthly sex acts***. | ||
3. Proportion of HR-MSM reporting source of obtaining condom last time from outreach worker/peer educator/nongovernmental organization | IBBA | |
c. Frequency of contact by peers HR- MSM/TG reporting number of times they were contacted by peer educators in the month preceding the survey | IBBA | |
d. Frequency of visit to clinic HR- MSM reporting the number of times they visited the Avahan program clinics for STI services | Individual level CMIS data | |
2. Has there been an increase in condom use by HR-MSM?
|
Change in condom use pattern
| |
a. Proportion of HR-MSM reporting last time condom use with paying male partners during two rounds of IBBA | IBBA | |
b. Proportion of HR-MSM reporting consistent condom use with paid male partners during two rounds of IBBA | IBBA | |
c. Proportion of HR-MSM reporting consistent condom use with regular male partners during two rounds of IBBA | IBBA | |
d. Proportion of HR-MSM reporting consistent condom use with other non-commercial male partners during two rounds of IBBA | IBBA | |
3. Has there been a reduction in STIs and new HIV infections?
|
Change in STI prevalence and visits to clinic with STI symptoms
| |
a. STI prevalence (reactive syphilis serology, high-titre syphilis, gonorrhoea (NG), chlamydia (CT), any STI (NG, or CT or high-titre syphilis) | IBBA | |
Change in HIV prevalence and new HIV infections
| IBBA | |
a. HIV prevalence among HR-MSM aggregated from all districts in two rounds of IBBA | ||
c. HIV prevalence among HR-MSM in the age group of 18–20 years | ||
4. Is Avahan exposure associated with increase in condom use and declining STIs?
|
Association of intermediate outcomes and STIs to program exposure
| IBBA |
a. Program exposures, defined as exposure to any one — ever contacted by peer, ever visited program clinic, and ever received condoms from peer educators; its link to consistent condom use with commercial and non-commercial partners, using pooled data from two rounds of IBBA | ||
b. Duration of program exposure and its link to condom use with commercial and non-commercial partners, using pooled data from two rounds of IBBA | ||
b. Program exposure, as defined above, and its link with presence of any STIs (NG, CT or high-titre syphilis) |
Analytical framework for evaluation
Indicators
Program coverage and intensity
Intermediate outcomes
Condom use
Sexually transmitted infections (including HIV)
Association between outcomes and program exposure
Statistical analyses
Ethics statement
Results
Program coverage and intensity
Coverage data from MIS
Clinic MIS
Coverage data from IBBA
HR-MSM | Transgender | ||||||
---|---|---|---|---|---|---|---|
Characteristics | Sub-groups | Round 1 | Round 2 | Wald-Pearson p-value | Round 1 | Round 2 | Wald-Pearson p-value |
(%; n = 1621) | (%; n = 1620) | (%; n = 404) | (%; n = 403) | ||||
Self-identity | Kothi | 54.3 | 80.1 | <0.01 | |||
Panthi | 11.9 | 1.3 | |||||
Double decker | 31.2 | 14.5 | |||||
Bisexual | 2.7 | 4.0 | |||||
Aqua aravani | 37.4 | 58.5 | 0.00 | ||||
Nirvana aravani | 62.6 | 41.5 | |||||
Current age (years) | < 25 | 39.44 | 27.1 | <0.05 | 33.6 | 26.9 | |
25-29 | 24.9 | 30.4 | 29.5 | 30.9 | 0.18 | ||
30-34 | 14.2 | 15.9 | 16.3 | 24.1 | |||
35-39 | 9.1 | 12.8 | 11.3 | ||||
40+ | 12.4 | 13.8 | 11.2% | 6.9 | |||
Mean | 29 | 29.2 | 28.8 | 28.7 | |||
Literacy | Cannot read or write | 21.9 | 8.3 | <0.01 | 34.9 | 11.2 | 0.00 |
Marital status | Currently married | 23.8 | 24.7 | 0.05 | 20.1 | 21.3 | |
Ever married | .79 | .68 | 4.8 | 1.5 | |||
Never married | 74.8 | 74.6 | 75.2 | 77.1 | 0.14 | ||
Main income | Unemployed/student | 8.2 | 3.8 | <0.01 | 30.6 | 2.6 | 0.00 |
Self-employed/business | 17.9 | 29.3 | 10.0 | 9.7 | |||
Laborer | 32.5 | 38.7 | 15.7 | 12.5 | |||
Service (govt./pvt.) | 32.4 | 17.2 | 5.1 | 9.5 | |||
Sex work | 4.4 | 5.3 | 20.2 | 41.0 | |||
Others (transport workers) | 4.3 | 5.6 | 18.4 | 24.7 | |||
Residency | Lives in same city as survey | 65.6 | 98.7 | <0.01 | 94.7 | 99.6 | 0.00 |
Age at first sex (years) | < 15 | 21.6 | 37.5 | <0.01 | 52.6 | 48.1 | 0.41 |
15+ | 78.4 | 62.5 | 47.4 | 51.9 | |||
Sex work outside residence district | Yes | 45.3 | 18.9 | <0.01 | 39.3 | 40.5 | 0.83 |
Condom availability
Intermediate outcomes
Changes in condom use
Condom-related outcomes and STI prevalence | Round 1 | Round 2 | Crude OR | Adjusted OR^ | p-value |
---|---|---|---|---|---|
% (N) | % (N) | (95% CI) | (95% CI) | (Wald test) Adjusted OR | |
3.1 Condom use indicators for HR-MSM
| |||||
Last time condom use with regular male partner | 72.6 (1265) | 83.2 (1276) | 1.8 (1.3-2.7) | 1.9 (1.3-2.9) | <0.01 |
Last time condom use with male paying partner | 80.8 (927) | 93.6 (1410) | 3.5 (2.2-5.6) | 3.6 (2.2-5.9) | <0.01 |
Last time condom use with paid male partner | 66.3 (364) | 94.2 (215) | 8.3 (2.2-30.8) | 11.2 (1.3-101.9) | <0.05 |
Last time condom use with casual male partner | 73.9 (949) | 92.5 (883) | 4.3 (2.4 – 7.9) | 5.2 (2.9-9.1) | <0.01 |
Consistent condom use with regular male partner | 32.9 (1265) | 46.3 (1276) | 1.8 (1.2-2.5) | 1.9 (1.3-2.7) | <0.01 |
Consistent condom use with paid male partner | 42.1 | 55.2 | 1.7 (0.82-3.5) | 1.9 (0.90-4.4) | 0.14 |
Consistent condom use with casual male partner | 26.6 (949) | 55.1 (883) | 3.4 (2.0-5.6) | 4.2 (2.6-6.7) | <0.01 |
3.2 Condom use indicators for TGs
| |||||
Last time condom use with regular male partner | 73.3 (268) | 60.9 (279) | 0.56 (0.3-0.9) | 0.59 (0.3-1.1) | 0.12 |
Last time condom use with paying male partner | 93.1 (297) | 79.5 (359) | 0.28 (0.13-0.63) | 0.36 (0.2- 0.8) | 0.02 |
Last time condom use with other casual male partner | 80.7 (105) | 67.3 (167) | 0.49 (0.2-1.2) | 0.25 (0.8-0.8) | 0.02 |
Consistent condom use with regular male partner | 34.5 (268) | 47.2 (279) | 1.7 (0.9-2.9) | 1.37 (0.7-2.7) | 0.35 |
Consistent condom use with other casual male partner | 18.0 (105) | 51.5 (167) | 4.8 (1.8 – 13.2) | 1.89 (0.6-5.9) | 0.27 |
Changes in STIs and HIV prevalence
Round 1 | Round 2 | Crude OR | Adjusted OR^ | p-value | |
---|---|---|---|---|---|
% N = 2032 | % N = 2006 | (95% CI) | (95% CI) | (Wald test) | |
HR-MSM
| |||||
HIV-1 infection | 9.7 | 10.9 | 1.2 (0.7-1.9) | 1.1 (0.7-1.9) | 0.57 |
Reactive RPR + positive TPHA | 14.3 | 6.8 | 0.43 (0.3-0.7) | 0.37 (0.2-0.6) | <0.01 |
Reactive RPR >1:8 + positive TPHA | 3.63 | 3.43 | 0.94 (0.5-1.8) | 1.15 (0.6-2.35) | 0.68 |
Chlamydia infection | 0.68 | 0.51 | 0.74 (0.3-2.1) | 2.2 (.5-8.9) | 0.29 |
Gonorrhoea infection | 0.07 | 0.15 | 2.0 (0.2-18.3) | 6.9 (0.3-159.5) | 0.23 |
Chlamydia and/or gonorrhoea infection | 0.76 | 0.56 | 0.75 (0.3-2.2) | 2.3 (.6-9.4) | 0.24 |
HIV prevalence (district-wise)
| |||||
Chennai | 4.8 | 10.9 | 2.5 (1.1-5.2) | 2.6 (0.97-6.8) | 0.06 |
Coimbatore | 6.5 | 11.2 | 1.8 (0.94-3.5) | 2.2 (0.97-5.0) | 0.06 |
Madurai | 22.3 | 14.4 | 0.59 (0.24-1.4) | 0.57 (0.23-1.4) | 0.23 |
Salem | 5.5 | 4.8 | 0.87 (0.29-2.6) | 0.56 (0.18-1.7) | 0.31 |
Syphilis prevalence (district wise)
| |||||
Chennai | 12.9 | 9.9 | 0.74 (5.0-16.6) | 0.62 (0.3-1.4) | 0.24 |
Coimbatore | 14.5 | 6.3 | 0.39 (0.2-0.7) | 0.37 (0.2-0.8) | <0.01 |
Madurai | 17.8 | 6.6 | 0.34 (0.1-1.2) | 0.25 (0.1-0.9) | <0.05 |
Salem | 12.2 | 1.9 | 0.14 (0.1-0.4) | 0.08 (0.0-0.2) | <0.01 |
TGs
| |||||
HIV-1 infection | 12 | 9.8 | 0.79 (0.4-1.6) | 1.3 (0.5-3.2) | 0.57 |
Reactive RPR + positive TPHA | 16.6 | 4.2 | 0.22(0.1-0.4) | 0.30 (0.1-0.7) | 0.01 |
Reactive RPR >1:8 + positive TPHA | 0 | 0 | - | - | - |
Chlamydia infection | 0 | 0 | - | -- | - |
Gonorrhoea infection | 0 | 0 | - | - | - |
Association between outcomes and program exposure
Condom use | Group | % who received any services | Crude OR (95% CI) | Adjusted OR^ (95% CI) | p-value (Wald test) |
---|---|---|---|---|---|
Last time condom use with paying male partner
|
HR-MSM
|
88.3
|
5.3 (3.4-8.3) |
4.78 (2.9-7.9) |
<0.01
|
TGs
|
86.8
| 1.6 (0.8-3.0) | 2.82 (1.3-6.1) |
<0.01
| |
Consistent condom use with regular male partner
|
HR-MSM
|
90.7
|
3.46 (2.3-5.2) |
3.98 (2.3-6.9) |
<0.001
|
TGs
|
43.1
| 1.74 (0.9-3.4) | 1.66 (0.8-3.3) |
0.14
| |
Consistent condom use with paid male partner
|
HR-MSM
|
74.8
|
0.76 (0.5-1.3) |
1.96 (0.9-4.4) |
0.10
|
Consistent condom use with other male partner
|
HR-MSM
|
93.1
|
5.46 (3.4-8.9) |
5.18 (2.9-9.2) |
<0.01
|
TGs
|
38.8
| 4.2 (1.6-11.1) | 5.46 (1.7-17.4) |
<0.01
| |
STI prevalence
| |||||
Any STIs (NG, CT or high-titre syphilis)
|
HR-MSM
|
3.95
|
0.70 (0.34-1.4)
|
0.66 (0.4-1.1) |
0.138
|
Syphilis
|
TGs
|
11.2
|
1.6 (0.8-3.3)
|
1.6 (0.7-3.8)
|
0.25
|
Duration of program exposure | p-value (Wald) | |||||
---|---|---|---|---|---|---|
Not exposed (%) | <12 months | 12.23 months | 24-33 months | >33 months | ||
Last time condom use with regular male partner
| 13.4 | 8.6 | 20.6 | 26.8 | 29.6 | <0.01 |
Last time condom use with male paying partner
| 9.9 | 8.3 | 16.9 | 27.3 | 36.2 | <0.01 |
Last time condom use with paid male partner
| 27.8 | 9.5 | 11.3 | 23.6 | 27.3 | <0.05 |
Last time condom use with other casual male partner
| 13.9 | 8.9 | 22.5 | 25.8 | 28.5 | <0.01 |
Consistent condom use with regular male partner
| 8.9 | 7.3 | 15.7 | 27.9 | 37.4 | <0.01 |
Consistent condom use with other casual male partner
| 5.9 | 7.5 | 14.4 | 30.6 | 40.8 | <0.01 |