Increase in condom use and decline in prevalence of sexually transmitted infections among high-risk men who have sex with men and transgender persons in Maharashtra, India: Avahan, the India AIDS Initiative

An estimated 2.47 million people were living with HIV in India in 2008 [1]. HIV epidemic in India has been concentrated among female sex workers (FSWs); men who have sex with men (MSM), including transgender (TG) persons; and injecting drug users (IDUs) [2]. Though the epidemic in India is largely due to heterosexual transmission, studies across the country have shown that sexual activity between men is relatively common [3‐6] and HIV among MSM/TG populations is increasingly becoming an important route of transmission [2]. In India male-to-male sexual behavior takes place in diverse contexts, and MSM are known to have multiple partners, use condoms selectively during anal sex with male and female partners, and have high consumption of alcohol and drugs [4, 5, 7‐12]. Social stigma and clandestine behavior add to the vulnerability of MSM/TG, making them an important target group for HIV prevention interventions. Estimated HIV prevalence in MSM/TG in India stood at 4.4% in 2010–2011, down from 7.4% in 2007. However, HIV prevalence in Maharashtra (9.91%) is much higher than the national average, and in 2007, Maharashtra (11.8%) had the second largest burden of the HIV infected in India [13, 14]. Most studies have consistently found HIV prevalence in MSM/TG to be higher than 5% in Maharashtra. Notably, studies have shown that MSM/TG in the country’s metropolitan cities, such as Mumbai, Chennai, Pune, and Bangalore show higher HIV prevalence [4, 10, 11, 15, 16].

The country’s National AIDS Control Organisation (NACO) has, since 1992, implemented targeted interventions for high-risk groups such as FSWs and men attending STI clinics. Maharashtra was among the first states in India to initiate targeted interventions for MSM [17]. Avahan: the India AIDS Initiative, funded by the Bill & Melinda Gates Foundation, was launched in 2003 with the aim of reducing the spread of HIV; it has since played a major role in supporting prevention interventions in the country [18]. Avahan worked in 83 districts of the country’s six high-HIV prevalence states among high-risk groups. One of these six states was the western state of Maharashtra, where Avahan covered 15 districts out of the total 35 districts; in eight of these districts Avahan was the sole provider of interventions (Table 1). Avahan’s strategies were designed to achieve high coverage (80% of the total estimated target population) through delivery of a package of proven prevention services that would address proximal and distal determinants of HIV risk [19, 20]. The key elements of the combination prevention program for HR-MSM/TG included peer-led outreach to promote behavior change, clinical services to treat STIs, provision of commodities (condoms and lubricants) for safe sex, support for community mobilization, and advocacy to reduce structural barriers to safer sexual practices [17]. Avahan’s intervention focus was on highly visible HR-MSM/TG in high-risk locations (cruising sites/sex venues, such as parks, local train stations, and bus stops), who tend to have a large number of sexual partners and regularly practice receptive anal sex or sell sex. They are therefore referred to as high-risk MSM [17]. The present analysis, using multiple data sources, was conducted to assess the overall effect of the Avahan program on HIV prevention in Maharashtra’s HR-MSM/TG population. The specific objectives of this paper are to examine the scale-up and coverage of the Avahan program, changes in condom use patterns and prevalence of HIV and other STIs, and the association between these outcomes and exposure to Avahan program among HR-MSM/TG in Maharashtra.

The Avahan program evaluation framework was adapted and used for this assessment (Table 2) [21]. We evaluated the impact of the program using this framework, based on the program logic model, and using data from two rounds of independent surveys and program monitoring data. The framework assesses the program in the following sequence: (1) program implementation fidelity to design (process and output indicators); (2) intermediate outcomes such as condom use and STIs in target populations, HIV prevalence in target population and general population; (3) role of high-risk interventions in any changes; and (4) Avahan’s contribution to these changes.

A total of 1,305 HR-MSM/TG (653 in Round 1 and 652 in Round 2) were sampled. The mean age of HR-MSM/TG in Round 1 and Round 2 was 25.7 years (95% CI: 24.7 – 26.7) and 24.2 years (95% CI: 23.7 – 24.8), respectively (p = 0.001). HR-MSM/TG were more likely to be literate (96.4% vs. 89.4%, p = 0.01) and live locally (83.2% vs. 65.7%, p = 0.02) in Round 2 than in Round 1. Though HR-MSM/TG were less likely to report having had a paid male partner in Round 2 compared with Round 1 (8.6% vs. 29.9%, p = 0.001), they were more likely to have a non-commercial male/male-to-female transgender partner (71.9% vs. 51.3%, p = 0.001). HR-MSM/TG were less likely to report sex outside the place of current residence in Round 2 compared with Round 1 (33.3%vs. 23.2%, p = 0.04). HR-MSM/TG were more likely to identify themselves as bisexual (33.6% vs. 6.6%) and significantly fewer as panthi (locally used term for a male partner who mainly penetrates) in Round 2 compared with Round 1 (15.4% vs. 43.3%, p < 0.001). Select demographic characteristics, sexual behaviors, condom use, and exposure to the Avahan intervention in both rounds of IBBA are presented in Table 3.

This paper is the first to present findings from a large-scale assessment of HR-MSM/TG in Maharashtra, following Avahan’s HIV-prevention interventions. The Avahan intervention was able to achieve the targeted 80% coverage of the HR-MSM/TG population in Maharashtra. The effect of this exposure to prevention interventions was evident in the target group. A significantly higher proportion of HR-MSM/TG reported attending the STI clinic in 2009, compared to 2006. Self-reported consistent condom use with regular male partners was significantly higher in 2009 than in 2006. HR-MSM/TG who were exposed to the Avahan intervention were more likely to report consistent condom use with various types of male partners than those who were not exposed to the intervention. Prevalence of reactive syphilis serology reduced significantly in 2009 compared with 2006; however HIV prevalence did not change over time.

The findings suggest that Avahan was successful in accessing the HR-MSM/TG population in selected districts, increasing the number of outreach workers and peer-led contacts with HR-MSM/TG, improving outreach, and increasing the distribution and access of condoms for this group. It is important to mention here that not only were these targets achieved but they were also sustained for the duration. A higher than 100 percent coverage, as reflected in the CMIS data, may likely be due to the highly mobile nature of the population; the denominator was fixed to the estimated population in March 2009 whereas the numerator (members of population) was cumulative, reflecting individual HR-MSM/TG contacted over the course of the intervention (this included members who are currently present or who may have been present at an earlier time but subsequently left the area). Similar high coverage was observed among FSWs in Avahan implementation districts of Maharashtra [30]. Indeed, in Andhra Pradesh a similar successful scale-up of the HR-MSM/TG intervention has also been reported [31]. In both these scenarios, the target reached was much higher than the global average of 31% outreach documented for low and middle-income countries [32]. However, we would like to state here that Avahan attempted to cover the visible MSM, who are presumably at a high risk and reachable; the percent coverage may thus be higher than the global percentage. Nonetheless, the high coverage in this group is important given the fact that targeted interventions had started as late as 1999–2000 among the MSM population in Maharashtra.

In addition to the improved infrastructure for HIV prevention for HR-MSM/TG, changes in risk behaviors are also evident. Study findings reveal that HR-MSM/TG reported higher condom use during the last sex act with a regular and paying male partner in the second round of IBBA. Furthermore, HR-MSM/TG who were exposed to the Avahan intervention were more likely to report consistent condom use with a regular male partner. The increased availability of condoms during the same period supports this finding. Although condom use during sex may be dependent on factors other than accessibility (such as negotiation and breakage), access to condoms does form an important component of HIV interventions [33]. However, decline in both condom use with paid partners during last sex and consistent condom use was observed; similarly, consistent condom use with female partners was low in both rounds of IBBA. An important risk factor associated with unprotected sex was mobility of the individual; MSM who were mobile were more likely to report unprotected sex with male partners compared with non-mobile MSM [34]. Thus, further analysis and studies are needed to better understand the factors affecting HR MSM’ and TGs’ condom use patterns with different partners, which would help HIV prevention programs develop more effective behavior change communication strategies. Low condom use with female partners, reported by other studies as well [4, 11], is an important area of concern for HIV prevention programs working with MSM/TG. Given that a sizable proportion of the MSM population has female partners, low condom use has significant implications for HIV transmission to general population [11]; HIV prevention programs must therefore take this into consideration when planning targeted interventions. Decline in condom use with paid partners could have been due to non-usage of condoms by kothis (locally used term for self-identified MSM who are generally feminine and receptive partners during anal sex) and bisexuals, who were the majority in Round 2. Also, bisexuals are usually difficult to identify and not covered by prevention programs. Thus, future programs targeting risk reduction should be more tailored to the local dynamics of MSM/TG, cover all MSM irrespective of their sexual identities, and be sensitive and culturally acceptable.

Another important finding was the reduction in syphilis prevalence over the three years’ duration. Focussed STI-prevention measures and proper management of STIs through dedicated clinics may have led to this decline in prevalence. Improved access to STI clinics is important for HIV prevention since prompt treatment of ulcerative and non-ulcerative STIs are useful in reducing the transmission of HIV in this high-risk group [35, 36]. Furthermore, STI clinics serve as an entry point for counselling, behavioral change, and health care access in general. A recent study also reported that a structured intervention (which included risk reduction counselling and self-acceptance among MSM) has also been useful in reduction of incident bacterial STIs [37]. Thus, this entry point becomes particularly relevant for marginalized populations like MSM/TG, who may have poor health care access due to stigma and discrimination [33, 38].

While, the HIV prevalence remained unchanged, the estimated prevalence among HR-MSM/TG reported here is lower than that reported by earlier studies [10, 15, 39] and the data is comparable to national HIV surveillance (2008–09) [40]. In one of the earliest reports (mid-1990s), Nandi and co-workers found HIV prevalence to be 21% in a sample of MSM in Mumbai [39]. Several factors influence HIV prevalence and it is a short period of time between the two IBBA surveys to plausibly associate any change in HIV following programmatic interventions.

Nonetheless, the present study does have a number of limitations. The first round of IBBA was conducted one year after the initiation of the Avahan intervention and therefore not a true baseline. Avahan’s evaluation design did not include a control group, given the ethical considerations to be applied for large-scale public health programs. However, the used evaluation framework did follow program logic, and data from multiple sources (both program monitoring and independent survey data) was used to suggest plausible evidences for the effectiveness of the intervention, as alternative to randomised controlled trials, which are now considered less suitable for large public health interventions [41‐44]. Although Avahan was a pan-Maharashtra intervention, the IBBA surveys were restricted to three districts; while the CMIS data shows the scale up and coverage of the program across all districts, the IBBS data provides outcomes in a sample of districts, providing confidence on validity of the monitoring data. Another limitation in IBBA was that gonorrhoea and chlamydia were tested based on urethral samples, as rectal samples could not be collected in the given field conditions. Other studies from India, where throat or rectal swabs were collected, prevalence of oropharyngeal and rectal gonorrhoea was 4.7% and 7.4%, respectively [45]. Other limitations include those applicable to cross-sectional studies. For example, there were changes in population profile over the two rounds of the survey; however, these were accounted for by controlling for changes in multivariate models. Social desirability bias for self-reported behaviors (such as condom use) is a limitation, but it was presumed that such bias was similar for both rounds of IBBA.

In spite of these limitations, this assessment has several strengths. It is one of the first assessments of a large public health intervention for HR-MSM/TG in Maharashtra. The analysis was based on Avahan’s evaluation framework and evidence presented along the program logic model, examining a sequence of infrastructure, intermediate outcomes (behavior change and STIs), and the role of the intervention in these changes, thereby providing congruency of expected trends.

The Avahan program in Maharashtra for HR-MSM/TG was successfully scaled up to achieve its targets through outreach, condom distribution and STI clinical services. The current evaluation shows that Avahan program effectively covered the target group, improved accessibility to condoms and reduced risk behaviours with male sexual partners. Syphilis prevalence declined; however HIV prevalence did not change and therefore a major concern. However, the evaluation also suggests that additional tailored and innovative behaviour change interventions are required to increase condom use behaviours with all types of partners, so as to reduce risk among HR-MSM/TG. Continued strengthening of core programmatic strategies will help bring sustained reductions in HIV risk in HR-MSM/TG and check its onward transmission.