BackgroundIt seems generally accepted that targeted interventions in India have been successful in raising condom use between female sex workers (FSWs) and their clients. Data from clients of FSWs have been under-utilised to analyse the risk environments and vulnerability of both partners.MethodsThe 2009 Integrated Biological and Behavioural Assessment survey sampled clients of FSWs at hotspots in Andhra Pradesh, Maharashtra and Tamil Nadu (n=5040). The risk profile of clients in terms of sexual networking and condom use are compared across usual pick-up place. We used propensity score matching (PSM) to estimate the average treatment effect on treated (ATT) of intervention messages on clients’ consistent condom use with FSW.ResultsClients of the more hidden sex workers who solicit from home or via phone or agents had more extensive sexual networks, reporting casual female partners as well as anal intercourse with male partners and FSW. Clients of brothel-based sex workers, who were the least educated, reported the fewest number/categories of partners, least anal sex, and lowest condom use (41%). Consistent condom use varied widely by state: 65% in Andhra Pradesh, 36% in Maharashtra and 29% in Tamil Nadu. Exposure to intervention messages on sexually transmitted infections was lowest among men frequenting brothels (58%), and highest among men soliciting less visible sex workers (70%). Exposure had significant impact on consistent condom use, including among clients of home-based sex workers (ATT 21%; p=0.001) and among men soliciting other more hidden FSW (ATT 17%; p=0.001). In Tamil Nadu no impact could be demonstrated.ConclusionCommercial sex happens between two partners and both need to be, and can be, reached by intervention messages. Commercial sex is still largely unprotected and as the sex industry gets more diffuse a greater focus on reaching clients of sex workers seems important given their extensive sexual networks.

SummaryFemale sex workers (FSWs) are vulnerable to HIV infection. Their socioeconomic and behavioural vulnerabilities are crucial push factors for movement for sex work. This paper assesses the factors associated with the likelihood of movement of sex workers from their current place of work. Data were derived from a cross-sectional survey conducted among 5498 mobile FSWs in 22 districts of high in-migration across four states in southern India. A multinomial logit model was constructed to predict the likelihood of FSWs moving from their current place of work. Ten per cent of the sampled mobile FSWs were planning to move from their current place of sex work. Educational attainment, marital status, income at current place of work, debt, sexual coercion, experience of violence and having tested for HIV and collected the results were found to be significant predictors of the likelihood of movement from the current place of work. Consistent condom use with different clients was significantly low among those planning to move. Likewise, the likelihood of movement was significantly higher among those who had any STI symptom in the last six months and those who had a high self-perceived risk of HIV. The findings highlight the need to address factors associated with movement among mobile FSWs as part of HIV prevention and access to care interventions.

Background: Mobile males are vulnerable to HIV and are potential bridge for HIV transmission to their sex partners, including spouses. To understand how mobility accentuates vulnerability to HIV, we assessed the association of degree of male mobility with paid sex, alcohol use and condom use at all places visited by migrants in past two years. Methods: A cross-sectional survey was done among male migrant workers [n = 2991] in five high in-migration districts of Maharashtra in India during 2007-08. Results: Multivariate logistic regression analysis revealed that higher mobility [moving 3+ places in the past two years] was associated with "sexual debut" in paid sex [3.7% Vs 6.9%, AOR = 1.70, p < 0.001] and having sex with sex worker at the current place of destination [8.7% Vs 16.9%, AOR = 2.10, p < 0.001], at the previous place of destination [7.2% Vs 15.1%, AOR = 2.05, p < 0.001], and at the place of origin [0.6% Vs 1.6%, AOR = 2.31, p < 0.001]. However, higher mobility was associated with unpaid sex with non-marital female partners [28.4% Vs 37.2%, AOR = 1.48, p < 0.001] and less consistent condom use at the current place [26.6% Vs 23.4%, AOR = 0.45, p < 0.05] as well as at place of origin [12.2% Vs 7.2%, AOR = 0.48, p < 0.01]. In addition, alcohol use prior to sex was more among more mobile migrants relative to less mobile migrants at current place [6.1% Vs 11.2%, AOR = 1.82, p < 0.001] and previous place [7.0% Vs 13.0%, AOR = 1.77, p < 0.001] of destination. Conclusion: Findings suggest that compared to the less mobile, highly mobile men report higher HIV risk behaviours: paid sex, alcohol use prior to paid sex and inconsistent condom use, at all locations along the routes of mobility. Interventions need to target men who are highly mobile along the routes of mobility and not at destination sites alone.

Accessibility and frequency of use of health care services among female sex workers (FSWs) are constrained by various factors. In this analysis, we examined the correlates of frequency of using health care services under targeted interventions among FSWs. A sample of FSWs (N = 1,973) was obtained from a second round (2012) of Behavioral Tracking Survey, conducted in five districts of Andhra Pradesh, a high-HIV-prevalence state in southern India. We used negative binomial regression models to analyze frequency of utilization of health care services among FSWs. Based on our analysis, we suggest that various predisposing and enabling factors were found to be significantly associated with the visit to NGO clinics for treatment of any health problem, any sexually transmitted infection symptom, and the number of condoms received from the peer worker or condom depot. We suggest the need for further research with respect to various correlates of frequency of using health care among FSWs to develop effective intervention strategies in countries that have high HIV prevalence among FSWs and targeted interventions need more diligent implementation to reach the unreached.

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