A comprehensive STD/HIV intervention programme in India
Presented by Dr Smarajit Jana, All India Institute of Hygiene and Public Health, Calcutta, India.
Although India’s overall HIV prevalence rate is still relatively low, conditions exist for an explosive increase of HIV transmission: there has been a 60% increase in the incidence of HIV infection between 1993 and 1994 alone. It is estimated that by the year 2000, the number of HIV infections will have reached five million and one million AIDS cases will have occurred. Heterosexual transmission is the predominant mode of transmission and in Bombay and Madras seroprevalence rates of 30 to 50% have been found among those at highest risk: commercial sex workers. Because of the importance in many countries of the link between commercial sex work and HIV transmission, prevention efforts in these commercial sex work settings and contexts is crucial.
Recognizing this, the government of India has given high priority, within its national plan, to HIV prevention among commercial sex workers and their clients. As part of this strategy, an STD/HIV intervention programme was launched in the Sonagachi red-light district of Calcutta. It is one of the oldest and largest of the 12 clearly identifiable such districts in the city, with about 5000 active female commercial sex workers. Many of them are illiterate, having been sent there in childhood from famine-stricken areas.
The socioeconomic context in which sex work takes place, and the way it operates, varies tremendously and interventions need to be tailored accordingly. For example, in some situations, women have more power than in others (e.g. in their ability to insist on condom use by their clients without serious economic risk), some are more highly organized and/or stable, while others may include mainly very mobile populations. The Sonagachi red light district represents a long established power structure which involves many players, such as pimps, long-term and short-term clients, madams and brothel owners, and the commercial sex workers themselves who, although they are the most vulnerable, are at the very bottom of the power structure. This poses particular obstacles to HIV prevention activities. In order to be able to operate, intervention implementors have had to maintain a balance between coexisting or cooperating with the existing oppressive, sexwork structure, while at the same time encouraging the organization of sex workers themselves to speak out on their own behalf.
Within this context, a research study was carried out to determine the feasibility of effectively implementing a three-pronged intervention among female commercial sex workers (CSWs) and their clients with the aims of reducing STD incidence and prevalence, reducing the incidence of HIV infection among sex workers and their clients by changing behavioural practices, maintaining and expanding the current relationship of trust and confidence established between the survey team and the community, and developing generic guidelines for the development of interventions in similar areas.
The three intervention components were STD service provision; information, education and communication (IEC) activities by peer educators; and condom programming and distribution. Working from a simple health clinic in the area, 65 peer educators went out and, for a small reward, spend approximately three hours a day distributing condoms and communicating with other commercial sex workers about STD/HIV. Their training includes a theoretical and practical 6-week course on STDs, followed by a final examination. Free clinic services were provided to the CSWs and an evening clinic opened to CSWs and their clients, who were provided not only with STD diagnosis and treatment, but also with condoms and counselling services.
The methodology included a baseline (N=360)/repeat (N=587) sexual behaviour and STD/HIV survey among a random sample of commercial sexworkers. Sex workers were stratified according to their economic status and samples were drawn from each stratum. Samples of cervical and vaginal swabs, as well as blood, were collected for bacteriological and serological tests. The time between surveys was 14 months (the follow-up took place in November-December 1993).
Study results indicate marked changes in condom use and in STD prevalence. Demand for condoms has increased throughout the intervention, with an average of 3000 condoms being distributed a day. Regular condom use increased from 1.1% to 47%, and percentage of people reporting that they often or regularly use condoms increased from 3% to 68% (Figure 6). Parallel to this, an important decrease in STD prevalence has been found. Gonorrhoea alone has decreased from 13.24% at baseline to 3.89% at post-test and the total number of people with an STD has decreased from 80.6% to 59.3%. One hope is that this approach will prevent the explosive increase in HIV/AIDS that has been seen in other Indian cities (i.e. that incidence will not rise above the current 1-2%). This study showed little change in seropositivity (1.13 at baseline and 1.16 at follow-up) between the surveys. The intervention is now being expanded to 5 other red light districts in the city.
Decreases in STD prevalence and increases in condom use in commercial sex workers in Calcutta
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