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Background The COVID-19 pandemic has brought an unprecedented adverse impact on women's health. Evidence from the literature suggests that violence against women has increased multifold. Gender-based violence in urban slums has worsened due to a lack of water and sanitation services, overcrowding, deteriorating conditions and a lack of institutional frameworks to address gender inequities. Methods The SAMBHAV (Synchronized Action for Marginalized to Improve Behaviors and Vulnerabilities) initiative was launched between June 2020 to December 2020 by collaborating with the Uttar Pradesh state government, UNICEF and UNDP. The program intended to reach 6000 families in 30 UPS (Urban Poor settlements) of 13 city wards. These 30 UPS were divided into 5 clusters. The survey was conducted in 760 households, 397 taken from randomly selected 15 interventions and 363 households from 15 control UPS. This paper utilized data from a baseline assessment of gender and decision-making from a household survey conducted in the selected UPS during July 03–15, 2020. A sample size of 360 completed interviews was calculated for intervention and control areas to measure changes attributable to the SAMBHAV intervention in the behaviours and service utilization (pre- and post-intervention). Results The data analysis showed a significant difference (p-value < 0.001) between respondents regarding women's freedom to move alone in the control and intervention area. It also reflected a significant difference between control and intervention areas as the respondents in the intervention area chose to work for the cause of gender-based violence. Conclusion The SAMBHAV initiative brought an intersectional lens to gender issues. The community volunteers were trained to approach issues based on gender-based violence with the local public, and various conferences and meetings were organized to sensitize the community. The initiative's overall impact was that it built momentum around the issue of applying the concept of intersectionality for gender issues and building resilience in the community. There is still a need to bring multi-layered and more aggressive approaches to reduce the prevalence of gender-based violence in the community.

The availability and access to water, sanitation and hygiene (WASH) facilities in schools have been associated with enhanced learning and nutritional outcomes among children in India and elsewhere. However, there is limited documentation of successful scaled-up models to improve WASH facilities in schools. This paper describes an innovative ‘transformation campaign’ to strengthen WASH facilities in government-run elementary schools in Uttar Pradesh, the most populous state in India. The campaign was launched in 2018 followed by an online monitoring portal using data-informed feedback and role modeling in 2020. A comprehensive baseline assessment was conducted in 114,790 government elementary schools in Uttar Pradesh, during which school focal persons ranked their schools' access to WASH services against the set benchmarks. Concurrently, high-ranking schools were established as ‘learning labs’ for neighboring schools and were provided with on-site capacity building opportunities. More than 150,000 teachers were systematically engaged through regular virtual training and automated calls that tracked progress, all parts of a centralized online portal. This champion-led transformation of school (CLTS) approach was adopted by the government to recognize best practices supported by students and teachers. Initiatives of teachers and village-elected representatives (Gram Pradhan), who were identified as ‘champions’, were recognized and disseminated to build an enabling environment that will sustain access and practices. As of July 2021, 65.8% of the assessed schools across 75 districts have improved their basic infrastructure through repairing/retrofitting defunct facilities and construction of new ones as per the gaps identified. They become ‘WASH compliant’ and leveraged around INR 45.71 billion of public financing from multiple sources in the last 3–4 years. Now, the state is rolling out a similar transformation campaign for 188,997 pre-school centers that will cover 5.6 million children between the ages of 3 and 6 years. The implementation process, challenges and learnings of this campaign can be used to formulate strategies and design scaled-up interventions to improve WASH facilities in schools.

This paper provides HIV estimation methodology used in India and key HIV estimates for 2010–2011. We used a modified version of the Spectrum tool that included an Estimation and Projection Package as part of its AIDS Impact Module. Inputs related to population size, age-specific pattern of fertility, gender-ratio at birth, age and gender-specific pattern of mortality, and volume and age–gender distribution of net migration were derived from census records, the Sample Registration System and large-scale demographic health surveys. Epidemiological and programmatic data were derived from HIV sentinel surveillance, large-scale epidemiological surveys and the programme management information system. Estimated adult HIV prevalence retained a declining trend in India, following its peak in 2002 at a level of 0.41% (within bounds 0.35–0.47%). By 2010 and 2011, it levelled at estimates of 0.28% (0.24–0.34%) and 0.27% (0.22–0.33%), respectively. The estimated number of people living with HIV (PLHIV) reduced by 8% between 2007 and 2011. While children accounted for approximately 6.3% of total HIV infections in 2007, this proportion increased to about 7% in 2011. With changing priorities and epidemic patterns, the programme has to customise its strategies to effectively address the emerging vulnerabilities and adapt them to suit the requirements of different geographical regions.

This paper examines whether truckers have been over-stigmatized as HIV carriers in the country. Data were taken from cross-sectional surveys of clients of female sex workers conducted in 2006-2007 in 12 districts of the country. A total 4822 clients of female sex workers were covered in the survey. Low-income skilled/semi-skilled men, including non-agricultural/casual labor, and petty businessmen/small shop owners, have the largest share in the clients’ population. There was no significant difference between truckers and other sub-group of clients’ population in terms of consistent condom use with female sex workers and prevalence of HIV or STI. These evidences suggest that the contribution of truckers in HIV epidemic in India might to similar to other sub-groups of clients’ population. Thus, truckers might have been over-stigmatized as HIV carriers in the country. However, there is no doubt that truckers constitute an extremely important target group for the HIV prevention programs and these efforts must be continued to prevent new HIV infections in the country.

Background: A systematic review portraying the changing pattern of sexual behaviors, STI and HIV prevalence and key strategies curb HIV and STI among truckers in India is lacking. This paper therefore aims to present a chronological review of literature regarding sexual behaviors, STI/HIV prevalence, and various HIV prevention programs implemented among truckers in India. Methodology: Published and unpublished studies (1990-2011) were identified through electronic databases, and hand searching. Results: Most studies on sexual behaviors and STI/HIV prevalence among truckers focused only on drivers and ignored their helpers. Evidences suggest that consistent condom use by truckers with both paid and non-paid female partners has increased during the past decade. Many recent studies suggest that the HIV prevalence among truckers is about 2% and it has been declining slowly during the past decade. The HIV prevention programs among truckers which started with the aim of raising awareness about HIV during early 1990s, have grown multi-folds to encompass not only the standard strategies like mid-media events, interpersonal counselling and STI care for HIV prevention, but also innovations such as the use of business franchisee models, and integrated research and evidence based planning in the program. The possibilities of using new approaches such as male circumcision and the use of pre-exposure prophylaxes are underway. Conclusion: More studies are needed to explore helpers’ vulnerabilities to HIV. Very few studies have attempted to examine the impact of large-scale prevention programs among truckers. Efforts are required to examine the impact of different components of such programs to guide the HIV prevention efforts among truckers in India.

We examine community collectivization among female sex workers (FSWs) and high-risk men who have sex with men and transgenders (HR-MSM) following several years of HIV prevention programming with these populations, and its association with selected outcome indicators measuring individual behaviors (condom use with different partners and sexually transmitted infection [STI] treatment-seeking from government health facilities). Data for this study were collected from a large-scale cross-sectional survey conducted in 2010–2011 among FSWs (sample size: 3557) and HR-MSM (sample size: 2399) in Andhra Pradesh, India. We measured collectivization among FSWs in terms of three binary (low, high) indices of collective efficacy, collective agency, and collective action. Collectivization among HR-MSM was measured by participation in a public event (no, yes), and a binary (low, high) index of collective efficacy. Adjusted odds ratios (adjusted OR) and their 95% confidence intervals (CI) were computed to assess the relationships between collectivization and outcome indicators directly and through mediation of variables such as self-efficacy for condom use and utilization of government health facilities. Results show that among FSWs, high levels of collective efficacy (adjusted OR: 1.3, 95% CI: 1.1–1.7) and collective action (adjusted OR:1.3, 95% CI: 1.1–1.8) were associated with consistent condom use (CCU) with regular clients. Among HR-MSM, participation in a public event (adjusted OR: 2.7, 95% CI: 2.0–3.6) and collective efficacy (adjusted OR: 1.9, 95% CI: 1.5–2.3) were correlated with condom use with paying partners. The association between collectivization and outcome indicators continued to be significant in most cases even after adjusting for the potential mediators. Indicators of collectivization exhibited significant positive association with self-efficacy for condom use and service utilization from government health facilities among both FSWs and HR-MSM. The association of high levels of collectivization with CCU, STI treatment- seeking from government health facilities, ability to negotiate for condom use, and self-efficacy in utilizing government health facilities is relevant to effort to improve the effectiveness and sustainability of HIV prevention programs in India and beyond.

This paper examines the impact of three components of an HIV prevention program (mid-media, interpersonal communication, and project-run clinics) on consistent condom use by long distance truckers with paid and non-paid female partners in India. Data from 2,723 long distance truckers were analyzed using the propensity score matching approach. Based on utilization of services, the following categories of intervention exposure were derived: no exposure, exposure only to mid-media, exposure only to mid-media and interpersonal communication, exposure only to mid-media and project-run clinics, and exposure to all three intervention components. Compared to those who were not exposed to any intervention, exposure to mid-media alone increased consistent condom use with paid female partners by about ten percent. Exposure to mid-media and visits to project-run clinics increased consistent condom use with non-paid female partners by 26 %. These findings suggest that mid-media events and clinics were the most effective package of services to increase consistent condom use among the long distance truckers.

This paper examines the association between female sex workers' (FSWs) noncommercial partnerships with risk of HIV in Andhra Pradesh, India. Data were drawn from a cross-sectional behavioral and biological survey conducted in 2009 among 3225 FSWs from Andhra Pradesh. Participants were asked about their sexual partnerships, condom use, and vulnerability factors and tested for HIV and sexually transmitted infections. The key independent variables considered were presence of a noncommercial sexual partner (no, yes) and the nature of such partnerships (regular, nonregular). FSWs who reported husband as noncommercial partner were considered to have a regular partner, while the rest were defined as having nonregular partners. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated to measure the associations between variables of interest. Almost three-fourths (74.8%) of FSWs reported having noncommercial partners (regular: 55.6%; nonregular: 19.3%). FSWs in nonregular partnerships were more likely to be HIV positive (13.1% versus 10.9%, adjusted OR: 1.4, 95% CI: 1.1–1.8), have syphilis (10.3% versus 4.2%, adjusted OR: 2.3, 95% CI: 1.6–3.3), use condoms inconsistently with occasional clients (21.0% versus 16.5%, adjusted OR: 1.5, 95% CI: 1.2–1.9), and report forced sex (25.1% versus 14.1%, adjusted OR: 1.9, 95% CI: 1.5–2.4) as compared to those in regular partnerships. HIV prevention programs need to emphasize safe sex behaviors, particularly among FSWs who have nonregular partners.

Background Violence and mobility have been identified as critical factors contributing to the spread of HIV worldwide. This study aimed to assess the independent and combined associations of mobility and violence with sexual risk behaviors and HIV, STI prevalence among female sex workers (FSWs) in India. Methods Data were drawn from a cross-sectional, bio-behavioral survey conducted among 2042 FSWs across five districts of southern India in 2005–06. Regression models were used to estimate odds ratios and 95% confidence intervals (CIs) for sexual risk behaviors and HIV infection based on experience of violence and mobility after adjusting for socio-demographic and sex work related characteristics. Results One-fifth of FSWs (19%) reported experiencing violence; 68% reported travelling outside their current place of residence at least once in the past year and practicing sex work during their visit. Mobile FSWs were more likely to report violence compared to their counterparts (23% vs. 10%, p Conclusions The findings indicate that mobility and violence were independently associated with HIV infection. Notably, the combined effect of mobility and violence posed greater HIV risk than their independent effect. These results point to the need for the provision of an enabling environment and safe spaces for FSWs who are mobile, to augment existing efforts to reduce the spread of HIV/AIDS.

Background: Mumbai is one of the most populous and high HIV prevalence cities in India. It has witnessed substantial changes in HIV-risk behaviors and a decline in HIV prevalence among high-risk groups during the past decade. Aim: To examine the changing pattern in the number of new HIV infections by transmission routes in Mumbai during 2000-2017. Methods: We used the Asian Epidemic Model by dividing the adult population (aged 15 and above) into seven subgroups: brothel-based and non-brothel based female sex workers (FSWs), heterosexual clients of FSWs, men who have sex with men/transgendered people (MSM), injecting drug users (IDUs), general women and general men. The MSM subgroup included homosexual and bisexual men. Results: New HIV infections among adults reduced by 86% during 2000-2010. The highest decline was among FSWs and their heterosexual clients (95%-98%), followed by MSM (82%), general women (77%), IDUs (51%) and general men (42%). Most new HIV infections during 2011-2017 are expected to occur among general women (1666) and general men (977) followed by MSM (715). Bisexual men were estimated to contribute about 14% of the new HIV infections among general women in 2010 and this proportion was estimated to increase to 19% in 2017. Discussion: HIV prevention programs for MSM and the general population need to be strengthened. Ensuring early detection of HIV, and higher levels of consistent condom use by HIV-infected men and women are essential to prevent new HIV infections in future.

Background To examine the association between the presence of community advocacy groups (CAGs) and female sex workers’ (FSWs) access to social entitlements and outcomes of police advocacy. Methods Data were used from a cross-sectional survey conducted in 2010e2011 among 1986 FSWs and 104 NGO outreach workers from five districts of Andhra Pradesh. FSWs were recruited using a probability-based sampling from 104 primary sampling units (PSUs). A PSU is a geographical area covered by one outreach worker and is expected to have an active CAG as per community mobilisation efforts. The presence of active CAGs was defined as the presence of an active committee or advocacy group in the area (PSU). Outcome indicators included acquisition of different social entitlements and measures of police response as reported by FSWs. Multivariate linear and logistic regression analyses were used to examine the associations. Results Areas with active CAGs compared with their counterparts had a significantly higher mean number of FSWs linked to ration cards (12.8 vs 6.8; p

Background To assess the association between female sex workers’ (FSWs) degree of community collectivisation and self-efficacy, utilisation of sexually transmitted infection (STI) services from government-run health centres in Andhra Pradesh, India. Methods Cross-sectional analyses of 1986 FSWs recruited using a probability-based sampling from five districts of Andhra Pradesh during 2010e2011. Multiple logistic regression models were constructed to assess associations. The independent variables includeddcollective efficacy, collective agency and collective actiondmeasured using a series of items that assessed the grouping of the community on issues that concern most sex workers. An additional independent variable included FSWs belonging to an area where there was a project partnership with government health centres to provide STI treatment services to FSWs. The outcome indicators included self-efficacy for service utilisation from government health facilities and the treatment for STIs from government health facilities at least once in the past year experience of STI symptoms. Results Of the 1986 FSWs, nearly two-fifths (39.5%) reported a high level of overall collectivisation (collective efficacy: 89%, collective agency: 50.7%; collective action: 12.7%). Sex workers with a high degree compared with low degree of overall collectivisation were significantly more likely to report high self-efficacy to use government health facilities (75.0% vs 57.3%, adjusted OR 2.5, 95% CI 2.0 to 3.1) and to use government health centres for STI treatment in past 1 year (78.1% vs 63.2%, adjusted OR 2.1, 95% CI 1.6 to 2.8), irrespective of project partnership with government centres. Conclusion The current research findings reinforce the need for stronger community mobilisation for better utilisation of government health facilities for STI and HIV prevention interventions.

Background and Objective The prevalence of HIV among MSM continues to be disproportionately high in India. The objective of this study was to identify the factors associated with change in the prevalence of HIV testing overtime and to assess their relative contribution in increasing (or decreasing) the prevalence of HIV testing among men who have sex with men. Methods Data are drawn from two rounds of cross-sectional bio-behavioural surveys of 7403 (round I: 3895, round II: 3508) self-identified MSM from three states of India, recruited through probability based sampling in 2005–06 and 2009–10 respectively. Logistic regression models were used to assess the relationship between socio-demographic characteristics, sexual behaviours, programme exposure and HIV testing. Significant factors were further parsed using decomposition analysis to examine the contribution of different components of that factor towards the change in HIV testing over time. Results There was a significant increase in the proportion of MSM reporting HIV testing from round I to round II (13% vs. 77%: p kothis (predominantly receptive); those who had both commercial and non-commercial partners and those who were exposed to the intervention contributed the most to the increase in HIV testing over time. Conclusions These study results underscore the potential of identifying and targeting segments within the at-risk MSM population which are currently not accessing HIV testing services. Voluntary HIV testing affects sexual behaviour leading to a positive motivation for safer sexual practises.

Ram Manohar Mishra,1 Madhulika Dube,2 Niranjan Saggurti,1 Arvind Pandey,3 Bidhubhusan Mahapatra,1 Sowmya Ramesh11Population Council, New Delhi, 2Department of Statistics, Maharshi Dayanand University, Rohtak, Haryana, 3National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, IndiaAbstract: This study examines the relationship between entry into the trucking industry during adolescence and both sexually transmitted infections (STIs) and infection by the human immunodeficiency virus (HIV) among long-distance truck drivers in India. Data were sourced from a cross-sectional survey (sample size: 2066) undertaken in 2007 among long-distance truck drivers. The survey spread across major transshipment locations covering the bulk of India's transport volume along four routes. Participants were interviewed about sexual behaviors and were tested for HIV and STIs. The present authors constructed two synthetic cohorts based on the participants' duration of employment in the trucking industry: (1) low (duration ≤ 6 years) and (2) high experience (duration ≥ 7 years). Based on age at entry into the trucking industry, participants were termed as either adolescent (age at entry < 18 complete years) or adult entrants (age at entry ≥ 18 complete years). In the low-experience cohort, the adolescent entrants were more likely than the adult entrants to have sex with paid female partners (42.6% versus 27.2%, respectively; adjusted odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.3–2.9) and to practice inconsistent condom use with such partners (69.1% versus 26.8%, respectively; adjusted OR: 5.3; 95% CI: 2.4–11.6). However, no significant differences were found in STI and HIV prevalence between the adolescent and the adult entrants in this cohort. In the high-experience cohort, the adolescent entrants were about two times more likely than the adult entrants to practice inconsistent condom use with paid female partners (38.5% versus 26.7%, respectively; adjusted OR: 1.7; 95% CI: 1.1–2.8) and to test positive for HIV (7.4% versus 4.0%, respectively; adjusted OR: 1.9; 95% CI: 1.2–3.1) and syphilis (5.7% versus 3.5%, respectively; adjusted OR: 1.8; 95% CI: 1.1–3.1). These results suggest the need for focused behavioral change programs in HIV prevention interventions for adolescent truckers in India and elsewhere.Keywords: sexually transmitted infections, condom use, risky sexual behavior, truckers

Background: Alcohol use has been found to correlate with risky sexual behavior as well as with sexually transmitted infections (STI) among populations with high-risk behavior in India. Objective: To examine the correlates of alcohol use and its association with STI among adult men in India. Materials and Methods: Data from a national representative large-scale household sample survey in the country were used. It included information on sociodemographic characteristics and alcohol use as a part of substance use. Clinical as well laboratory testing was done to ascertain the STI. Results: The overall STI prevalence among adult males was found to be 2.5% (95% confidence interval (CI): 1.9-3.1). Over 26% adult men were found to have been using alcohol in the study population. It was higher among men who were illiterate and unskilled industrial workers/drivers. The men who consumed alcohol had higher prevalence of STI (3.6%; 95% CI: 2.9-5.1) than those who did not consume alcohol (2.1%; 95% CI: 1.5-2.6). The degree of association between alcoholism and STI was slightly reduced after adjusting for various sociodemographic characteristics (adjusted odds ratio: 1.5; 95% CI: 0.9-2.3; P=0.06). Conclusions: The findings of present study suggest integrating alcohol risk reduction into STI/HIV prevention programmes.

Background Using data from two rounds of a cross-sectional, national-level survey of long-distance truck drivers, this paper examines the extent and trend of sexual risk behavior, prevalence of STI/HIV, and the linkage between exposure to HIV prevention programs and safe sex behavior. Methods Following the time location cluster sampling approach, major transshipment locations covering the bulk of India’s transport volume along four routes, North-East (NE), North-South (NS), North-West (NW) and South-East (SE) were surveyed. First round of the survey was conducted in 2007 (sample size 2066) whereas the second round was undertaken in 2009-2010 (sample size 2085). Long distance truck drivers were interviewed about their sexual behaviors, condom use practices, exposure to different HIV prevention interventions, and tested for HIV, reactive syphilis serology, Neiserria gonorrhoeae and Chlamydia trachomatis. The key variable of this evaluation study - exposure to HIV prevention interventions was divided into three categories - no exposure, less intensive exposure and intensive exposure. Data were analyzed using multiple logistic regression methods to understand the relationship between risk behavior and exposure to intervention and between program exposure and condom use. Results The proportion of truckers exposed to HIV prevention interventions has increased over time with much significant increase in the intensive exposure across all the four routes (NE: from 14.9% to 28%, P < 0.01; NS: from 20.9% to 38.1%; NW: 11.5% to 39.5%, P < 0.01; SE: 4.7% to 9.7%, P Conclusions These evaluation study results highlight the ability of intensive program to reach truckers who have sex outside marriage with HIV prevention interventions and promote safe sex behaviors among them. Truckers who practice safe sex behaviors with an exposure to intensive program are less likely to suffer from STIs and HIV, which has implications for HIV prevention program with truckers’ population in India and elsewhere. The simultaneous targeted interventions among female sex workers appeared to have contributed to safe sexual practices among truckers.