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The objectives of this cross-sectional study were to determine the prevalence of HIV and sexually transmitted infections (STI) in Hijras (self-identified transgenders of South Asia), study associated risk factors, and compare the prevalence with that in heterosexual men and men having sex with men (MSM) in Pune, India, between 1993 and 2002.After informed consent, individuals attending 3 STI clinics were administered a questionnaire regarding their demographic, socioeconomic, and sexual behaviors. Blood samples were collected for STI and HIV diagnosis. Bivariate and multivariate analyses were performed to determine the correlates of HIV infection.The prevalence of HIV (45.2% in Hijras vs 20% in heterosexual men vs 18.9% in MSM, P0.0001) and warts (10.3% vs 4.6% vs 7.0%; P = 0.004) was higher in Hijras as compared with heterosexual men and MSM; whereas that of genital ulcer disease (15.3% vs 32.6% vs 21.5%; P0.0001) and discharge (5.4% vs 13.6% vs 9.0%; P0.0001) was lower. Hijras were more likely to have received money for sex and have an earlier sexual debut than the comparison groups. In multivariate analysis, receiving money for sex (adjusted odds ratio: 4.49; P0.04) and having genital ulcer disease (odds ratio: 3.87; P0.08) were independently associated with high HIV prevalence in Hijras.Considering the high HIV and STI burden, it is important to review current prevention strategies and stress the need to engage Hijra community members through appropriate targeted intervention programs.

A recent report suggesting declining HIV transmission rates in southern India has been based on HIV seroprevalence data to estimate HIV incidence. We analyzed HIV incidence rates among 3 cohorts (male female non-sex worker female sex worker [FSW]) presenting to sexually transmitted infection (STI) clinics in Pune India over 10 years. Between 1993 and 2002 consenting HIV-uninfected individuals were enrolled in a prospective study of the risks for HIV seroconversion. Standardized HIV incidence estimates were calculated separately for the 3 cohorts. HIV acquisition risk declined by more than 70% for FSWs (P = 0.02) and men (P < 0.001) attending the STI clinics. There was no significant reduction in HIV incidence among women attending STI clinics (P = 0.74). The decline in HIV acquisition risk among male patients with STIs was associated with an increase in reported condom use with recent FSW contact and a decrease in genital ulcer disease. We report the first direct evidence for a decline in HIV incidence rates in FSWs and male patients with STIs over time. The lack of change in HIV infection risk among non-sex worker women highlights the need for additional targeted HIV prevention interventions. (authors)

The objective was to investigate changes over a decade in prevalence and correlates of HIV among high-risk women attending sexually transmitted infection (STI) clinics in Pune India who deny a history of commercial sex work (CSW). Design: Cross-sectional. Methods: From 1993 to 2002 2376 women attending 3 STI clinics in Pune were offered HIV screening. Women who denied CSW were included (n = 1020). Of 1020 women 21% were HIV infected. The annual HIV prevalence increased from 14% in 1993 to 29% in 2001-2002 (P < 0.001). The change in HIV prevalence over time was paralleled by changes in clinic visitor characteristics; in later periods women were older more often employed less likely to be currently married and more likely to report condom use. In multivariate analysis factors independently associated with HIV were calendar period (adjusted odds ratio [AOR] 1.9 for 1997-1999 vs. 1993-1996; 95% CI 1.2- 3.0; AOR 2.3 for 2000-2002 vs. 1993-1996; 95% CI 1.5-3.6) lack of formal education (AOR 2.0; 95% CI 1.4-2.9) having been widowed (AOR 3.1; 95% CI 1.6-6.1) current employment (AOR 1.8; 95% CI 1.2-2.6) and genital ulcer disease on examination (AOR 1.8; 95% CI 1.2-2.7). Women attending STI clinics in India who deny a history of CSW represent a small hidden subgroup likely put at risk for HIV because of high-risk behavior of their male partners generally their husbands. Educational and awareness efforts that have targeted other subgroups in India (men and CSWs) should also focus on these hard-to-reach women. Risk reduction in this subgroup of Indian women would also be expected to reduce perinatal infections in India. (authors)