Voluntary counselling and testing (VCTC) for HIV is currently being scaled up in India [1,2]. The uptake of VCTC can reduce the rates of sexually transmitted infections and high-risk sexual practices [3,4]; however, stigma and discrimination are among the major barriers to the uptake of VCTC . HIV transmission in India is largely linked to sex work [1,2]. HIV prevalence among female sex workers (FSW) in the Indian state of Andhra Pradesh was estimated to be 16% (range 8–41%) in 2004 . Knowledge about the rate of and willingness for HIV testing among FSW is important for planning comprehensive HIV prevention. We report these data from a large sample of FSW in Andhra Pradesh.
This study was carried out as part of the baseline for an impact assessment study of the Frontiers Prevention Project, which aims to reduce the spread of HIV through the provision of HIV interventions among high-risk population groups. The necessary ethical approval for this study was obtained.
Forty geographical sites (72 cities/towns/villages) in 13 districts of Andhra Pradesh state were identified where access to FSW was considered feasible through non-governmental organizations (NGO) having links with them. FSW were contacted and recruited at bus and rail stations, cinema theatres, parks, brothels, their homes, small informal hotels, and some other places. A total of 7251 FSW 16 years of age and older were contacted for participation between July 2003 and April 2004. Confidential interviews were conducted after obtaining their written informed consent. Relevant to this report, FSW were asked if they had undergone HIV testing. The place and cost of the HIV test, whether they had received the test results, and the reasons for undergoing HIV testing were documented for those who reported having been tested. The willingness to undergo testing in the future was documented for those who had heard of HIV/AIDS but had not been tested for HIV. Those who had heard of HIV/AIDS also responded to two statements reflecting negative beliefs about individuals living with HIV/AIDS. The FSW who had not heard of HIV/AIDS were considered as not having undergone HIV testing for this analysis. Self-reported condom non-use for penetrative sex with the last three clients was documented as an indication of HIV risk behaviour. The 95% confidence intervals (CI) of the estimates of the assessed variables were adjusted for the design effect of cluster sampling . Multivariate analysis was performed to assess the associations for having undergone HIV testing and an unwillingness to undergo HIV testing using SPSS and Stata software. The 95% confidence intervals of the estimates were adjusted for the design effect of cluster sampling .
Of the FSW contacted, 6648 (91.7%) participated, with a median age of 27 years (range 16–54 years), of whom 523 (7.9%, 95% CI 5.0–10.8%, design effect 19.5) reported having undergone HIV testing. Among the 4843 FSW who had heard of HIV/AIDS but had not undergone HIV testing, 3548 (73.2%, 95% CI 69.9–76.7%, design effect 7.5) were unwilling to undergo testing in the future.
The major predictors of having undergone HIV testing included being a non-street-based FSW, participation in a support group, sex work duration greater than 5 years, and higher income; and those for the unwillingness to undergo HIV testing included FSW age 16–17 years, no participation in a support group, and lower income (Table 1).
Among the 523 FSW who reported having undergone HIV testing, 266 (50.9%), 204 (39%), and 43 (8.2%) underwent testing at private, government, and NGO facilities, respectively. At the government health facilities, 56 (27.7%) paid no money, 122 (60.4%) paid Indian Rupees (Rs) 10–50 (Rs 50 = US$1.1), 19 (9.4%) paid Rs 51–100, and five (2.5%) paid Rs 101–300 for the HIV test. At private health facilities two (0.8%) paid no money, three (1.1%) paid Rs 10–50, 11 (4.1%) paid Rs 51–100, 157 (59%) paid Rs 101–300, and 93 (34.9%) paid more than Rs 300 for the HIV test. All the HIV testing at NGO was carried out for Rs 50 or less. Of the 523 FSW who had undergone testing, 472 (90.2%) reported having received their HIV test results. The reasons for undergoing HIV testing were reported as ‘being a sex worker’ by 341 (65.2%), ‘asked to undergo test by doctor for illness’ by 90 (17.2%), and ‘prompted by HIV/AIDS awareness’ by 54 (10.3%) (not mutually exclusive).
Condom non-use for penetrative vaginal/anal sex with at least one of the last three clients in the past 15 days was reported by 1440 (43.4%) of the 3319 FSW who were unwilling to undergo testing compared with 470 (27.6%) of the 1703 FSW who had had test/were willing to undergo testing (P < 0.001). The former were also significantly more unwilling to take care of a relative with AIDS (58.6%) or share a water tap with someone suspected of having AIDS (59.8%) than the latter (38.9% and 41.2%, respectively; P < 0.001).
Only 7.9% of FSW in this study reported having undergone HIV testing, and nearly three out of four among those who had heard about HIV/AIDS but were not tested were unwilling to undergo HIV testing in the future. The risk of HIV infection was higher among the FSW who reported not having been tested and were also unwilling to get tested, as they reported higher condom non-use for penetrative sex with clients. These results should be interpreted against the background that FSW who participated may not be representative of all FSW as they were recruited through FSW facilitators, suggesting a bias towards those who are better connected with their peers, and that this study relied on self-reported HIV testing status.
FSW who were unwilling to undergo HIV testing held significantly more HIV/AIDS-related negative beliefs. These beliefs were also prevalent among those who reported having been tested, but to a lesser degree. Similar results have been reported recently from a study of an adult black population in South Africa . Results from our study suggest that FSW support groups could have a potentially significant role in increasing the uptake of HIV testing and that there is an urgent need to reduce HIV/AIDS-related negative beliefs.
Knowledge of HIV status is important for FSW to protect themselves and their clients from acquiring/transmitting HIV infection, and to access HIV treatment. Given the significant societal discrimination against FSW in India, their low willingness to undergo HIV testing is not surprising as this could add another source of stigma and discrimination against them. Further exploration of this low willingness is needed within the human rights context , for FSW to benefit from the increasing HIV prevention and treatment efforts in India .
The authors would like to thank the FSW for participating in this study and the various facilitators, NGO, the Andhra Pradesh State AIDS Control Society and its Technical Resource Unit, and the International HIV/AIDS Alliance and India HIV/AIDS Alliance, for supporting and facilitating this study. The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the funding agency or other organizations that supported this study.
Sponsorship: The Frontiers Prevention Project, including this study, is supported by a grant from the Bill and Melinda Gates Foundation.
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The members of the ASCI FPP Study Team other than the named authors include (in alphabetical order): G. M. Mushtaq Ahmed, M. Akbar, M. Abdul Ameer, C. Arjun, N. Arjun, M. Sai Baba, C. Satish Babu, J. Kishore Babu, I. Balasubrahmanyam, V.S. Udaya Bhaskar, T. Gangadhar, P. Gopal, Lavanya Gotety, Shaik Omar Hussain, V. Indira, S. Krishna, P. Kiran Kumar, C. Sri Jaya Lakshmi, T. Uma Maheshwar, P. Chandra Mouli, S. Radhakrishnan, K. Raghu, S.P. Ramgopal, A. Srinivas Rao, A. Srinivasa Rao, K. Hanumantha Rao, N. Ananda Rao, P. Venkateswara Rao, Parsa V.R. Rao, D. Ravinder, A. Srinivas Reddy, G. Brahmananda Reddy, S. Krishna Reddy, G. Uma Sankar, A. Satyam, Y.S. Sivan, P.V. Sridhar.