Need for innovative intervention strategies to reduce HIV transmission among men who have sex with men in Andhra Pradesh, India – following a large scale HIV prevention intervention Sharmistha Khobragade 1, Prabuddhagopal Goswami 2, Lakshmi Ramakrishnan 2, Bitra George 2, Rajatashuvra Adhikary 3, Shreena Ramanathan 2, Shajan Mathew 2, Rachakulla Harikumar 4, Venkaiah Kodali 4, Ramesh Paranjape 5 1 FHI 360, India, Mumbai, India 2 FHI 360, India, New Delhi, India 3 FHI 360, Washington DC, Washington DC, United States 4 National Institute of Nutrition (NIN), Hyderabad, India 5 National AIDS Research Institute

Background As per HIV estimates (NACO/UNAIDS) in data, India had an estimated 2.4 million (CI:2.1 million- 2.8million) HIV-positive persons HIV prevalence among HR-MSM in Andhra Pradesh has shown an upward trend (10.25% in 2006, 17.0% in 2007 and 23.6% in 2008) The Bill & Melinda Gates Foundation funded Avahan in 2004, a program designed to reduce the spread of the AIDS epidemic in six high prevalence states of India focusing on high-risk groups including men who have sex with men (HR-MSM) Avahan’s strategy for HR-MSM group included HIV awareness, condom education, STI management and condom social marketing As a part of Avahan program’s evaluation, two rounds of cross- sectional bio-behavioral surveys in 2006 (R1) and 2009 (R2) among HR-MSM were carried out in four districts of Andhra Pradesh, India, supported by BMGF Avahan program

Objectives To examine change in condom use behavior and change in prevalence of HIV and sexually transmitted infections (STIs) among the HR-MSM in four districts of Andhra Pradesh, India over time Hyderabad Map of Andhra Pradesh, India

Methods HR-MSM aged 18 years or older who acknowledged having had paid or unpaid sex with another men in past one month were recruited Two-stage cluster sampling approach was adopted to recruit respondents in both rounds of survey A sample size of 1621 in Round 1 and 1608 in Round 2 were achieved Demographic profiles and behavioral information were collected through structured questionnaires Blood and urine specimen were collected and tested for HIV and STIs status. Multivariate analysis was carried out to measure change in condom use and biological outcomes

Profile of respondents p=0.46 p=0.01 p=0.06

Condom use with different male partners increased among HR-MSM p<0.001 p=0.236 p<0.001

No significant change in HIV and STI prevalence among HR-MSM p=0.10 p=0.65 p=0.63

Exposure to HIV prevention intervention and HIV testing increased over two rounds of survey p<0.001

Multivariate analysis of selected outcomes compared between Round 1 and Round 2 among clients of female sex workers (Ref: Round 1) OutcomesAdjusted odds ratio 95% CIp-value Consistent condom use with regular male partner – 89.1<0.001 Consistent condom use with other non- commercial male partner – 46.5<0.001 Last time condom use with male partners from whom they bought sex – 71.9<0.001 Last time condom use with male partners to whom they sold sex – HIV prevalence – High titer syphilis (RPR>=1:8) – Urethral NG and/or CT –

Summary of results from analysis Few changes were seen in the profiles of HR-MSM between R1 and R2 Condom use with all type of male partners significantly increased in R2 compared to R1 No significant change in HIV and STI prevalence was observed over time between R1 and R2 The proportion of HR-MSM exposed to intervention and those reporting ever having undergone an HIV test increased significantly between the two rounds of survey Multivariate analysis also shows that among HR-MSM, there was significant increase in condom use with no change in HIV/STI prevalence

Conclusion Despite significant increase in condom use and exposure to HIV prevention services, HIV and STI prevalence show no change among HR-MSM in Andhra Pradesh. More investigations and operation research are needed to identify new and innovative approaches for reducing HIV transmission among HR-MSM in Andhra Pradesh

Acknowledgment The analysis presented here is based on the data collected as part of the Avahan evaluation strategy supported by the Bill & Melinda Gates Foundation

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