Non-disclosure of HIV sero-status by Indian female sex workers

With the roll-out of the Bill and Melinda Gates initiated Avahan interventions in India over the last decade, a growing body of evidence has accumulated on the contribution of commercial sex-work to the spread of the HIV epidemic, and the effectiveness of behavioural interventions focussed on this sector.  With the international effort concentrating elsewhere primarily on the deployment of ART, the epidemiological and preventative emphasis of Avahan has broken new ground: attention has been increasingly focussed on influencing the behaviour of key populations (http://sti.bmj.com/content/86/Suppl_1/i6.full?sid=8303ee2c-d0ce-4be1-92a5-f867afdc04d5 ).  Commercial male and female sex workers (FSW/MSW) seem to be an important one of these in the Indian context, due to the importance of male sex activity outside marriage as a factor in Indian HIV epidemiology (http://sti.bmj.com/content/87/6/516.abstract?sid=8133c62b-75db-4498-950e-e277d5687aed).  One neglected aspect of this behaviour has apparently been the disclosure of HIV status.  This is a gap in the research that Saggurti, Samat et al. seek to fill a recent paper (https://springerlink3.metapress.com/content/h26722575803101p/resource-secured/?target=fulltext.html&sid=d0ncj2mkanq0gcji3muoiwrc&sh=www.springerlink.com).

Their headline finding is that 58% of the 211 women (FSM) surveyed by the study, and 41% of the 205 men (clients) had not disclosed their sero-status to any sexual partner.  This would seem to have implications that are more interesting for the relationships of FSM to their non-commercial partners than to their commercial ones.  After all, non-disclosure between FSM and clients is surely what we would expect.  However, non-disclosure in the context of non-commercial and married partners, where consistent condom use may not be the norm (http://sti.bmj.com/content/87/Suppl_1/A67.1.abstract?sid=a9751fe7-af53-4e56-ac3c-352cb5079122) indicates the potential vulnerability of “bridging populations”.  Here Saggurti et al. give further data on the 18 married women and 76 married men included in the study:  39% of the women and 1% of the men had not disclosed HIV status to their married partner; while 78% of the women and 36% of the men claimed not to know the sero-status of the partner.  These findings suggest a marked imbalance – though an imbalance that might reflect behavioural differences between sex-workers and sex-workers’ clients, rather than gender differences per se.

Literature on the epidemiology of HIV transmission stresses the importance of “bridging populations” – which in the case of FSM presumably includes the wives of male clients, on the one hand, and the non-commercial partners of the FSM themselves, on the other.  As regards the former group, a recent study of FSW in Karnataka (Shaw, Deering, Blanchard et al., 2011) indicates that clients of FSW with NCP are less likely (OR 1.8) than those without NCP to use a condom, and more likely (OR 1.5) to be infected with HSV-2.  (http://sti.bmj.com/content/87/Suppl_1/A67.1.abstract?sid=a9751fe7-af53-4e56-ac3c-352cb5079122). But with this group the findings of Saggurti et al. suggest high levels of disclosure.  The case is different with the NCP of FSW, who represent the other bridging group (though here the bridge could well be from NCP to FSW rather than from FSW to NCP).  One of the few studies of the latter group, also from Karnataka (Deering, Bhattacharjee, Alary et al., 2011) finds that levels of consistent condom use (CCU) of FSW with husbands and cohabiting partners is low (22.6% and 40.3% respectively) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287549/).  Thus, here, low disclosure would appear to go with low CCU.  An interesting recent study of FSW and their NCP in Vietnam that would seem to bear out this general picture, Hoffman & Niccolai 2011, examines the relationship between intra-couple “communication divergence” and low CCU, and discovers a relatively strong correlation of OR 0.54 (http://www.springerlink.com.libproxy.ucl.ac.uk/content/r562533h71367j06/fulltext.html).

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