Risky Behaviors among HIV-Positive Female Sex Workers in Northern Karnataka, India

Purpose. Little is known about the risky sexual behaviors of HIV-positive female sex workers (FSWs) in the developing world, which is critical for programmatic purposes. This study aims to shed light on their condom use with regular clients as well as husband/cohabiting partner, a first in India. Methods. Multivariate logistic regression analyses for consistent condom use with regular clients and husband/cohabiting partner are conducted for the sample of 606 HIV-positive FSWs. Results. Older FSWs are 90% less likely and nonmobile FSWs are 70% less likely to consistently use condoms. FSWs on ART are 3.84 times more likely to use condoms. Additionally, FSWs who changed their occupation after HIV diagnosis are 70% less likely to use condoms. FSWs who are currently cohabiting are more likely to consistently use condoms with repeat clients and are 3.22 times more likely to do so if they have felt stigma associated with being HIV-positive. FSWs who have multiple repeat clients, and who do not know the sexual behavior of these clients, are more likely to use condoms consistently. Conclusion. This study would help inform programs to target the following particularly vulnerable HIV-positive FSWs: those who are older, those who changed their occupation post-HIV diagnosis, and those who are nonmobile. 1. Introduction While overall HIV prevalence is low, India has the third largest number of people living with HIV/AIDS in the world [1]. Sexual transmission of HIV is the most dominant route of infection in the country and is concentrated among high risk groups, particularly female sex workers (FSWs), their clients, men who have sex with men (MSM), and injection drug users. Sentinel surveillance data from 2008-2009 indicates that 7.2% of injecting drug users, 7.4% of MSM, and 5.1% of FSWs are HIV-positive, in stark contrast to the 0.5% of attendees in antenatal clinics who tested positive [1]. These indicators suggest that the HIV epidemic in India is in its concentrated phase. FSWs have long been acknowledged as one of the primary drivers of sexually transmitted infections in developing countries [2, 3] and HIV in particular [4]. Due to the larger number of sexual partners compared to other populations, FSWs are at a higher risk of becoming infected and infecting their clients and other partners. Direct interventions among vulnerable groups like FSWs can prove to be very effective in India; Nagelkerke et al. [5] predict that effective HIV intervention among FSWs in the country can drive the epidemic to its extinction. National HIV prevalence among FSWs is estimated