Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India
Identifieur interne : 002748 ( Pmc/Corpus ); précédent : 002747; suivant : 002749Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India
Auteurs : Souradet Y. Shaw ; Robert Lorway ; Parinita Bhattacharjee ; Sushena Reza-Paul ; Elsabé Du Plessis ; Lyle Mckinnon ; Laura H. Thompson ; Shajy Isac ; Banadakoppa M. Ramesh ; Reynold Washington ; Stephen Moses ; James F. BlanchardSource :
- LGBT Health [ 2325-8292 ] ; 2016.
Abstract
Url:
DOI: 10.1089/lgbt.2015.0023
PubMed: 27058882
PubMed Central: 4976224
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PMC:4976224Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India</title><author><name sortKey="Shaw, Souradet Y" sort="Shaw, Souradet Y" uniqKey="Shaw S" first="Souradet Y." last="Shaw">Souradet Y. Shaw</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Lorway, Robert" sort="Lorway, Robert" uniqKey="Lorway R" first="Robert" last="Lorway">Robert Lorway</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Bhattacharjee, Parinita" sort="Bhattacharjee, Parinita" uniqKey="Bhattacharjee P" first="Parinita" last="Bhattacharjee">Parinita Bhattacharjee</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Reza Paul, Sushena" sort="Reza Paul, Sushena" uniqKey="Reza Paul S" first="Sushena" last="Reza-Paul">Sushena Reza-Paul</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Du Plessis, Elsabe" sort="Du Plessis, Elsabe" uniqKey="Du Plessis E" first="Elsabé" last="Du Plessis">Elsabé Du Plessis</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Mckinnon, Lyle" sort="Mckinnon, Lyle" uniqKey="Mckinnon L" first="Lyle" last="Mckinnon">Lyle Mckinnon</name><affiliation><nlm:aff id="aff3"></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"></nlm:aff></affiliation></author><author><name sortKey="Thompson, Laura H" sort="Thompson, Laura H" uniqKey="Thompson L" first="Laura H." last="Thompson">Laura H. Thompson</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Isac, Shajy" sort="Isac, Shajy" uniqKey="Isac S" first="Shajy" last="Isac">Shajy Isac</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Ramesh, Banadakoppa M" sort="Ramesh, Banadakoppa M" uniqKey="Ramesh B" first="Banadakoppa M." last="Ramesh">Banadakoppa M. Ramesh</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Washington, Reynold" sort="Washington, Reynold" uniqKey="Washington R" first="Reynold" last="Washington">Reynold Washington</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation><affiliation><nlm:aff id="aff5"></nlm:aff></affiliation></author><author><name sortKey="Moses, Stephen" sort="Moses, Stephen" uniqKey="Moses S" first="Stephen" last="Moses">Stephen Moses</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation><affiliation><nlm:aff id="aff6"></nlm:aff></affiliation></author><author><name sortKey="Blanchard, James F" sort="Blanchard, James F" uniqKey="Blanchard J" first="James F." last="Blanchard">James F. Blanchard</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27058882</idno><idno type="pmc">4976224</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976224</idno><idno type="RBID">PMC:4976224</idno><idno type="doi">10.1089/lgbt.2015.0023</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">002748</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002748</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India</title><author><name sortKey="Shaw, Souradet Y" sort="Shaw, Souradet Y" uniqKey="Shaw S" first="Souradet Y." last="Shaw">Souradet Y. Shaw</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Lorway, Robert" sort="Lorway, Robert" uniqKey="Lorway R" first="Robert" last="Lorway">Robert Lorway</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Bhattacharjee, Parinita" sort="Bhattacharjee, Parinita" uniqKey="Bhattacharjee P" first="Parinita" last="Bhattacharjee">Parinita Bhattacharjee</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Reza Paul, Sushena" sort="Reza Paul, Sushena" uniqKey="Reza Paul S" first="Sushena" last="Reza-Paul">Sushena Reza-Paul</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Du Plessis, Elsabe" sort="Du Plessis, Elsabe" uniqKey="Du Plessis E" first="Elsabé" last="Du Plessis">Elsabé Du Plessis</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Mckinnon, Lyle" sort="Mckinnon, Lyle" uniqKey="Mckinnon L" first="Lyle" last="Mckinnon">Lyle Mckinnon</name><affiliation><nlm:aff id="aff3"></nlm:aff></affiliation><affiliation><nlm:aff id="aff4"></nlm:aff></affiliation></author><author><name sortKey="Thompson, Laura H" sort="Thompson, Laura H" uniqKey="Thompson L" first="Laura H." last="Thompson">Laura H. Thompson</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Isac, Shajy" sort="Isac, Shajy" uniqKey="Isac S" first="Shajy" last="Isac">Shajy Isac</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Ramesh, Banadakoppa M" sort="Ramesh, Banadakoppa M" uniqKey="Ramesh B" first="Banadakoppa M." last="Ramesh">Banadakoppa M. Ramesh</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation></author><author><name sortKey="Washington, Reynold" sort="Washington, Reynold" uniqKey="Washington R" first="Reynold" last="Washington">Reynold Washington</name><affiliation><nlm:aff id="aff2"></nlm:aff></affiliation><affiliation><nlm:aff id="aff5"></nlm:aff></affiliation></author><author><name sortKey="Moses, Stephen" sort="Moses, Stephen" uniqKey="Moses S" first="Stephen" last="Moses">Stephen Moses</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation><affiliation><nlm:aff id="aff6"></nlm:aff></affiliation></author><author><name sortKey="Blanchard, James F" sort="Blanchard, James F" uniqKey="Blanchard J" first="James F." last="Blanchard">James F. Blanchard</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></analytic><series><title level="j">LGBT Health</title><idno type="ISSN">2325-8292</idno><idno type="eISSN">2325-8306</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Abstract</title><p><bold><italic>Purpose:</italic></bold> Men and transgender women who have sex with men (MTWSM) continue to be an at-risk population for human immunodeficiency virus (HIV) infection in India. Identification of risk factors and determinants of HIV infection is urgently needed to inform prevention and intervention programming.</p><p><bold><italic>Methods:</italic></bold> Data were collected from cross-sectional biological and behavioral surveys from four districts in Karnataka, India. Multivariable logistic regression models were constructed to examine factors related to HIV infection. Sociodemographic, sexual history, sex work history, condom practices, and substance use covariates were included in regression models.</p><p><bold><italic>Results:</italic></bold> A total of 456 participants were included; HIV prevalence was 12.4%, with the highest prevalence (26%) among MTWSM from Bellary District. In bivariate analyses, district (<italic>P</italic> = 0.002), lack of a current regular female partner (<italic>P</italic> = 0.022), and reported consumption of an alcoholic drink in the last month (<italic>P</italic> = 0.004) were associated with HIV infection. In multivariable models, only alcohol use remained statistically significant (adjusted odds ratios: 2.6, 95% confidence intervals: 1.2–5.8; <italic>P</italic> = 0.02).</p><p><bold><italic>Conclusion:</italic></bold> The prevalence of HIV continues to be high among MTWSM, with the highest prevalence found in Bellary district.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Moses, S" uniqKey="Moses S">S Moses</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vassall, A" uniqKey="Vassall A">A Vassall</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Blanchard, Jf" uniqKey="Blanchard J">JF Blanchard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="O Neil, J" uniqKey="O Neil J">J O'Neil</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Blanchard, Jf" uniqKey="Blanchard J">JF 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uniqKey="Solomon S">SS Solomon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Shinde, S" uniqKey="Shinde S">S Shinde</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Setia, Ms" uniqKey="Setia M">MS Setia</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kumta, S" uniqKey="Kumta S">S Kumta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chakrapani, V" uniqKey="Chakrapani V">V Chakrapani</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dandona, L" uniqKey="Dandona L">L Dandona</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dandona, L" uniqKey="Dandona L">L Dandona</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gupta, A" uniqKey="Gupta A">A Gupta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thompson, Lh" uniqKey="Thompson L">LH Thompson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Krug, Eg" uniqKey="Krug E">EG Krug</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Safren, Sa" uniqKey="Safren S">SA Safren</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Phillips, Ae" uniqKey="Phillips A">AE Phillips</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Steinbrook, R" uniqKey="Steinbrook R">R Steinbrook</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lorway, R" uniqKey="Lorway R">R Lorway</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Beattie, Ts" uniqKey="Beattie T">TS Beattie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vassall, A" uniqKey="Vassall A">A Vassall</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jha, Um" uniqKey="Jha U">UM Jha</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thomas, B" uniqKey="Thomas B">B Thomas</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Saidel, T" uniqKey="Saidel T">T Saidel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Phillips, Ae" uniqKey="Phillips A">AE Phillips</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Verma, R" uniqKey="Verma R">R Verma</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Beyrer, C" uniqKey="Beyrer C">C Beyrer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Shaw, Sy" uniqKey="Shaw S">SY Shaw</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pandey, A" uniqKey="Pandey A">A 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Venkatesh</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">LGBT Health</journal-id><journal-id journal-id-type="iso-abbrev">LGBT Health</journal-id><journal-id journal-id-type="publisher-id">lgbt</journal-id><journal-title-group><journal-title>LGBT Health</journal-title></journal-title-group><issn pub-type="ppub">2325-8292</issn><issn pub-type="epub">2325-8306</issn><publisher><publisher-name>Mary Ann Liebert, Inc.</publisher-name><publisher-loc>140 Huguenot Street, 3rd FloorNew Rochelle, NY 10801USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27058882</article-id><article-id pub-id-type="pmc">4976224</article-id><article-id pub-id-type="publisher-id">10.1089/lgbt.2015.0023</article-id><article-id pub-id-type="doi">10.1089/lgbt.2015.0023</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Shaw</surname><given-names>Souradet Y.</given-names></name><degrees>MSc</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lorway</surname><given-names>Robert</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Bhattacharjee</surname><given-names>Parinita</given-names></name><degrees>MSc</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Reza-Paul</surname><given-names>Sushena</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>du Plessis</surname><given-names>Elsabé</given-names></name><degrees>MSc</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>McKinnon</surname><given-names>Lyle</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff3"><sup>3,</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Thompson</surname><given-names>Laura H.</given-names></name><degrees>MSc</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Isac</surname><given-names>Shajy</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Ramesh</surname><given-names>Banadakoppa M.</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Washington</surname><given-names>Reynold</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff2"><sup>2,</sup></xref><xref ref-type="aff" rid="aff5"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Moses</surname><given-names>Stephen</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff1"><sup>1,</sup></xref><xref ref-type="aff" rid="aff6"><sup>6</sup></xref></contrib><contrib contrib-type="author"><name><surname>Blanchard</surname><given-names>James F.</given-names></name><degrees>MD, PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><aff id="aff1"><label><sup>1</sup></label>Department of Community Health Sciences, Centre for Global Public Health,<institution>University of Manitoba</institution>, Winnipeg, Manitoba,<country>Canada</country>.</aff><aff id="aff2"><label><sup>2</sup></label><institution>Karnataka Health Promotion Trust</institution>, Bangalore,<country>India</country>.</aff><aff id="aff3"><label><sup>3</sup></label>Department of Medicine,<institution>University of Toronto</institution>, Toronto, Ontario,<country>Canada</country>.</aff><aff id="aff4"><label><sup>4</sup></label>Department of Medical Microbiology,<institution>University of Nairobi</institution>, Nairobi,<country>Kenya</country>.</aff><aff id="aff5"><label><sup>5</sup></label><institution>St. John's Research Institute</institution>, Bangalore,<country>India</country>.</aff><aff id="aff6"><label><sup>6</sup></label>Department of Medical Microbiology,<institution>University of Manitoba</institution>, Winnipeg, Manitoba,<country>Canada</country>.</aff></contrib-group><author-notes><corresp><addr-line>Address correspondence to:</addr-line><addr-line><italic>Souradet Y. Shaw, MSc</italic></addr-line><addr-line><italic>Department of Community Health Sciences</italic></addr-line><addr-line><italic>Centre for Global Public Health</italic></addr-line><institution><italic>University of Manitoba</italic></institution><addr-line><italic>R070 Med Rehab Building</italic></addr-line><addr-line><italic>771 McDermot Avenue</italic></addr-line><addr-line><italic>Winnipeg R3E 0T6</italic></addr-line><addr-line><italic>Manitoba</italic></addr-line><country>Canada</country><break></break><italic>E-mail:</italic><email xlink:href="mailto:umshaw@myumanitoba.ca">umshaw@myumanitoba.ca</email></corresp></author-notes><pub-date pub-type="ppub"><day>01</day><month>8</month><year>2016</year><pmc-comment>string-date: August 2016</pmc-comment>
</pub-date><pub-date pub-type="pmc-release"><day>01</day><month>8</month><year>2016</year><pmc-comment>string-date: August 2016</pmc-comment>
</pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on the
<volume>3</volume><issue>4</issue><fpage>292</fpage><lpage>299</lpage><permissions><copyright-statement>© Souradet Y. Shaw et al. 2016; Published by Mary Ann Liebert, Inc.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access"><license-p>This Open Access article is distributed under the terms of the Creative Commons Attribution Noncommercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:type="simple" xlink:href="lgbt.2015.0023.pdf"></self-uri><abstract><title>Abstract</title><p><bold><italic>Purpose:</italic></bold> Men and transgender women who have sex with men (MTWSM) continue to be an at-risk population for human immunodeficiency virus (HIV) infection in India. Identification of risk factors and determinants of HIV infection is urgently needed to inform prevention and intervention programming.</p><p><bold><italic>Methods:</italic></bold> Data were collected from cross-sectional biological and behavioral surveys from four districts in Karnataka, India. Multivariable logistic regression models were constructed to examine factors related to HIV infection. Sociodemographic, sexual history, sex work history, condom practices, and substance use covariates were included in regression models.</p><p><bold><italic>Results:</italic></bold> A total of 456 participants were included; HIV prevalence was 12.4%, with the highest prevalence (26%) among MTWSM from Bellary District. In bivariate analyses, district (<italic>P</italic> = 0.002), lack of a current regular female partner (<italic>P</italic> = 0.022), and reported consumption of an alcoholic drink in the last month (<italic>P</italic> = 0.004) were associated with HIV infection. In multivariable models, only alcohol use remained statistically significant (adjusted odds ratios: 2.6, 95% confidence intervals: 1.2–5.8; <italic>P</italic> = 0.02).</p><p><bold><italic>Conclusion:</italic></bold> The prevalence of HIV continues to be high among MTWSM, with the highest prevalence found in Bellary district.</p></abstract><kwd-group kwd-group-type="author"><title><bold>Key words:</bold> </title><kwd>alcohol use</kwd><kwd>HIV risk</kwd><kwd>India</kwd><kwd>men who have sex with men</kwd></kwd-group><counts><table-count count="2"></table-count><ref-count count="55"></ref-count><page-count count="8"></page-count></counts></article-meta></front><body><sec sec-type="intro" id="s001"><title>Introduction</title><p>T<sc>he human immunodeficiency virus</sc> (HIV) epidemic in India continues to be a global concern, with the heterosexual spread of HIV through female sex work, an important factor in earlier phases of the HIV epidemic in southern India.<sup><xref rid="B1" ref-type="bibr">1</xref></sup> With a prevalence of 1.3% in prenatal clinics, Karnataka state in southern India was found to be one of six states with a high HIV prevalence,<sup><xref rid="B1" ref-type="bibr">1</xref></sup> triggering a considerable amount of investment in resources for prevention and intervention work.<sup><xref rid="B2" ref-type="bibr">2</xref></sup></p><p>A challenge for prevention and intervention efforts is the tremendous amount of heterogeneity that exists in India.<sup><xref rid="B3" ref-type="bibr">3</xref></sup> For example, within northern Karnataka, the presence of the <italic>Devadasi</italic> tradition (a form of sex work where young women are dedicated through marriage to gods or goddesses),<sup><xref rid="B4" ref-type="bibr">4</xref></sup> geographic proximity to large urban centers in Maharashtra state, and a largely rural population have conspired to produce substantially different drivers of the HIV epidemic compared to southern Karnataka.<sup><xref rid="B5" ref-type="bibr">5–8</xref></sup> In fact, a gradient in HIV prevalence from north to south, with a higher prevalence in the northern parts of Karnataka, is known to exist.<sup><xref rid="B6" ref-type="bibr">6</xref></sup></p><p>Increasing emphasis has been placed on characterizing and responding to heterogeneity in the Indian HIV epidemic, and the different risk populations currently affected by HIV,<sup><xref rid="B9" ref-type="bibr">9–11</xref></sup> such as among men and transgender women who have sex with men (MTWSM).<sup><xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B12" ref-type="bibr">12–15</xref></sup> MTWSM are recognized as a core group and are thus a priority for targeted interventions by the National AIDS Control Organization of India.<sup><xref rid="B16" ref-type="bibr">16</xref></sup> Although recent studies have increased our understanding of MTWSM,<sup><xref rid="B9" ref-type="bibr">9</xref>,<xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B18" ref-type="bibr">18</xref></sup> there is still a paucity of data on the correlates of HIV infection among MTWSM in India. It is known that MTWSM in southern India have high rates of infection with HIV,<sup><xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B13" ref-type="bibr">13</xref></sup> as well as other sexually transmitted infections (STIs),<sup><xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B13" ref-type="bibr">13</xref></sup> relative to the general Indian population. For example, two studies of MTWSM in Karnataka state have reported HIV prevalence to be between 13% and 17% among MTWSM in their samples.<sup><xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B11" ref-type="bibr">11</xref></sup> In comparison, the HIV prevalence in the general male population in Karnataka state has been estimated at less than 1%.<sup><xref rid="B12" ref-type="bibr">12</xref>,<xref rid="B19" ref-type="bibr">19</xref></sup> One survey of men living in Chennai slums found that the HIV prevalence was ninefold higher among MTWSM, compared to non-MTWSM individuals.<sup><xref rid="B20" ref-type="bibr">20</xref></sup></p><p>Among MTWSM, HIV prevalence is known to vary by age,<sup><xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B22" ref-type="bibr">22</xref></sup> sexual identity,<sup><xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B23" ref-type="bibr">23</xref></sup> and location of residence,<sup><xref rid="B11" ref-type="bibr">11</xref></sup> while the cruising location and level of literacy have been associated with HIV risk behaviors.<sup><xref rid="B22" ref-type="bibr">22</xref>,<xref rid="B24" ref-type="bibr">24</xref>,<xref rid="B25" ref-type="bibr">25</xref></sup> A large body of literature exists on the relationship between sex work and HIV among MTWSM in India.<sup><xref rid="B23" ref-type="bibr">23</xref>,<xref rid="B26" ref-type="bibr">26</xref>,<xref rid="B27" ref-type="bibr">27</xref></sup> Research has demonstrated that a substantial proportion of MTWSM are married, or have female sex partners<sup><xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B22" ref-type="bibr">22</xref>,<xref rid="B25" ref-type="bibr">25</xref></sup>; at the same time, condom use has been demonstrated to be low among MTWSM.<sup><xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B28" ref-type="bibr">28</xref></sup> Age at first sex and composition of current sexual partners have been shown to be associated with HIV risk.<sup><xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B22" ref-type="bibr">22</xref>,<xref rid="B29" ref-type="bibr">29</xref></sup> Contributing to their risk for HIV, MTWSM in India remain highly stigmatized and marginalized in the Indian society<sup><xref rid="B26" ref-type="bibr">26</xref>,<xref rid="B30" ref-type="bibr">30</xref></sup> and experience high rates of sexual violence.<sup><xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B26" ref-type="bibr">26</xref>,<xref rid="B31" ref-type="bibr">31</xref>,<xref rid="B32" ref-type="bibr">32</xref></sup> Finally, substance use, including alcohol use, has been shown to be elevated among MTWSM<sup><xref rid="B33" ref-type="bibr">33</xref></sup> and has also been demonstrated to be associated with HIV.<sup><xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B22" ref-type="bibr">22</xref></sup></p><p>Thus, the higher prevalence of HIV and social and structural vulnerabilities (such as stigma, marginalization, and oppression) contribute to the creation of conditions that mirror the early spread of HIV among Indian female sex workers (FSWs).<sup><xref rid="B13" ref-type="bibr">13</xref>,<xref rid="B34" ref-type="bibr">34</xref></sup> For example, MTWSM often live in poverty, are often involved in sex work, and are harassed by state institutions such as the police in India.<sup><xref rid="B26" ref-type="bibr">26</xref>,<xref rid="B35" ref-type="bibr">35</xref></sup> At the same time, collectivization, community mobilization, and empowerment of FSWs are all thought to have played a vital role in curtailing the HIV epidemic among FSWs in Karnataka state.<sup><xref rid="B36" ref-type="bibr">36</xref>,<xref rid="B37" ref-type="bibr">37</xref></sup> Although broadly less successful in MTWSM communities, due to the high stigmatization and illegality (in India) of same-sex relationships among men, Jha et al. note that peer-led education, community-led program planning and implementation, condom distribution and promotion, and integrated testing and treatment services were hallmarks of successful interventions among MTWSM communities.<sup><xref rid="B38" ref-type="bibr">38</xref></sup> In terms of program planning, there are substantial gaps in knowledge regarding the correlates of HIV infection, and how, in turn, these correlates may affect prevention, screening, and treatment.<sup><xref rid="B38" ref-type="bibr">38</xref>,<xref rid="B39" ref-type="bibr">39</xref></sup> For example, Thomas et al. note that the effect of alcohol and other substance use on risk for HIV has not been well studied in the Indian context.<sup><xref rid="B39" ref-type="bibr">39</xref></sup> Therefore, studies describing the distribution of HIV among MTWSM and that examine the correlates of HIV infection are a priority for program planning. Using the most recent data available from a series of cross-sectional surveys of four districts in Karnataka State, southern India, this study sought to describe the prevalence of HIV among MTWSM and to examine factors related to HIV prevalence. The cross-sectional surveys were used to help evaluate the impact of the Bill & Melinda Gates Foundation's <italic>Avahan</italic> program in India, which sought to curtail the spread of HIV in India.<sup><xref rid="B40" ref-type="bibr">40</xref>,<xref rid="B41" ref-type="bibr">41</xref></sup></p></sec><sec sec-type="methods" id="s002"><title>Methods</title><sec id="s003"><title>Study design and sampling</title><p>Institutional Review Boards at the University of Manitoba in Winnipeg, Canada, and St. John's Medical College and Hospital in Bangalore, India, approved the study and the verbal consent process. Interviews were conducted anonymously; because of the high level of stigmatization of MTWSM populations in India, verbal consent was obtained for all respondents in lieu of written consent, as MTWSM are reluctant to sign their names to documents. An independent witness signed each consent form, affirming that consent was correctly obtained.</p><p>Data were collected from the second round of a cross-sectional survey (i.e., the Integrated Biological and Behavioural Assessment [IBBA]) of MTWSM populations in four districts in Karnataka State, southern India: Belgaum, Bellary, Mysore, and Shimoga. As part of a comprehensive monitoring and evaluation strategy, results from the IBBA were used to evaluate the impact of the <italic>Avahan</italic> program, which aimed to slow HIV transmission in India by bringing prevention efforts to scale among populations thought most at risk for HIV, including MTWSM.<sup><xref rid="B40" ref-type="bibr">40</xref>,<xref rid="B41" ref-type="bibr">41</xref></sup> MTWSM in Belgaum (<italic>n</italic> = 198), Bellary (<italic>n</italic> = 71), Mysore (<italic>n</italic> = 100), and Shimoga (<italic>n</italic> = 87) were recruited in 2011 through multistage cluster sampling.<sup><xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B42" ref-type="bibr">42</xref></sup> Briefly, multistage cluster sampling is a sampling technique that takes advantage of natural, relatively homogenous clusters in a population and is thought to be highly efficient in the sampling of hard-to-reach populations.<sup><xref rid="B43" ref-type="bibr">43</xref></sup> A sample size of 400 at the district level was thought adequate to detect an absolute difference of 15% or more from an assumed value of 50% in key behavioral characteristics between survey administrations, with 95% confidence and 90% power.<sup><xref rid="B41" ref-type="bibr">41</xref></sup> The four districts in this analysis were treated as a single study. Program and mapping activities were directed at the most at-risk MTWSM and focused on those practicing receptive anal intercourse. These two concepts were operationalized by concentrating on MTWSM who gathered at cruising sites and other public spaces.<sup><xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B42" ref-type="bibr">42</xref></sup> Selection of solicitation sites occurred in the first stage of sampling, and selection of MTWSM in the second. Time–location cluster sampling was used to select specific clusters. Informed by previous mapping exercises, a total of 110 clusters with a minimum of five interviews in each cluster were targeted across the four districts. Within each cluster, MTWSM were randomly approached by field staff and asked to participate. Free transportation was then arranged to a private venue for MTWSM agreeing to participate. At the venue, MTWSM were explained IBBA procedures in detail and given the opportunity to ask questions; the voluntary nature of the survey was emphasized, especially the ability of the participant to withdraw participation at any point in the survey. Before field work and recruitment, a specific effort was made to inform community members of the scope, purpose, and the risks and benefits of the IBBA by field workers through community-based organizations. Participants were included in the study if they were 18 years or older and reported having had sex with a man at least once in their lifetime. Participants who were intoxicated or were otherwise unable to provide consent were excluded.</p></sec><sec id="s004"><title>Survey organization and methods</title><p>MTWSM were interviewed individually by trained peer workers using a structured questionnaire administered in the local language. Biological data were gathered using blood and urine samples as described in previous studies.<sup><xref rid="B17" ref-type="bibr">17</xref>,<xref rid="B42" ref-type="bibr">42</xref></sup> HIV serological testing was conducted using MicroELISA (J. Mitra and Company, India), and positive tests were confirmed using Genedia HIV 1/2 ELISA 3.0 (Green Cross Life Science Corporation, South Korea). When serum samples were not provided, dried blood spot testing was performed on finger prick blood using the same serological tests. When neither serum nor finger prick samples were provided, urine samples were tested for HIV by Calypte Biomedical Corporation (Berkeley, CA) and confirmed by Western blot. Because surveys and tests were conducted anonymously, results from HIV tests could not be linked back to individuals; however, syndromic treatment for bacterial sexually transmitted infections was provided on site, and vouchers were given to participants for free testing at community-based clinics.</p></sec><sec id="s005"><title>Measures</title><p>In addition to the primary outcome (HIV status), respondents were compared on sociodemographic, sexual history, sex work-related, condom use, and substance use characteristics. Age group, literacy level (ability to read and write), marital status (ever married or never married), district of residence, and sexual identity were included as sociodemographic variables. Sexual identity among MTWSM is highly diverse; similar to other studies,<sup><xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B17" ref-type="bibr">17</xref></sup> MTWSM could self-identify as <italic>Kothis</italic> (those who primarily practice receptive anal sex and are feminine-acting males); <italic>Hijras</italic> (transgender people who often self-identify as female; many are castrated); <italic>Panthis</italic> (those who primarily practice insertive anal sex and are often clients of Kothis or Hijras); <italic>Double-deckers</italic> (DD) (those who practice both insertive/receptive anal sex), and <italic>others.</italic> MTWSM were grouped into the following identities: <italic>Kothis/Hijras</italic>; DD; and all others.<sup><xref rid="B10" ref-type="bibr">10</xref></sup> Kothis and Hijras were grouped together for the purposes of statistical power. Finally, where respondent was recruited into the study (public garden/washroom, railway station/bus stop, or Hamam) was used as a proxy for where respondents cruised for sex with other MTWSM.</p><p>Sexual history included age at first sexual encounter with a man, whether first sex was forced (yes/no), and history of vaginal intercourse (yes/no). Binary variables for each of the following were created: whether the respondent currently had a regular female partner, a regular male partner, or no partner at all. Sex work-related questions included whether the respondent had ever engaged in sex work and binary variables created from questions asking whether respondents had ever paid for sex from FSWs and/or male sex workers. Condom use questions included asking whether respondents had ever used condoms, whether condoms were used at last anal sex with a male partner, whether respondents ever felt they could not use a condom in the past 6 months, and whether the decision to use condoms at last sex was entirely up to their partner. Finally, variables were created to capture the use of alcohol in the last month (ever vs. never), injection drug use, and use of other drugs. No respondent reported injection drug use, and only one reported use of other drugs; therefore, only alcohol use was included in further analyses.</p></sec><sec id="s006"><title>Statistical analysis</title><p>Descriptive analyses included comparisons between HIV-positive and HIV-negative MTWSM based on sociodemographic, sexual history, sex work, condom use, and substance use characteristics.</p></sec><sec id="s007"><title>Multivariable analyses</title><p>A hierarchical, stepwise approach was taken for parsimonious model building in multivariable logistic regression analyses. Factors of interest were grouped into five blocks: sociodemographic, sexual history, sex work, condom use, and substance use. <italic>A priori</italic>, age group, district of residence, and sexual identity were forced into models. As a consequence, the null model (Model 1) used for each comparison included age group, district, and sexual identity as covariates. In the first step, each block was entered separately into multivariable regression models in the following sequence: substance use, condom use, sex work, sexual history, and sociodemographic blocks. All blocks not associated with HIV status (adjusted for age group, sexual identity, and district) at <italic>P</italic> < 0.10 were excluded from further analysis. In the second step, for each block remaining, covariates comprising the included block were entered into regression models individually. Covariates were kept if they were associated with the outcome at <italic>P</italic> < 0.10 (Model 2). In the third step, all covariates that were excluded in the first and second steps of the model building process were entered individually into Model 2; any covariates significant at the <italic>P</italic> < 0.05 level were then retained. This final step was repeated until no other covariates were associated with HIV status at <italic>P</italic> < 0.05. Wald tests were used to assess statistical significance, and sampling weights were utilized in regression models to account for the complex sampling design, using survey methods in Stata 12 (College Station, TX). Multicollinearity was assessed using the variance inflation factor and tolerance statistics, corrected for the survey methods used.<sup><xref rid="B44" ref-type="bibr">44</xref></sup></p></sec></sec><sec sec-type="results" id="s008"><title>Results</title><p>A total of 456 respondents were included from an original study sample of 459. Two respondents were eliminated because they did not consent to HIV testing, and one other respondent was excluded due to missing responses for several variables. <xref ref-type="table" rid="T1">Table 1</xref> includes a description of the sample, both for the total study group and by HIV status. The mean age of the sample was 32.1 years, with MTWSM identifying as DD composing 50% of the sample. At the bivariate level, HIV-positive respondents were more likely to be from Bellary (<italic>P</italic> = 0.002), less likely to report having a current regular female partner (<italic>P</italic> = 0.022), and more likely to report having at least one alcoholic drink in the last month (<italic>P</italic> = 0.004). HIV prevalence in the total sample was 12.4% (<xref ref-type="table" rid="T2">Table 2</xref>), with prevalence lowest among 18–24-year olds (11.1%) and highest among 25–29-year olds (14.7%). HIV prevalence was highest in Bellary (26.3%) and lowest in Belgaum (7.9%). HIV prevalence among Kothis/Hijras, Panthis/Bisexuals/others, and DDs was 15.3%, 13.7%, and 9.9%, respectively.</p><table-wrap id="T1" orientation="portrait" position="float"><label><sc>Table</sc> 1.</label><caption><p><sc>Sample Characteristics by HIV Status, MTWSM South India (Weighted %, <italic>N</italic> = 456)</sc></p></caption><pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead><tr><th align="left"><italic>Variables</italic></th><th align="center"><italic>HIV −ve MTWSM (</italic>n<italic> = 399)</italic></th><th align="center"><italic>HIV +ve MTWSM (</italic>n<italic> = 57)</italic></th><th align="center"><italic>Total (</italic>n<italic> = 456)</italic></th><th align="center">P</th></tr></thead><tbody><tr><td colspan="5" align="left">Sociodemographic</td></tr><tr><td colspan="5" align="left">Age group</td></tr><tr><td align="left"> 18–24</td><td align="center">29.2%</td><td align="center">25.6%</td><td align="center">28.7%</td><td align="center">0.888</td></tr><tr><td align="left"> 25–29</td><td align="center">17.0%</td><td align="center">20.6%</td><td align="center">17.5%</td><td align="left"> </td></tr><tr><td align="left"> 30–39</td><td align="center">28.8%</td><td align="center">27.1%</td><td align="center">28.6%</td><td align="left"> </td></tr><tr><td align="left"> 40+</td><td align="center">25.0%</td><td align="center">26.7%</td><td align="center">25.2%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Sexual identity</td></tr><tr><td align="left"> Panthi/bisexual/other</td><td align="center">11.8%</td><td align="center">13.1%</td><td align="center">11.9%</td><td align="center">0.320</td></tr><tr><td align="left"> DD</td><td align="center">50.9%</td><td align="center">39.6%</td><td align="center">49.5%</td><td align="left"> </td></tr><tr><td align="left"> Kothi/Hijra</td><td align="center">37.3%</td><td align="center">47.3%</td><td align="center">38.6%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">District</td></tr><tr><td align="left"> Belgaum</td><td align="center">54.9%</td><td align="center">33.1%</td><td align="center">52.2%</td><td align="center">0.002</td></tr><tr><td align="left"> Bellary</td><td align="center">10.4%</td><td align="center">26.1%</td><td align="center">12.3%</td><td align="left"> </td></tr><tr><td align="left"> Shimoga</td><td align="center">5.4%</td><td align="center">5.3%</td><td align="center">5.4%</td><td align="left"> </td></tr><tr><td align="left"> Mysore</td><td align="center">29.3%</td><td align="center">35.6%</td><td align="center">30.1%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Where recruited</td></tr><tr><td align="left"> Public garden/toilet</td><td align="center">11.2%</td><td align="center">20.6%</td><td align="center">12.4%</td><td align="center">0.209</td></tr><tr><td align="left"> Railway station/bus-stop</td><td align="center">22.8%</td><td align="center">24.5%</td><td align="center">23.0%</td><td align="left"> </td></tr><tr><td align="left"> Hamam</td><td align="center">66.0%</td><td align="center">54.9%</td><td align="center">64.6%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Can read and write</td></tr><tr><td align="left"> No</td><td align="center">34.6%</td><td align="center">32.6%</td><td align="center">34.3%</td><td align="center">0.763</td></tr><tr><td align="left"> Yes</td><td align="center">65.4%</td><td align="center">67.4%</td><td align="center">65.7%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Ever married</td></tr><tr><td align="left"> No</td><td align="center">49.8%</td><td align="center">63.6%</td><td align="center">51.6%</td><td align="center">0.058</td></tr><tr><td align="left"> Yes</td><td align="center">50.2%</td><td align="center">36.4%</td><td align="center">48.4%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Sexual history</td></tr><tr><td colspan="5" align="left">Age at first sex (with male)</td></tr><tr><td align="left"> <15</td><td align="center">17.0%</td><td align="center">15.6%</td><td align="center">16.9%</td><td align="center">0.579</td></tr><tr><td align="left"> 15–18</td><td align="center">45.4%</td><td align="center">54.2%</td><td align="center">46.5%</td><td align="left"> </td></tr><tr><td align="left"> 19–21</td><td align="center">23.7%</td><td align="center">15.6%</td><td align="center">22.7%</td><td align="left"> </td></tr><tr><td align="left"> >21</td><td align="center">13.8%</td><td align="center">14.5%</td><td align="center">13.9%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">First sex with male forced</td></tr><tr><td align="left"> No</td><td align="center">60.5%</td><td align="center">59.9%</td><td align="center">60.4%</td><td align="center">0.938</td></tr><tr><td align="left"> Yes</td><td align="center">39.5%</td><td align="center">40.1%</td><td align="center">39.6%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Have regular male partner</td></tr><tr><td align="left"> No</td><td align="center">46.1%</td><td align="center">50.5%</td><td align="center">46.6%</td><td align="center">0.602</td></tr><tr><td align="left"> Yes</td><td align="center">53.9%</td><td align="center">49.5%</td><td align="center">53.4%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Have regular female partner</td></tr><tr><td align="left"> No</td><td align="center">53.4%</td><td align="center">69.7%</td><td align="center">55.5%</td><td align="center">0.022</td></tr><tr><td align="left"> Yes</td><td align="center">46.6%</td><td align="center">30.3%</td><td align="center">44.5%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Has no regular partner</td></tr><tr><td align="left"> No</td><td align="center">74.7%</td><td align="center">64.3%</td><td align="center">73.4%</td><td align="center">0.160</td></tr><tr><td align="left"> Yes</td><td align="center">25.3%</td><td align="center">35.7%</td><td align="center">26.6%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Has had vaginal sex</td></tr><tr><td align="left"> No</td><td align="center">45.7%</td><td align="center">43.3%</td><td align="center">45.4%</td><td align="center">0.742</td></tr><tr><td align="left"> Yes</td><td align="center">54.3%</td><td align="center">56.7%</td><td align="center">54.6%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Sex work</td></tr><tr><td colspan="5" align="left">Ever</td></tr><tr><td align="left"> No</td><td align="center">62.5%</td><td align="center">52.6%</td><td align="center">61.2%</td><td align="center">0.186</td></tr><tr><td align="left"> Yes</td><td align="center">37.5%</td><td align="center">47.4%</td><td align="center">38.8%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Ever paid for sex (MSW)</td></tr><tr><td align="left"> No</td><td align="center">90.5%</td><td align="center">88.7%</td><td align="center">90.3%</td><td align="center">0.702</td></tr><tr><td align="left"> Yes</td><td align="center">9.5%</td><td align="center">11.3%</td><td align="center">9.7%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Ever paid for sex (FSW)</td></tr><tr><td align="left"> No</td><td align="center">98.0%</td><td align="center">98.8%</td><td align="center">98.1%</td><td align="center">0.620</td></tr><tr><td align="left"> Yes</td><td align="center">2.0%</td><td align="center">1.2%</td><td align="center">1.9%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Condom use</td></tr><tr><td colspan="5" align="left">Could not use condom (last 6 months)</td></tr><tr><td align="left"> No</td><td align="center">88.9%</td><td align="center">83.8%</td><td align="center">88.3%</td><td align="center">0.396</td></tr><tr><td align="left"> Yes</td><td align="center">11.1%</td><td align="center">16.2%</td><td align="center">11.7%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Partner decides when to use condom</td></tr><tr><td align="left"> No</td><td align="center">92.9%</td><td align="center">91.0%</td><td align="center">92.6%</td><td align="center">0.621</td></tr><tr><td align="left"> Yes</td><td align="center">7.1%</td><td align="center">9.0%</td><td align="center">7.4%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Ever used condom</td></tr><tr><td align="left"> No</td><td align="center">2.5%</td><td align="center">0.0%</td><td align="center">2.2%</td><td align="center">0.263</td></tr><tr><td align="left"> Yes</td><td align="center">97.5%</td><td align="center">100.0%</td><td align="center">97.8%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Used condom at last sex</td></tr><tr><td align="left"> No</td><td align="center">1.0%</td><td align="center">0.0%</td><td align="center">0.8%</td><td align="center">0.446</td></tr><tr><td align="left"> Yes</td><td align="center">99.0%</td><td align="center">100.0%</td><td align="center">99.2%</td><td align="left"> </td></tr><tr><td colspan="5" align="left">Substance use</td></tr><tr><td colspan="5" align="left">Alcohol frequency</td></tr><tr><td align="left"> Never</td><td align="center">38.7%</td><td align="center">18.9%</td><td align="center">36.3%</td><td align="center">0.004</td></tr><tr><td align="left"> Ever</td><td align="center">61.3%</td><td align="center">81.1%</td><td align="center">63.7%</td><td align="left"> </td></tr></tbody></table><table-wrap-foot><fn id="tf1"><p>DD, double-deckers; FSW; female sex worker; HIV, human immunodeficiency virus; MSW, male sex worker; MTWSM, men and transgender women who have sex with men.</p></fn></table-wrap-foot></table-wrap><table-wrap id="T2" orientation="portrait" position="float"><label><sc>Table</sc> 2.</label><caption><p><sc>HIV Prevalence and AOR and 95% CI from Logistic Regression Models Examining Characteristics Associated with HIV Status, MTWSM South India (<italic>N</italic> = 456)</sc></p></caption><pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col><col align="left"></col></colgroup><thead><tr><th align="left"> </th><th align="left"> </th><th colspan="3" align="center"><italic>Model 1</italic></th><th colspan="3" align="center"><italic>Model 2</italic></th></tr><tr><th align="left"> </th><th align="center"><italic>HIV prevalence</italic></th><th align="center"><italic>AOR</italic></th><th align="center"><italic>95% CI</italic></th><th align="center">P</th><th align="center"><italic>AOR</italic></th><th align="center"><italic>95% CI</italic></th><th align="center">P</th></tr></thead><tbody><tr><td colspan="8" align="left">Age group</td></tr><tr><td align="left"> 18–24</td><td align="center">11.1</td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td></tr><tr><td align="left"> 25–29</td><td align="center">14.7</td><td align="center">1.57</td><td align="center">0.57–4.35</td><td align="center">0.38</td><td align="center">1.41</td><td align="center">0.52–3.83</td><td align="center">0.50</td></tr><tr><td align="left"> 30–39</td><td align="center">11.8</td><td align="center">1.45</td><td align="center">0.60–3.47</td><td align="center">0.40</td><td align="center">1.32</td><td align="center">0.57–3.07</td><td align="center">0.51</td></tr><tr><td align="left"> 40+</td><td align="center">13.2</td><td align="center">2.01</td><td align="center">0.60–6.73</td><td align="center">0.25</td><td align="center">2.02</td><td align="center">0.61–6.67</td><td align="center">0.24</td></tr><tr><td colspan="8" align="left">Sexual identity</td></tr><tr><td align="left"> Panthi/bisexual/other</td><td align="center">13.7</td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td></tr><tr><td align="left"> DD</td><td align="center">9.9</td><td align="center">0.60</td><td align="center">0.16–2.23</td><td align="center">0.43</td><td align="center">0.64</td><td align="center">0.16–2.51</td><td align="center">0.51</td></tr><tr><td align="left"> Kothi/Hijra</td><td align="center">15.3</td><td align="center">0.87</td><td align="center">0.23–3.32</td><td align="center">0.83</td><td align="center">0.93</td><td align="center">0.22–3.85</td><td align="center">0.92</td></tr><tr><td colspan="8" align="left">District<sup><xref ref-type="table-fn" rid="tf3">**</xref></sup></td></tr><tr><td align="left"> Belgaum</td><td align="center">7.9</td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td></tr><tr><td align="left"> Bellary</td><td align="center">26.3</td><td align="center">5.15</td><td align="center">2.37–11.21</td><td align="center">0.00</td><td align="center">4.52</td><td align="center">2.17–9.42</td><td align="center"><0.001</td></tr><tr><td align="left"> Shimoga</td><td align="center">12.2</td><td align="center">1.75</td><td align="center">0.74–4.12</td><td align="center">0.20</td><td align="center">1.78</td><td align="center">0.74–4.30</td><td align="center">0.13</td></tr><tr><td align="left"> Mysore</td><td align="center">14.7</td><td align="center">1.98</td><td align="center">0.76–5.16</td><td align="center">0.16</td><td align="center">1.32</td><td align="center">0.48–3.62</td><td align="center">0.58</td></tr><tr><td colspan="8" align="left">Where recruited</td></tr><tr><td align="left"> Public garden/toilet</td><td align="center">20.7</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Railway station/bus-stop</td><td align="center">13.2</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Hamam</td><td align="center">10.6</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Can read and write</td></tr><tr><td align="left"> No</td><td align="center">11.8</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">12.8</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Ever married</td></tr><tr><td align="left"> No</td><td align="center">15.4</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">9.3</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Age at first MSM sex</td></tr><tr><td align="left"> <15</td><td align="center">11.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> 15–18</td><td align="center">14.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> 19–21</td><td align="center">8.6</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> >21</td><td align="center">13.0</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">First MSM sex forced</td></tr><tr><td align="left"> No</td><td align="center">12.2</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">12.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Have regular male partner</td></tr><tr><td align="left"> No</td><td align="center">13.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">11.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Have regular female partner</td></tr><tr><td align="left"> No</td><td align="center">15.6</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">8.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Has no regular partner</td></tr><tr><td align="left"> No</td><td align="center">10.9</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">16.7</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Has had vaginal sex</td></tr><tr><td align="left"> No</td><td align="center">11.9</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">12.9</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Sex work–ever</td></tr><tr><td align="left"> No</td><td align="center">10.7</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">15.2</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Ever paid for sex (MSW)</td></tr><tr><td align="left"> No</td><td align="center">12.2</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">14.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Ever paid for sex (FSW)</td></tr><tr><td align="left"> No</td><td align="center">12.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">7.8</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Could not use condom (6 months)</td></tr><tr><td align="left"> No</td><td align="center">12.1</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">17.6</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Partner decides on condom use</td></tr><tr><td align="left"> No</td><td align="center">12.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">15.6</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Ever used condom</td></tr><tr><td align="left"> No</td><td align="center">0.0</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">12.7</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Used condom at last sex</td></tr><tr><td align="left"> No</td><td align="center">0.0</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td align="left"> Yes</td><td align="center">12.8</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">/</td></tr><tr><td colspan="8" align="left">Alcohol frequency (last 1 month)<sup><xref ref-type="table-fn" rid="tf2">*</xref></sup></td></tr><tr><td align="left"> Never</td><td align="center">6.5</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">Ref</td><td align="center"><italic>—</italic></td><td align="center"><italic>—</italic></td></tr><tr><td align="left"> Ever</td><td align="center">15.8</td><td align="center">/</td><td align="center">/</td><td align="center">/</td><td align="center">2.61</td><td align="center">1.19–5.76</td><td align="center">0.02</td></tr></tbody></table><table-wrap-foot><fn id="tf2"><label><sup>*</sup></label><p>Statistical significance at <italic>P</italic> < 0.05 in Model 2.</p></fn><fn id="tf3"><label><sup>**</sup></label><p>Statistical significance at <italic>P</italic> < 0.01 in Model 2.</p></fn><fn id="tf4"><p>“/” are placeholders to signify exclusion from Models 1 and 2.</p></fn><fn id="tf5"><p>AOR, adjusted odds ratios; CI, confidence intervals.</p></fn></table-wrap-foot></table-wrap><sec id="s009"><title>Multivariable analysis</title><p><xref ref-type="table" rid="T2">Table 2</xref> presents the results from multivariable analyses, with Models 1 and 2 showing the results from the hierarchical stepwise procedure. Model 2 was the final model chosen. In <xref ref-type="table" rid="T2">Table 2</xref>, Model 1 represents the base model used in the stepwise procedure. After the first step in the procedure through which all five blocks were entered independently (from 5 to 1), only Block 5 (alcohol use, <italic>P</italic> = 0.046) remained significantly associated with HIV status at the <italic>P</italic> < 0.10 level. In the next step, alcohol use within the last month (<italic>P</italic> = 0.046) was retained (Model 2). In this final model, after adjusting for all other variables in the model, only recruitment from Bellary (adjusted odds ratios [AOR]: 4.5; 95% confidence intervals [CI]: 2.2–9.4; <italic>P</italic> < 0.001) and reporting having at least one alcoholic drink (AOR: 2.6; 95% CI: 1.2–5.8; <italic>P</italic> = 0.02), relative to reporting never having an alcoholic drink in the last month, were significantly associated with HIV infection.</p></sec></sec><sec sec-type="discussion" id="s010"><title>Discussion</title><p>Our results demonstrate that HIV infection continues to be a major issue among MTWSM in southern India, with an overall HIV prevalence of 12% in our sample. HIV prevalence reported in this study is slightly lower than the prevalence of 14% reported using data from Round 1 of the IBBA.<sup><xref rid="B10" ref-type="bibr">10</xref></sup> HIV prevalence in our study is similar to those found among MTWSM in North America (15.4%), Central/South America (14.9%), and other parts of South and Southeast Asia (14.7%), but lower than those reported from the Caribbean (25.4%) and sub-Saharan Africa (17.7%).<sup><xref rid="B45" ref-type="bibr">45</xref></sup> Among MTWSM in India, HIV prevalence in our sample is higher than prevalence reported in the states of Maharashtra (11%) and Tamil Nadu (8%),<sup><xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B20" ref-type="bibr">20</xref></sup> but lower than prevalence reported in Andhra Pradesh state (21%).<sup><xref rid="B11" ref-type="bibr">11</xref></sup> Compared to a recent study of MTWSM in 12 cities in India, the prevalence reported in our study was higher than the prevalence in 10 of 12 cities; only Hyderabad (12.7%) and Madurai (13.1%) reported higher HIV prevalence. In comparison to other priority populations in Karnataka state, studies have found HIV prevalences of ∼15% among FSWs, 5% among clients of FSWs,<sup><xref rid="B46" ref-type="bibr">46</xref></sup> and 0.8% in the general population.<sup><xref rid="B47" ref-type="bibr">47</xref></sup> Consistent with other studies from India, our study found that HIV prevalence was highest among MTWSM who self-identified as <italic>Kothi</italic> or <italic>Hijra</italic>.<sup><xref rid="B11" ref-type="bibr">11</xref></sup> Unlike other published studies,<sup><xref rid="B11" ref-type="bibr">11</xref></sup> those who identified as DD had the lowest HIV prevalence, at 10%. This may have been related to our inclusion of <italic>Panthis</italic> with the “Others” group, as <italic>Panthis</italic> were shown to have the lowest HIV prevalence in the study by Brahmam et al.<sup><xref rid="B11" ref-type="bibr">11</xref></sup> In addition, the fact that more than 50% of our sample was composed of DD may have contributed to lowering HIV prevalence in this group through regression to the mean.</p><p>The observation that HIV prevalence was highest in Bellary, at 26.3%, is consistent with Round 1 data from Karnataka state, with prevalence reported to be as high as 30% among MTWSM.<sup><xref rid="B48" ref-type="bibr">48</xref></sup> Using the same data, Alary et al. reported HIV prevalence to be 16% among FSWs from Bellary, which was midway between the range of 10%–34% reported from five districts in Karnataka.<sup><xref rid="B48" ref-type="bibr">48</xref></sup> Conversely, HIV prevalence among clients of FSWs was 6%, which was one of the higher prevalences reported from Karnataka state.<sup><xref rid="B48" ref-type="bibr">48</xref></sup> Bellary was identified as one of the high priority districts in Karnataka state by the United Nations Development Programme,<sup><xref rid="B48" ref-type="bibr">48</xref></sup> given its high HIV prevalence in the general population, incidence of poverty, and more challenging socioeconomic conditions, including a high degree of wealth inequality.<sup><xref rid="B1" ref-type="bibr">1</xref>,<xref rid="B48" ref-type="bibr">48</xref></sup> Moreover, and contributing to its vulnerability to HIV,<sup><xref rid="B49" ref-type="bibr">49</xref></sup> Bellary district is home to a large and prosperous mining industry and thus hosts a highly mobile migrant worker population.<sup><xref rid="B48" ref-type="bibr">48</xref></sup></p><p>The impact of alcohol use on decision-making and risky sexual practices has been acknowledged,<sup><xref rid="B50" ref-type="bibr">50</xref></sup> and further exploration of this issue among MTWSM in the Indian context has been argued for previously.<sup><xref rid="B39" ref-type="bibr">39</xref></sup> However, with few exceptions, the impact of alcohol use on HIV risk among Indian MTWSM has rarely been studied.<sup><xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B51" ref-type="bibr">51</xref></sup> One Chennai-based study found that, at the univariate level, heavier alcohol use was associated with marriage to women and having unprotected anal and vaginal sex.<sup><xref rid="B51" ref-type="bibr">51</xref></sup> These results highlight the role that subgroups of MTWSM may have in furthering HIV transmission to both the MTWSM and general populations. Mimiaga et al. observed that 28% of MTWSM reported using alcohol to the point of being intoxicated or buzzed weekly, and they recommend the provision of alcohol counseling as part of comprehensive prevention and intervention strategies for MTWSM.<sup><xref rid="B51" ref-type="bibr">51</xref></sup> Although our study did not include a formal measure of alcohol use or abuse (such as the CAGE measure),<sup><xref rid="B52" ref-type="bibr">52</xref></sup> our results do confirm the need to include measures that enable a higher resolution of alcohol use in future studies. As others have suggested, discerning the extent to which alcohol is being used as a coping strategy to deal with issues of stigma and trauma would also be an important step to inform interventions focused on developing stronger adaptive coping strategies.<sup><xref rid="B53" ref-type="bibr">53</xref></sup> Furthermore, on the treatment side, alcohol use has been associated with nonadherence to HIV medication,<sup><xref rid="B54" ref-type="bibr">54</xref>,<xref rid="B55" ref-type="bibr">55</xref></sup> potentially affecting both the transmission of HIV and the health and well-being of MTWSM and other persons living with HIV/AIDS.</p><p>Our study had a number of strengths, including the integration of biological information with behavioral data. In addition, the focus of the IBBA was on MTWSM who were thought to be at highest risk of HIV infection/transmission. Finally, extensive premapping exercises and rigorous sampling methodology across several districts provided a robust and representative sample of MTWSM, to the greatest extent possible. Our study also had a number of limitations. First and foremost, alcohol use was measured broadly; future studies should incorporate more specific (and validated) measures of both frequency and abuse of alcohol. Second, although MTWSM were sampled from four different districts, substantial differences in sociocultural and political environments exist across different states in India; thus, inferences from our sample to other states and populations should only be undertaken with caution. Third, IBBA sampling methodology primarily relied on sampling from cruising sites and, therefore, our findings may not be generalizable to those MTWSM who do not frequent cruising sites. This sampling strategy was used, however, on the rationale that MTWSM who frequent cruising sites are at the highest risk of contracting HIV. It should also be noted that participants did receive a small gift as compensation for participating; this, as well as the fact that participants who were willing to participate in the survey may not be representative of MTWSM in Karnataka, further limits the generalizability of our findings. Fourth, the sexual identity categories for MTWSM were necessarily simplified and broad. Fifth, the possibility of recall bias exists as all behavioral questions were self-reported. Finally, data were of a cross-sectional nature and, thus, causality cannot be inferred from our study. The lack of statistical associations observed may indicate that a larger sample size may be needed in future studies. There was a large discrepancy in HIV prevalence, by district; however, samples were not sufficiently powered to perform district-level analyses.</p></sec><sec sec-type="conclusion" id="s011"><title>Conclusion</title><p>In conclusion, using the latest available data on MTWSM from Karnataka state in India, we have found that HIV prevalence remains high and therefore remains a public health priority. Our results demonstrate an association between alcohol use and prevalent HIV infection, highlighting the need for further research to understand whether alcohol use may lead to further vulnerability.</p></sec></body><back><sec id="s012" sec-type="ack"><title>Acknowledgments</title><p>The authors thank the participants, program staff, and field team for their time and dedication to this study. This research was funded by the Bill & Melinda Gates Foundation. S.Y.S. is supported, in part, by doctoral awards from the Manitoba Health Research Council, David G. Fish Memorial Scholarship, the International Infectious Disease and Global Health Training Program, and the Canadian Institutes of Health Research.</p></sec><sec id="s013"><title>Disclaimer</title><p>The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation. 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