Increases in Self-Reported Consistent Condom Use among Male Clients of Female Sex Workers following Exposure to an Integrated Behaviour Change Programme in Four States in Southern India

Published in Sexually Transmitted Infections (86(S1): i25-32), this paper explores one of the components of the Avahan India AIDS Initiative, a behaviour change communication (BCC) programme that sought to increase consistent condom use (CCU) among male clients of female sex workers (FSWs) in 4 Indian states. This paper presents key findings related to programme coverage levels, trends over time in self-reported condom use, and correlations between levels of exposure to programme activities and self-reported condom use.

In brief, conducted from November 2004 through September 2008 by Population Services International (PSI) with funding from the Bill and Melinda Gates Foundation, PSI/Avahan involved activities conducted in 100 hotspots (venues where FSWs are solicited) in the 4 southern states of Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu. These activities were designed to reach male clients of FSWs and included:

1. use of outdoor static promotional materials, such as posters;
2. interpersonal communication (IPC), such as small group and one-on-one discussions, and;
3. mid-media activities, such as street theatre and interactive game shows.

As part of the evaluation, 5 stratified 2-stage cluster sample surveys were conducted between April 2006 and November 2008 (sample sizes ranged from 1,741 to 2,041). The independent samples were composed of clients of FSWs in selected clusters. The following exposure categories were used: none/outdoor static; IPC or mid-media in addition to outdoor static; and IPC and mid-media in addition to outdoor static. Multivariate logistic regression was used to model whether behavioural outcomes varied between baseline and endline and whether they varied with levels of exposure to the intervention. The main outcome of interest was CCU, which was a composite measure including only those respondents who (a) reported having used a condom at last sex with an FSW, (b) reported always using condoms with such partners in the past 12 months, and (c) confirmed that there were no exceptions to having always used a condom with an FSW in the last 12 months.

The results found that PSI/Avahan was estimated to have reached approximately 700,000 men monthly, and over two-thirds of men in each survey round recalled one or two of the main intervention channels. An increase in CCU with FSWs was found between baseline and endline (63.6% vs. 86.5; p<0.01). At endline, men who had been exposed to both IPC and mid-media reported significantly higher condom use at last sex (96.2% vs. 92.6% for those exposed to none/outdoor static); moreover, consistent condom use was significantly higher among men exposed to both IPC and mid-media as compared to those in the none/outdoor static category (89.4% vs. 82.0%, p<0.05).

The evaluation suggests that a multi-channel behavioural intervention delivered at sites where FSWs are solicited can increase CCU among male clients of FSWs. "Further research is warranted to explore the dynamics of exposure to multiple behaviour change communication channels, as well as the contributions of various complementary interventions in the overall goal of increasing condom use among FSW and their clients."