AN INTERVENTION FOR MALE STD PATIENTS IN INDIA

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India now has the greatest number of HIV infections of any country in the world, with heterosexual transmission responsible for 75% of its reported HIV cases. In Mumbai, formerly Bombay, the prevalence of HIV among sex workers (CSWs) is 60-80%. Interventions targeting CSWs have met with limited success given these women's lack of power to negotiate condom use; concomittantly, HIV infection among male sexually transmitted disease (STD) patients, a majority of whom are regular clients Of CSWs, has risen to 36%. Targeting male STD patients can be an effective HIV prevention strategy, as these men represent a critical link in the transmission Of HW to the general population. The high prevalence of STDs, particularly genital ulcers, as well as lack of adequate diagnosis and timely treatment, also contribute to increased HIV transmission in this group. We have conducted a pilot study among male STD patients in a public clinic in Mumbai that has provided baseline information on sexual risk behavior and the feasibility of performing a behavioral intervention. We base our current proposal on this extensive pilot data. The goals of this proposal are to perform a randomized, controlled trial of a behavioral intervention when added to standard care (STD treatment, with HIV testing and counseling) compared with standard care alone, among male STD patients in two public clinics in Mumbai. We will determine the impact of the intervention using biological outcome measures, specifically, HIV incidence over a one-year follow-up period. We will also measure the program's effect on self-reported risk behaviors, including condom use, visits to sex workers, number of sexual partners and health seeking behavior. We will determine the incidence and prevalence of bacterial and viral STDs using nucleic acid amplification techniques to identify the etiology of genital ulcer disease, urethritis, and asymptomatic infections. There have been no controlled trials of behavioral interventions in India targeting male clients of sex workers or STD patients. There is an urgent need to test strategies that are feasible, effective, sustainable and applicable to similar settings in India and elsewhere in Asia. This study will provide valuable information on the added efficacy of a behavioral approach to HIV control.