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      Two cross-sectional studies in south India assessing the effect of an HIV prevention programme for female sex workers on reducing syphilis among their clients

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          Abstract

          Objective

          To assess the impact of the Avahan HIV prevention programme for female sex workers (FSWs) in south India on reducing syphilis prevalence among their clients, by comparing rates of syphilis over time as reported in two large-scale surveys of FSWs’ clients.

          Methods

          A random-effect multilevel logistic regression analysis was performed using syphilis as the dependent variable, with individual independent variables (from the two survey rounds) at level 1 and the district-level programme (from the Avahan computerised monitoring and information system) and contextual variables (from Indian government datasets) at level 2. Programme variables included their 2006 value and their difference in value between 2008 and 2006, as well as the interaction between the latter and the study round. The analysis also controlled for baseline syphilis prevalence and its interaction with the study round.

          Results

          Syphilis decreased significantly among FSWs’ clients, from 4.8% (round 1) to 2.6% (round 2), p<0.001. The OR of the interaction term between the difference in programme coverage of FSWs and the round was 0.98 (p=0.023), suggesting that increased coverage was associated with a reduced incidence of syphilis.

          Conclusions

          This study suggests that the Avahan intervention programme among FSWs reduced syphilis rates among their clients.

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          Syphilis and HIV: a dangerous combination.

          J. Lynn, S. L. Lightman (2004)
          HIV and syphilis affect similar patient groups and co-infection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.
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            Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections.

            Kate Buchacz, Pragna Patel, Melanie Taylor … (2004)
            Syphilitic ulcers are known to facilitate the transmission of HIV infection, but the effect of syphilis infection on HIV viral loads and CD4 cell counts is poorly understood. We abstracted medical records for HIV-infected male syphilis patients seen at three clinics in San Francisco and Los Angeles from January 2001 to April 2003. We compared plasma HIV-RNA levels and CD4 cell counts during syphilis infection with those before syphilis infection and after syphilis treatment, using the Wilcoxon signed rank test. Fifty-two HIV-infected men with primary or secondary syphilis had HIV viral load and CD4 cell count data available for analysis; 30 (58%) were receiving antiretroviral therapy. Viral loads were higher during syphilis compared with pre-syphilis levels by a mean of 0.22 RNA log10 copies/ml (P = 0.02) and were lower by a mean of -0.10 RNA log10 copies/ml (P = 0.52) after syphilis treatment. CD4 cell counts were lower during syphilis infection than before by a mean of -62 cells/mm3 (P = 0.04), and were higher by a mean of 33 cells/mm3 (P = 0.23) after syphilis treatment. Increases in the HIV viral load and reductions in the CD4 cell count were most substantial in men with secondary syphilis and those not receiving antiretroviral therapy. Syphilis infection was associated with significant increases in the HIV viral load and significant decreases in the CD4 cell count. The findings underscore the importance of preventing and promptly treating syphilis in HIV-infected individuals.
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              Evaluation design for large-scale HIV prevention programmes: the case of Avahan, the India AIDS initiative.

              Stephen Mills, Marie-Claude Boily, Michel Alary … (2008)
              Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes. This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning. The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework. Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities. Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Sex Transm Infect
                Journal ID (iso-abbrev): Sex Transm Infect
                Journal ID (hwp): sextrans
                Journal ID (publisher-id): sti
                Title: Sexually Transmitted Infections
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Print): 1368-4973
                ISSN (Electronic): 1472-3263
                Publication date (Print): November 2014
                Publication date (Electronic): 8 May 2014
                Volume: 90
                Issue: 7
                Pages: 556-562
                Affiliations
                [1 ]CHARME-India II Project , Bangalore, Karnataka, India
                [2 ]Karnataka Health Promotion Trust , Bangalore, Karnataka, India
                [3 ]Department of Epidemiology, National Institute of Mental Health and Neurosciences , Bangalore, Karnataka, India
                [4 ]St. John's Research Institute , Bangalore, Karnataka, India
                [5 ]National AIDS Research Institute , Pune, India
                [6 ]FHI 360 , Washington, DC, USA
                [7 ]URESP, Centre de recherche du CHU de Québec , Québec, Canada
                [8 ]Département de mathématiques et statistique, Université Laval , Québec, Canada
                [9 ]Department of Community Health Sciences, University of Manitoba , Winnipeg, Canada
                [10 ]Département de médecine sociale et préventive, Université Laval , Québec, Canada
                Author notes
                [Correspondence to ] Dr Subramanian Potty Rajaram, Karnataka Health Promotion Trust (KHPT), IT Park, Rajajinagar Industrial Area, Behind KSSIDC Admin Office, Rajajinagar, Bangalore 560044, Karnataka, India; rajaram@ 123456khpt.org
                Article
                Publisher ID: sextrans-2013-051301
                DOI: 10.1136/sextrans-2013-051301
                PMC ID: 4215352
                PubMed ID: 24812406
                SO-VID: dcba43fa-a9ba-4d22-a612-77d0bc4b0199
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

                History
                Date received : 25 July 2013
                Date revision received : 20 March 2014
                Date accepted : 4 April 2014
                Categories
                Subject: 1506
                Subject: Epidemiology
                Series title: Original article
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                ScienceOpen disciplines: Sexual medicine
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                ScienceOpen disciplines: Sexual medicine

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