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    • you can look here Seven of the remaining districts had stron

    2019-04-28

    Seven of the remaining 22 districts had strong evidence (Bayes factor >5) and six had moderate evidence (Bayes factor >2 to 5) that consistent condom use by female sex workers increased during Avahan. Nine districts had weak evidence (Bayes factor ≤2). In districts with weak evidence, the overall difference in consistent condom use between the intervention and control condom hypotheses in 2010 was generally smaller (16%) than for districts with moderate or strong evidence (57%; p=0·01 [Mann-Whitney test of the medians]; figure 2). This result was partly caused by the estimated baseline consistent condom use being higher (48%) in the districts with weak evidence than in the districts with moderate to strong evidence (12%). In four of the five modelled districts in which Avahan was the first intervention targeted at female sex workers, there was moderate or strong evidence for the intervention condom hypothesis; the exception was Yevatmal, where there was weak evidence, probably because its small IBBA sample size of female sex workers resulted in less informative estimates of condom use and HIV prevalence. Figure 1 also shows the overall district-specific median proportions and numbers of infections averted in all you can look here groups (including the general population) over the first 4 years of Avahan. New HIV infections decreased substantially in most IBBA districts, with 42% (95% CrI 33–51) of infections averted across the modelled districts. Generally, a larger proportion of infections was averted in districts with moderate to strong evidence than in those with weak evidence (median 51% vs 30%). Intervention effectiveness varied across states, largely because of differences in baseline consistent condom use, with 67% of infections averted in Tamil Nadu, 49% in Andhra Pradesh, 36% in Karnataka, and 12% in Maharashtra. Over 10 years, effectiveness increased in all districts, with 57% (46–68%) of HIV infections averted across the modelled districts. The district-specific estimates of effectiveness (figure 1) include infections averted in all population subgroups over the first 4 years, even for districts without surveys of men who have sex with men and the general population, and the state-level and overall proportion of infections averted across all modelled districts. Table 2 shows the overall infections averted over 4 and 10 years, by increasing degree of uncertainty. In 18 IBBA districts, the modelled HIV prevalence among female sex workers fell during the first 4 years under the intervention condom hypothesis by 11% to 52% dependent on the district, whereas it increased in four districts. Over 10 years, the projected median HIV prevalence fell in all districts to less than 14% among female sex workers, with only six districts having a median prevalence higher than 5% in this subpopulation (district-level prevalence-trend graphs are provided in the appendix). By comparison, under the control condom hypothesis HIV prevalence among female sex workers remained high, with seven districts having a prevalence higher than 20% after 10 years. Figure 2 shows the mean prevalence trends weighted by the size of the female sex worker population, grouped by strength of evidence. After the first 4 years, the HIV incidence ratio between the intervention and matched counterfactual varied by between 0·08 and 0·92 (median 0·30) across modelled districts. For the intervention condom hypothesis, incidence in low-risk women fell during the first 4 years in 19 districts, and after 10 years it had fallen by at least 70% in all districts, with larger reductions in incidence among female sex workers (appendix). When only the subset of variables available across all Avahan districts was used, 62% of the variability in the number of HIV infections averted over the first 4 years across IBBA districts, as measured by the R2 value of the linear regression model, was accounted for by: the number of female sex workers in a district (positively associated, accounted for 24% of the variability); whether Avahan was the main intervention provider for female sex workers in the first year in that district (positively associated, 26%); and being a district in Maharashtra state (negatively associated, 12%). When this regression model, described in the appendix, was used to extrapolate effectiveness estimates to all non-IBBA districts, the overall effectiveness of Avahan for all 69 districts was estimated to be 202 000 HIV infections averted over the first 4 years (table 2), with 37% of infections averted in Andhra Pradesh, 30% in Karnataka, 8% in Maharashtra, and 25% in Tamil Nadu. Over 10 years, the number of infections averted increased to 606 000 across all districts. The two regression models for effectiveness over 4 and 10 years had the same independent variables, although they were built independently. Figure 3 shows how the number of infections averted varied geographically across all Avahan districts.