Current prevention programmes fail to address this issue. The manual labourers in the current study include agricultural and non-agricultural labourers and cultivators. Although studies from the early s have highlighted anal intercourse as a risk factor for HIV, 9 , 36 most AIDS prevention messages targeting heterosexuals continue to focus only on vaginal and oral sex transmission. Acknowledgments The authors wish to thank the Avahan state implementation partners for their partnership in this study. Inconsistent condom use during vaginal intercourse with FSWs was found to be significantly associated with older clients. When compared with the prevalence reported by FSWs in these studies, the prevalence reported by clients in the current analysis is comparable and an almost similar prevalence was reported by FSWs in round one of IBBA. For one, anal intercourse and condom use are both self-reported measures and may, therefore, be influenced by the social desirability bias. Such an association could be attributed to the fact that knowledge and perceptions about safe or risky sex may not be sufficient to change an individual's behaviour until self-efficacy and determination in executing a behaviour or action are present.
It appears that the survey has been able to capture high-risk clients who have a higher volume of sex acts with FSWs, engage in anal intercourse and do not use condoms. A possible explanation for this risky behaviour among older men could be the need to fulfil sexual desires or experimentation, followed by the belief that paying for sex would be less troublesome and more entertaining than sexual involvement with a non-sex worker. The manual labourers in the current study include agricultural and non-agricultural labourers and cultivators. Given the multidirectional risk, condom promotion programmes must be extended to include specific information on the benefits of consistent condom use while engaging in anal and other types of sex. As indicated by previous research, the social desirability bias gives rise to the possibility of under-reporting. Alcohol use and its association with HIV-related sexual risk is well documented. Future studies are needed to address these gaps. Given the difficulty in evaluating the magnitude of under-reporting, we must be cautious in concluding that anal intercourse is practiced at relatively low rates among this population. Cultural taboos have possibly played a major role against acknowledging anal sexual practice. Conclusions The study indicates that HIV prevention programmes targeting FSWs and their clients must highlight the increased risk unprotected anal intercourse poses for self as well as partners. Interventions also need to address factors that influence condom negotiation ability of sex workers. Older men who have sex with men have also been found to practice risky sexual behaviour such as inconsistent condom use. Finally, the authors thank the respondents for their participation in the study. Current prevention programmes fail to address this issue. In spite of these limitations, this is one of the first studies to document for the clients of FSWs the practice of anal intercourse and the correlates of condom use during anal intercourse. The finding that older clients are at a higher risk of inconsistent condom use has been reported previously. Clients who were 26 years or older, frequently used alcohol, worked as manual labourers and reported a higher number of sex acts with FSWs were at an increased risk of unprotected anal intercourse. When compared with the prevalence reported by FSWs in these studies, the prevalence reported by clients in the current analysis is comparable and an almost similar prevalence was reported by FSWs in round one of IBBA. For one, anal intercourse and condom use are both self-reported measures and may, therefore, be influenced by the social desirability bias. Research on vulnerable populations, including FSWs and youth, indicates that those particularly at risk of being infected by or transmitting HIV are more likely to practice anal intercourse. These men could be captured through networks of labour contractors and migrant populations. Acknowledgments The authors wish to thank the Avahan state implementation partners for their partnership in this study. In addition, the gendered power dynamics and the lack of choice sex workers have with heterosexual anal intercourse exacerbates their vulnerability. Independent factors associated with inconsistent condom use during anal intercourse with FSWs in multivariate analysis Discussion IBBA, one of the few surveys in India to study large samples of clients of FSWs, has documented the practise of unprotected anal intercourse in three high HIV prevalence states of the country. Inconsistent condom use during vaginal intercourse with FSWs was found to be significantly associated with older clients. Men who consume alcohol have been found more likely to engage in unprotected sex and anal sex and have more than 10 FSW partners. In addition, qualitative studies are needed to better understand the context in which anal intercourse occurs.
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