Indian Journal of Public Health

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 64  |  Issue : 5  |  Page : 8--14

HIV Risk profile and its socio-demographic correlates among long-distance truckers in West Bengal, India: Evidence from national HIV sentinel surveillance 2017


Subrata Biswas1, Debjit Chakraborty2, Piyali Ghosh3, Pradeep Kumar4, Rajatashuvra Adhikary5, Malay Kumar Saha6,  
1 Project Coordinator, ICMR - National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
2 Scientist D, ICMR - National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
3 Project Assistant, ICMR - National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India
4 Programme Officer, National AIDS Control Organization, New Delhi, India
5 National Professional Officer, World Health Organization, Country Office for India, New Delhi, India
6 Scientist F, ICMR - National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India

Correspondence Address:
Dr. Malay Kumar Saha
ICMR - National Institute of Cholera and Enteric Diseases, P-33, C I T Road, Scheme-XM, Beliaghata, Kolkata - 700 010, West Bengal
India

Abstract

Background: Long-distance truckers (LDTs) belong to a special sentinel group with potentially high risk of acquisition of HIV owing to their high mobility, sociodemographic vulnerability, and high-risk behaviors. Objective: The objective is to estimate the prevalence of HIV and identifies its sociodemographic correlates among a representative population of LDTs in West Bengal, India. Methods: Between May and July 2017, HIV Sentinel Surveillance (HSS) was conducted in West Bengal by the National AIDS Control Organization. A total of 749 LDTs were recruited for the study, were interviewed, and tested for HIV. Descriptive and logistic regression analysis of socio-demographics, sexual risk behavior, and HIV serostatus were performed using SAS 9.3.2. Results: The prevalence of HIV among LDT was 1.2% (95% confidence interval [CI] = 0.4–2.0). Mean age was 32.8 years (standard deviation 8.5), 77.1% were currently married, 89.9% were literate, 85.7% visited HSS site for collecting condoms or seeking medical care and treatment, 53.1% were rural residents, 86.7% had sex at least once with a female partner other than wife in the past 6 months, 2.7% had sex with a male partner and 1.7% injected drugs for recreational purpose. Higher age (odds ratio [OR] = 1.1 [95% CI = 1.0–1.1]), literate (OR = 0.3 [95% CI = 0.1–0.9]), visiting HSS sites for collecting condoms or seeking medical care and treatment (adjusted OR [AOR] = 0.2 [95% CI = 0.1–0.6]), rural residence (OR = 0.2 [95% CI = 0.1–0.3]) and duration of stay in home (AOR = 1.3 [95% CI = 1.1–1.5]) were found to be significant predictors of having sex with a female partner other than wife.Conclusion: High HIV burden calls for urgency in the implementation of targeted intervention to minimize HIV risk among LDTs in West Bengal to fight against HIV/AIDS.



How to cite this article:
Biswas S, Chakraborty D, Ghosh P, Kumar P, Adhikary R, Saha MK. HIV Risk profile and its socio-demographic correlates among long-distance truckers in West Bengal, India: Evidence from national HIV sentinel surveillance 2017.Indian J Public Health 2020;64:8-14


How to cite this URL:
Biswas S, Chakraborty D, Ghosh P, Kumar P, Adhikary R, Saha MK. HIV Risk profile and its socio-demographic correlates among long-distance truckers in West Bengal, India: Evidence from national HIV sentinel surveillance 2017. Indian J Public Health [serial online] 2020 [cited 2020 May 26 ];64:8-14
Available from: http://www.ijph.in/text.asp?2020/64/5/8/282423


Full Text



 Introduction



India ranked third in the global list of estimated number of people living with HIV (estimated nationwide adult HIV prevalence was 0.22%, and PLWH were about 21.4 lakhs at the end of 2017).[1],[2] Despite of significant strides toward controlling HIV in India (overall declining of prevalence among antenatal care attendees, female sex workers [FSWs], and men who have sex with men [MSM]) by the National AIDS Control Organization (NACO) over the past few years, emerging newer pockets of HIV infection have been reported among bridge populations (transmitting infection from core high-risk groups, namely, FSWs, MSM, injecting drug users [IDUs] to general population) namely migrants and long-distance truckers (LDTs), possibly driving the current HIV epidemic in this country.[1],[3],[4] Given the dynamics of HIV transmission from high-risk networks into low-risk population, prevention of new infections among these vulnerable groups through targeted behavior-changed interventions became a priority of HIV Sentinel Surveillance (HSS) under the National AIDS Control Programme (NACP)-III (2006) and intensified in NACP-IV (2014).[5],[6] Despite national commitments and sincere public health efforts, Indian truck-drivers are at persistent risk for HIV (estimated prevalence = 2.59% in 2010–2011) and play an important role in the geographic spread of the disease.[1],[7]

The road goods transport industry has emerged as a dominant mode of trade in India over the past few decades.[8],[9] India holds the distinction of world's largest road network stretching over 3.3 million km, and 65%–70% of nation's goods are transported through road. According to the Asian Institute of Transport Development estimates, there are about 5–6 million truckers (including helpers), and 40%–60% of them operate on long routes. On average, LDTs travel approximately 800 km or more in one direction and about 67% of their time are spent on road.[10],[11]

The role of LDTs in HIV epidemic in this country is manifold. Empirical evidence from previous behavioral surveillance surveys revealed that compared to men in the general population, truckers were thrice likely to have nonregular sexual partner, about one-third were engaged in commercial sex and accounting for 10%–12% of clients of sex workers.[12] The integrated biological and behavioral assessment survey among high-risk groups in 2007 indicated that about 1%–7% truckers suffered from at least one sexually transmitted infection during any given point of time.[13] Moreover, because of extreme mobility, poverty, illiteracy, harsh working conditions, relatively young age, staying away from families for long durations, easy access to highly active sexual networks along the highways and major halt points (unsafe sex with multiple partners namely FSW, migratory female road workers who sell sex at cheaper rate, MSM), low-self-perceived risk, limited access to sexual health services, nonavailability of bare minimum basic HIV prevention services on high ways, concomitant untreated sexually transmitted co-infections, they became potential carriers of HIV infection in India.[10] In addition, the unorganized traditional framework of trucking industry, loose operating system among truck operators, intermediaries and users, private ownerships and predominance of middlemen and small operators and lack of well-defined infra-structure are some of the potential operational barriers for intervention design by transport planners and health policy-makers that further worsen the scenario.[8],[9]

Given the high-risk sexual behaviors and dominant vector of HIV,[1] there has been little effort toward the identification of high-risk social networks of truckers and their potential role in HIV transmission. Most of the previous studies among truck drivers were conducted in the southern, northern, and western parts of the country, and sample sizes were relatively smaller.[14],[15] Paucity of information regarding determinants of HIV among LDTs in the eastern region, therefore, called for a detailed investigation. The objectives of the current study were to estimate the prevalence of HIV infection and identify its socio-demographic correlates among a representative population of LDTs in West Bengal, India.

 Materials and Methods



Study subjects and selection

National HSS 2017 by NACO was also undertaken for LDTs in three designated surveillance sites under in each of the three districts (Howrah, Jalpaiguri, East Medinipur) of West Bengal. Standard national technical guidelines were followed by all implementing sites. The selection of surveillance sites was based on epidemiologic need and availability of adequate numbers of the specific target population subgroups.[16],[17] Aged between 15 and 49 years, truckers traveled more than 800 km one way between source and destination, agreed to participate, and visited designated HSS sites in West Bengal during the said period were found eligible for the study. After obtaining written informed consent as per the operational guideline of NACO, the consecutive sampling strategy was used to recruit the participant during May–July, 2017.[16],[17]

Data collection

The recruitment process at each HSS site continued until the target of 250 LDTs was achieved or 3 months' period was over. Altogether 749 eligible LDTs who attended the HSS sites in West Bengal during the study were recruited and interviewed. Information was collected anonymously on sociodemographic characteristics namely age, marital status, education, reasons for coming to the service point, current place of residence (rural/urban), average days spent with families in a month and high-risk behaviors namely sex with a female partner (other than wife) or a male partner in the past 6 months and history of injecting drugs in the last 12 months from each subject using a pretested interviewer's administered questionnaire without any personal identifiers. For ensuring quality, database was checked at every step of data collection process as per the NACO protocol.

HIV testing

Based on the principles of NACO, unlinked anonymous HIV testing was performed using dried blood samples (through finger prick).[18] Each sample was labeled with unique codes for maintaining the anonymity. No personal information was recorded. Blood samples were initially screened for HIV using a sensitive enzyme-linked immunosorbent assay (ELISA). Samples detected positive were retested using another specific ELISA. As per the NACO guideline of two-test strategy, samples reactive for both the testing were considered as HIV seropositive. All HIV-positive sample and 2% of HIV-negative samples were sent to HIV Apex laboratory for ensuring quality.

Ethics statement

All procedures of HSS were conducted following the unlinked anonymous testing strategy approved by Ethics Committee of NACO, New Delhi, India. The study involving human participants was following the Helsinki Declaration. Prior to interview and blood collection, written informed consent/assent were obtained. Subjects were also ensured about the confidentiality of the collected information. The Institutional Ethics Committee, ICMR-National Institute of Cholera and Enteric Diseases also approved the study.

Data analysis

For ensuring data quality, multiple logic checks were done. All data analyses were done using SAS version 9.3.2 (SAS software, SAS Institute Inc., Cary, NC, USA). Descriptive analyses were conducted to determine the distributions of HIV serostatus, various sociodemographic characteristics, and high-risk behaviors (overall as well as HIV seropositive). Bivariate (unadjusted) and multivariable (adjusted for potential confounders) logistic regression analyses were performed to find the associations of various sociodemographic exposures keeping sexual experience with a female (other than wife) in the past 6 months (both paid and nonpaid) and injecting drug use in the past 6 months as dependent variables. These outcome variables were identified as a surrogate of HIV-risk since the occupation of LDT does not per SE exposes to HIV risk unless he is exposed to any of the above risk behavior. The strength and direction of associations were expressed in odds ratio (OR) and 95% confidence interval (CI) for both the regression models.

 Results



Of total 749 participating LDTs, overall HIV seropositivity was 1.2% (95% CI = 0.4–2.0). Mean age was 32.8 years (standard deviation 8.5), on average, subjects stayed 3.8 days/months at home, 77.1% were currently married, 89.9% were literate, 85.7% visited HSS site for collecting condoms or seeking medical care and treatment, 53.1% were rural residents, 86.7% had sex at least once with a female partner other than wife in the last 6 months, 2.7% had sex with a male partner and 1.7% injected drugs for recreational purpose [Table 1].{Table 1}

Higher age (OR = 1.1 [95% CI = 1.0–1.1]), literate (OR = 0.3 [95% CI = 0.1–0.9]), visiting HSS sites for collecting condoms or seeking medical care and treatment (adjusted OR [AOR] =0.2 [95% CI = 0.1–0.6]), rural residence (OR = 0.2 [95% CI = 0.1–0.3]), and duration of stay in home (AOR = 1.3 [95% CI = 1.1–1.5]) were found to be significant predictors of having sex with a female partner (other than wife) in the regression analyses. These five independent variables contributed to around 33.5% variability of the outcome variable [Table 2].{Table 2}

Higher age (OR = 1.1 [95% CI = 1.0–1.1]) and those who stayed longer at home (AOR = 1.1, 95% CI = 1.1–1.5) were more likely to have paid sex with a casual female sex partner in the last 6 months. Those who were unmarried/widower/separated (OR = 0.5, 95% CI = 0.3–0.8) as against currently married, who were literate (OR = 0.3, 95% CI = 0.1–0.8) against illiterate, and rural population (OR = 0.1, 95% CI = 0.1–0.2) were less likely to have paid sex with a casual female sex partner in the last 6 months. Unmarried/widower/separated (reference = currently married; OR = 2.6 [95% CI = 1.5–4.6] and AOR = 2.8 [1.2–6.4]) and those who stayed longer at home (AOR = 1.4, 95% CI = 1.2–1.6) were more likely to have unpaid sex with a casual female sex partner in the past 6 months. Variability of paid and unpaid sex as explained by these exposure variables were, respectively, 39.8% and 45% [Table 2].

None of the sociodemographic factors were associated with having sex with a male partner in the last 6 months. Visiting HSS sites for collecting condoms or seeking medical care and treatment (OR = 0.2 [95% CI = 0.1–0.8]) as against recreational and other nonspecific purposes were less likely associated with the risk of injecting drug use. On univariate analysis, a significant risk of Injecting Drug use was observed among rural LDT as compared to urban; however, this association did not stand significant on multivariable analysis [Table 3].{Table 3}

 Discussion



HIV seropositivity was 1.2% among 749 participating LDTs attending designated HSS sites in the state of West Bengal during 2017. The observed HIV seropositivity status was higher than 2017 national estimate (0.86%),[1] truckers in Hyderabad (2.1%),[14] Siliguri-Guwahati (2.3%),[19] Andhra Pradesh (2.1%),[20] and China (3.33%)[21] but lower than previous estimates reported in national level trucker survey (4.6%) in 2007, similar studies in South India (15.9%), Nigeria (10%).[22] The risk of HIV infection was observed to be highest on the southeast route connecting Kolkata-Bengaluru and lowest on the north-south route connecting Delhi-Ghaziabad-Bengaluru. This marked variation in the proportion of HIV cases among LDTs across the country might be partially explained by a complex interplay between differential behavioral risk among truckers, diverse population characteristics, and spatial attributes of trucking context and sociostructural influences. HIV being a social disease, the risk of HIV in these bridge populations should be conceptualized more contextually as interplay of socioenvironment and robust sexual culture rather than individual behavior as outlined by Marck.[23]

We found that about 86.7% of subjects reported having sex with a female other than wife in the last 6 months. However, lower figures were reported from studies of truck drivers in Siliguri-Guwahati (67% visited commercial sex workers),[19] Pune (57%),[24] Punjab-Uttar Pradesh-Bihar-West Bengal (58.6%),[25] Mumbai (66%),[26] Bangladesh (54%),[27] and New Mexico (21%).[28] Findings from these studies clearly specified that sexual opportunities and HIV risk were raised for long-haul truckers in the absence of a regular home life. Although prior studies indicated that a large proportion of truckers were clients of FSWs and attributed significantly toward HIV transmission, but researchers in recent year argued that truckers were over-stigmatized as HIV carriers in the country.[28]

About 70% of participants reported to have paid sex with female casual partner in the past 6 months in our study which was higher than that reported in Andhra Pradesh (34% had contact with FSWs).[20] Contrary to prior studies, unmarried/widowed/separated were less likely to have paid sex with female partner in our study. Participants with education were less likely to have paid sex compared to their illiterate counterparts. It seemed that paying for sex is considered normal within the context of their job by most of the truckers. However, raising awareness through peer-led interpersonal communication and innovative education programs among truckers (particularly targeting single and illiterate group) at major catchment areas where they congregate and providing them necessary information about service points even before the start of the job might be effective in optimum utilization of available services with resultant control of the HIV epidemic. It is also necessary to make them realize (especially naïve truckers) the probability of getting an HIV-positive sex worker (depending on HIV prevalence of the state they pass through), the huge expense associated with such activities, and risk of unnecessary paid sex.

Same-sex behavior among truckers is perhaps the most alarming among all other infection risk. About 3% reported having sex with a male partner in the last 6 months in our study which was lower than reported among truckers in north India (10%)[15] and Bangladesh (7.2%).[27] The current analysis demonstrated that none of the sociodemographic factors were associated with having sex with a male partner in the past 6 months. However, Apostolopoulos et al., in his study, on cruising for truckers on highways emphasized the potential role of an elusive and yet extensive sexual network on highways having concurrent MSM sex partnerships in shaping sexual health of truckers and subsequent HIV risk.[29] In addition, because of power dynamics within the Indian trucking industry, misconception about anal sex (safer than vaginal sex), and nonavailability of women, senior truckers often sexually exploit largely ignorant, powerless, and poor helper/cleaner or even young truckers.[7],[10] Therefore, large-scale prevention program providing risk-reduction information within homosexual context targeting both truckers and helpers are urgently needed.

About 1.7% of study participants reported injecting drugs in the last 12 months which was lower among North Indian truckers (6%)[15] in New Mexico (14%)[28] but higher than a similar study in Bangladesh (1%).[27] Although the prevalence of IDU among truckers seemed low, further research is needed to explore whether it was a reality or due to under-reporting.

The present sample comprised of LDTs who volunteered to participate and so might not be representative of all LDTs in the eastern region of India. Therefore, results could not be generalizable, and inference should be drawn within the context of the study sample. The study design being cross-sectional, chances of temporal ambiguity could not be rule out, limiting causal interpretation. Chances of selection bias might be there if their risky behaviors and HIV serostatus influenced participation, but we think the probability of such bias would be minimal because of consecutive sampling. Moreover, as information related to risky behaviors was all self-reported, the possibility of under or over-reporting of risky behaviors might lead to social desirability bias that we tried to minimize by assuring confidentiality and anonymity of data to the participants. Despite these limitations and dearth of information on sociobehavioral determinants of HIV among LDTs in eastern region, by virtue of large sample size, cost-effective efficient methodology, and advanced statistical analyses, we believe findings from this study would provide important insights into transmission dynamics of HIV among this heterogeneous population of truckers.

 Conclusion



It seemed that the burden of HIV was higher among LDTs in West Bengal. The risk of HIV was higher among truckers with relatively lower education and those staying away from home for a long duration. Thus, urgent changes in the targeted interventions program to minimize HIV risk among LDTs seemed to be the need of the hour.

Acknowledgments

The authors would like to acknowledge National AIDS Control Organization, New Delhi, and West Bengal State AIDS Prevention and Control Society for supporting the study. The author(s) received funding from NACO for conducting the HSS, authorship, and publication of this article.

Financial support and sponsorship

National AIDS Control Organization, New Delhi.

Conflicts of interest

There are no conflicts of interest.

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