Background: A systematic review portraying the changing pattern of sexual behaviors, STI and HIV prevalence and key strategies curb HIV and STI among truckers in India is lacking. This paper therefore aims to present a chronological review of literature regarding sexual behaviors, STI/HIV prevalence, and various HIV prevention programs implemented among truckers in India. Methodology: Published and unpublished studies (1990-2011) were identified through electronic databases, and hand searching. Results: Most studies on sexual behaviors and STI/HIV prevalence among truckers focused only on drivers and ignored their helpers. Evidences suggest that consistent condom use by truckers with both paid and non-paid female partners has increased during the past decade. Many recent studies suggest that the HIV prevalence among truckers is about 2% and it has been declining slowly during the past decade. The HIV prevention programs among truckers which started with the aim of raising awareness about HIV during early 1990s, have grown multi-folds to encompass not only the standard strategies like mid-media events, interpersonal counselling and STI care for HIV prevention, but also innovations such as the use of business franchisee models, and integrated research and evidence based planning in the program. The possibilities of using new approaches such as male circumcision and the use of pre-exposure prophylaxes are underway. Conclusion: More studies are needed to explore helpers’ vulnerabilities to HIV. Very few studies have attempted to examine the impact of large-scale prevention programs among truckers. Efforts are required to examine the impact of different components of such programs to guide the HIV prevention efforts among truckers in India.
Truck drivers and their helpers (hereafter referred to as truckers) are considered to be at high risk of acquiring human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) in many parts of the world [
India is estimated to have about two to two and half million long-distance truckers [
Even though several studies have attempted to describe sexual behaviors and its determinants among truckers in the country, a systematic review portraying the changing pattern of sexual behaviors, STI and HIV prevalence and key strategies to curb HIV and STI among truckers in India is lacking. Such information, if available, is critical for understanding the complex dimensions of sexual behaviors of truckers and also in drawing inputs for initiating and scaling up the HIV prevention strategies among mobile-populations like truckers in India and beyond. Hence, this paper aims to present a chronological review of literature regarding sexual behaviors, STI/ HIV prevalence, and various HIV prevention programs implemented among truckers in India. It also identifies and highlights research gaps and their program implications.
Peer-reviewed articles and reports were identified through a systematic search of online databases including PubMed, Web of Sciences, CrossRef, HIV and AIDS data hub, HIV/AIDS surveillance database of U.S. Census Bureau, Cochrane Review Group on HIV/AIDS, The AIDS Education Global Information System (AGEiS), and Google Scholar. Bibliographies of identified articles were hand searched. Documents and reports available on the websites of National AIDS Control Organization, and other research and program implementation organizations working in the field of HIV prevention in India were researched. We also searched for the abstracts presented in the national and international conferences wherever they were available online. A time-frame of 1990- 2011 was used for the search to better describe the changing pattern of sexual behaviors, STI/HIV and strategies of HIV prevention programs among truckers in India. The articles, reports, presentations, and abstracts with the key words such as “sexual behavior”, “prevalence of HIV/STI”, “HIV intervention programs”, or “HIV prevention”, among truckers in India were included in the review.
A total of 50 relevant literatures about sexual behaviors and STI/HIV prevalence were found (peer reviewed papers: 28; reports: 08; and abstracts presented in conferences: 14). Of these, 38 had information only on sexual behaviors while 12 had information on both sexual behaviors and STI/HIV prevalence. A total of 28 studies were found which described interventions among truckers in India (peer reviewed papers: 8; reports: 10; abstracts presented in conferences: 10).
. An overview of selected studies on sexual behavior and prevalence of STI and HIV among truckers in India, 1990- 2011.
Participants | Study year/ period | Study design and methods | Relevant findings in context of sexual behavior | Relevant findings in context of STI/HIV prevalence | Reference |
---|---|---|---|---|---|
Truck drivers | 1992 | Behavioral survey of 200 truck drivers in Delhi; A total of 302 truck drivers were tested for HIV. | About 78% of the respondents reported ever having sex with non-regular female partners (defined as any female other than wife or steady sexual partner of the respondent). The life-time exposure to FSWs was reported as 62%. 5% reported ever having sex with men/transgender | HIV: 1.0% | [27] |
Truck drivers and helpers | 1992 | Behavioral survey of 210 drivers and 210 helpers at major transshipment location in Indore, Madhya Pradesh. | About 63% of the truckers (drivers: 83% of the helpers: 44%) reported ever having sex with FSWs and females other than their wives. Consistent condom use in such relationships was 1%. | Not available. | [23] |
Truck drivers | 1992 | Behavioral survey of 506 truck drivers recruited at a check post in Beltola-Basistha area of Assam. | 82% of the respondents reported ever having sex with FSWs. None of the respondents admitted using condom consistently with FSWs. About 15% reported ever having sex with men/ transgender. | Not available. | [25] |
Truck drivers | 1994 | Behavioral survey of 5709 consecutive truck drivers who consented to take part in the study while passing through a check post at the Andhra Pradesh-Orissa border in the Srikakulam, Andhra Pradesh. | 87% of the participants reported ever having sex with non-regular female partners (defined as any female other than wife or steady sexual partner of the respondent). Information on type of partners was not available. Condom use with non-regular female sexual partners was about 11%. | Not available. | [24] |
Truck drivers | 1998 | Behavioral survey of 153 truck drivers recruited from (road side hotels) along different highways in Rajasthan. | 80% of truck drivers reported ever having sex with FSWs. Consistent condom use with FSWs was about 14%. | Not available. | [28] |
Truck drivers | 1998 | Behavioral interview of 300 drivers recruited from variety of locations including brokers’ offices, workshops, and loading/ unloading stations in Chennai, Tamil Nadu. | About 95% of the respondent reported ever having had sex with females other than their wives. Nearly three-fourth (75%) reported ever having had sex with FSWs. Consistent condom use was about 2%. | Not available. | [30] |
Truck drivers and their helpers | 1998-2000 | Behavioral interview and diagnosis of STIs among 53 drivers and helpers from a highway STD clinic in South India. All participants were tested for HIV | About 90% of the respondents had a history of multiple sex partners and 65% reported ever having sex with FSWs. Results were not available separately for drivers and helpers. | HIV: 56.8% | [29] |
Truck drivers and their helpers | 2000 | Behavioral interview and diagnosis of STIs and HIV among 4811 drivers and 1200 helpers) recruited from truckers’ halt points on major national highways. | About 34% drivers and 30% helpers reported having sex with FSWs in past 12 months. Consistent condom use in sex with FSWs was reported by 43% of the drivers and 29% of the helpers. | [31] | |
Truck drivers and their helpers | 2000 | Behavioral interview and diagnosis of STIs and HIV among 335 truckers (211 drivers and 124 helpers) recruited from truckers’ stop in Kolkata, West Bengal. Participants were tested for HIV, syphilis, gonorrhea, genital chlamydial infection, and Hepatitis B. | About 28% of the respondents reported having sex with FSWs in past 12 months. Consistent condom use in sex with FSWs was reported as 8%. Results were not available separately for drivers and helpers. | HIV: 3.0% Syphilis: 6.3% Gonorrhea: 1.8% Genital clamydial infection: 1.2% Hepatitis B: 6.3% | [43] |
Truck drivers and their helpers | 1999-2001 | Behavioral interview about sexual behaviors and diagnosis of STIs among drivers and helpers from a highway STD clinic in Pondicherry, Tamil Nadu. All participants were tested for HIV, Hepatitis B virus infection, and syphilis. | About two-third (67%) truckers reported contacts with FSWs in their life-time. Vaginal sex was the predominant risk in all participants followed by oral sex (4%), and anal sex (1%). Consistent condom use with FSWs (defined as use of condom in every sexual encounter) was about 16%. About 1% reported having sex with men. Results were not available separately for drivers and helpers. | HIV: 15.9% Syphilis: 13.9% Hepatitis B: 21.2% | [19] |
Truck drivers | 2004 | Behavioral interviews of 283 long-distance truck drivers recruited from a group of Dhabas (road side hotels) in Pune, Maharashtra. | About 57% respondents reported to ever had having sex with FSWs. Consistent condom use with FSWs (defined as use of condom in every sexual encounter) was about 7%. | [15] | |
Truck drivers and their helpers | 2004 | A behavioral and biological survey among 301 long-distance truck drivers and their helpers recruited from different transport workers’ stops on the Siliguri-Guwahati national highway. Participants were tested for HIV, hepatitis B virus, and syphilis. | About 67% reported having sex with FSWs in their lifetime. The condom use rate was reported as 58%. | HIV: 2.3% Syphilis: 6.3% Hepatitis B: 3.7 % | [32] |
Truck drivers | 2006 | Behavioral interviews of 300 truck drivers recruited from a truck terminal in Mumbai, Maharashtra. | About 36% of the respondents reported regular visits to FSWs. Consistent condom use with FSWs was about 53%. | Not Available. | [34] |
Truck drivers | 2007 | A behavioral and biological survey among 2066 long-distance truck drivers recruited from seven transshipment locations in Delhi, Ghaziabad, Kolkata, Mumbai, Bangalore, Ahmadabad, and Kandla. Participants were interviewed about their sexual behavior and tested for HIV, syphilis, Neisseria gonorrhea and Chlamydia trachomatis. | Nearly one-third (31%) reported having sex with FSWs in past one year. The consistent condom use in past one year with such partners was reported as 67%. One-fifth (20%) of the respondents reported having sex with casual non-paid female partners in past one year. The consistent condom use with such partners in past one year was about 18%. About 2% reported having sex with men/transgender in past one year and consistent condom use with such partners was reported as 30%. | HIV: 4.6% Syphilis: 2.7% Neisseria gonorrhea: 0.2% Chlamydia trachomatis: 0.3% | [16] |
Truck drivers | 2007 | Behavioral survey of 400 long-distance truck drivers recruited from highways connecting Punjab to Uttar Pradesh, Bihar and West Bengal. | About 57% of the respondents reported relationships with multiple sexual partners. Nearly one-third (33%) reported having sex with FSWs. About 64% reported using condom consistently with FSWs. | Not Available. | [20] |
Truck drivers and their helpers | 2008-2009 | Four rounds of behavioral surveys of approximately 1400 long-distance truckers in each round recruited from seven transshipment locations in the country. | About 40% reported having sex with FSWs in past 12 months. Consistent condom use with FSWs was about 73%. About 23% reported having sex with casual female sexual partners in past 12 months and consistent condom use with such partners was about 39%. About 10% reported to have anal sex in past 12 months with men/ women (irrespective of partners). The consistent condom use among such relationships was about 62%. | Not Available. | [36] |
Truck drivers | 2009-10 | A behavioral and biological survey among 2085 long-distance truck drivers recruited from six transshipment locations in the country. Participants were interviewed about their sexual behavior and tested for HIV, syphilis, Neisseria gonorrhea and Chlamydia trachomatis. | Nearly one-fourth (24%) reported having sex with FSWs in past one year. The consistent condom use with such partners was reported as 75%. Nearly one-fifth (21%) reported having sex with casual non-paid female partners in past one year. The Consistent condom use with such partners in past one year was about 37%. | HIV: 2.5% Syphilis: 1.7% Neisseria gonorrhea: 0.1% Chlamydia trachomatis: 0.1% | [17] |
FSWs: Female Sex Workers; HIV: Human immunodeficiency virus; STI: Sexually transmitted infections.
Truckers’ life-time exposure to FSWs and other non-regular sex partners continued to be high in studies conducted after 2000 although it started showing a sign of declining trend. Studies conducted during 2000-2005 found that about 57% - 67% of the truckers ever had sex with FSWs [
Only recent studies conducted after 2005 collected information on sexual behaviors with non-paid female partners who are defined as females whom truckers were not married and did not pay in cash for sex [
Compared to studies to explore sexual behaviors of truckers, fewer studies captured information STI/HIV prevalence among truckers in India [
Efforts to curb the HIV among truckers started in early 1990s in the forms of stand-alone intervention programs primarily in southern and eastern parts of the country with different intervention strategies [
The HIV prevention efforts among truckers were strengthened towards the end of 1990s. This was the time when a large-scale HIV prevention program among truckers, named as Healthy Highway was initiated [
By the end of the 1990s, the key lessons learnt from the various programs for truckers in India were the need to adopt an integrated national approach for programming and management to maintain effectiveness of interventions, selection of intervention sites, and inclusion of transport companies and other stakeholders such as brokers and transport associations [
Considering these facts about the structure of the industry and learning from previous efforts under HIV prevention programs for truckers, a large-scale HIV prevention program named as Kavach (meaning “shield” in Hindi) among truckers was initiated in 2004 [
The Kavach intervention had three components: mid-media events; one-to-group discussions by trained peer educators, and one-to-one counseling and STI care at Khushi clinics by professionals and qualified medical doctors. Mid-media events included street plays, health games, film shows, truckers’ festival and the distribution of audio cassettes/compact discs. Films shows were organized to attract truckers and messages on the availability of Khushi clinics were imparted during the movie. Truckers’ festivals were large-scale events conducted annually to create an interest among brokers, transporters and truckers and about the program. Audio cassettes/ compact discs with catchy local songs interspersed with spoofs on popular film actors delivering HIV prevention messages and endorsing services at Khushi clinics were distributed to truckers to reinforce positive messages on HIV when they were on the move along the highways. At each intervention site, static and mobile Khushi clinics were established at strategically chosen locations that were accessible to the truckers from that intervention site. These mobile clinics operated either at brokers’ premises or in a mobile van. Social marketing of condoms was promoted in partnership with condom marketing organizations by opening non-traditional outlets such as tea stalls, and installing condom vending machines at strategically chosen places at the intervention sites. More details of the Kavach intervention are available elsewhere [
Another large-scale intervention which included truckers as one of the targeted populations was implemented during 2002-2006 at 12 port cities in nine states of the country. The project was named as “Operation Lighthouse” and it targeted adult men including truckers, port laborers, and fishermen at selected intervention sites [
Besides the large-scale interventions, few attempts have been made to explore new approaches for HIV prevention among truckers. An Information-Motivation-Behavioral (IMB) model-based HIV prevention program was implemented among truckers in 2003 in Chennai, Tamil Nadu [
Another study conducted among truckers in Andhra Pradesh assessed the association between hygiene, sexual behavior and HIV infection. Participants were recruited into an integrated HIV and hygiene Information-Moti- vation (IM) program [
This study provides a systematic review of the studies conducted to describe sexual behavior and STI/HIV prevalence as well as efforts to prevent HIV among truckers in India during 1990-2011. This review indicates towards increase in consistent condom use by truckers and decline in STI/ HIV prevalence among them over time in India. However, the HIV prevalence among truckers is still high at slightly above 2% which is approximately seven times higher than the HIV prevalence among general population (0.31%) in the country [
Although, many studies have been conducted to understand the sexual behaviors of truckers, relatively fewer measured the STI/HIV prevalence among them. Considerable variations in the indicators of sexual risk behaviors and STI/HIV prevalence was noticed across studies conducted in different geographic regions of the country within a short interval of time. Although such variations indicate towards the geographic variability in the HIV epidemic among truckers, the comparison across studies is challenged due to differentials in study design, and methods of recruitment. For instance, the STI/HIV prevalence among studies which recruited participants from STI clinics [
Very few studies which relied on large samples confirmed the spatial variations in sexual behaviors and STI/ HIV prevalence among truckers in the country [
The HIV prevention programs among truckers in the country seem to have evolved based on the learning and evidences from earlier efforts from India and outside. For instance, the recommendations of health highway program [
Although there is dearth of studies focusing on rigorous evaluation of large-scale HIV prevention interventions among truckers in India, results from few such efforts are suggestive of success of different programs including the national response to the HIV epidemic among truckers [
This paper was written as part of a mentorship programme under the Knowledge Network project of the Population Council, which is a grantee of the Bill & Melinda Gates Foundation through Avahan, its India AIDS Initiative.