1. Behavioural Surveillance Survey Pravin Pisudde

2. Behavioural Surveillance One of the component & essential part of the HIV surveillance BSS is an important effort to – Monitor changes in behavioural aspects of general population as well as specific population groups vulnerable to HIV infection. – To derive necessary implications from the resultant differences between the ‘recommended behaviour’ and ‘reported behaviour’ for strategising appropriate programmatic solutions. – Track trends in HIV/AIDS knowledge, attitudes and risk behaviour in selected segments of a country.

3. Need for BSS To understand the multifaceted dynamics of the expanding HIV epidemic Effective utilization of limited resources To know about warning signals for newly emerging pockets of infection Provide rich inputs to plan the preventive interventions and awareness campaigns.

4. Methodology Consultative Process in Planning the Survey – All key stakeholders agree on the goals of data collection. – A Technical Resource Group (TRG) was constituted by NACO (UNAIDS, UNICEF, WHO, NIMS, Clinton Foundation, RCSHA, and Population Council) – TRG meetings were held on weekly basis at every stage Target Population for the Study – General Population – High Risk Group Female Sex Workers (FSWs), Clients of FSWs Men who have Sex with Men (MSM), Injecting Drug Users (IDUs) Coverage of the survey – Rural and urban areas from all the states and union territories of India.

5. Key indicators Awareness of HIV/AIDS Knowledge of HIV prevention methods Incorrect beliefs about HIV transmission Awareness of Sexually Transmitted Diseases (STDs) Knowledge of STD symptoms Awareness of condom Access to condoms Age at first sex Sex with different types of sex partners Last time condom use with different type of sex partners Consistent condom use with different types of sex partners HIV risk perceptions Exposure to media Exposure to interventions

6. The structured and pretested of the questionaires was used for both BSS 1 and BSS 2 Additional issues were covered in BSS 2: – Awareness about HIV and AIDS separately – Awareness about PPTCT and ICTC – Whether last partner was commercial or casual – Sexual history – Men who have Sex with Men A detailed manual was prepared for field teams for their ready reference. The bilingual questionnaires were used for the survey.

7. Sample size n = The required sample size D = Design effect=2 P1 = The estimated proportion at the time of BSS 2001 P2 = The target proportion in BSS 2006, so that (P 2 – P 1 ) is the magnitude of change to be detected P = (P 1 + P 2 )/2 Z 1- α = Z – score corresponding to the desired level of significance = 1.645 Z 1- ß = the Z – score corresponding to the desired level of power = 0.84

8. Methodology contd…. The indicators considered for calculating the sample size for each state/groups of states were: – Consistent condom use with non-regular partners in the last 12 months – Percent of the target group who had sex with non-regular partners in the last 12 months The total urban and rural sample was equally divided among male and female respondents. One respondent from a selected household. Sample was calculated with the assumption that there would be 20 % points increase in the indicator value over BSS 2001. Desired sample size was – males: 48,623; – females: 48,617; – total: 97,240

9. Sampling procedures(In the Rural areas) 1.Selection of Districts – Four to six districts in each state/groups of states were selected randomly. – The required number of districts from each region was selected using PPS method. 2.Selection of Villages – The number of respondents to be covered from each village was fixed at 40, considering this the number of villages to be covered was calculated. – Required number of villages was selected using PPS systematic random sampling method. 3.Selection of Target Respondents – In each selected village, the total number of respondents was fixed at 40 per village. – An extra sample of six households were selected. (Care was taken to ensure to cover all the households/communities/hamlets in the village.)

10. Sampling procedures(In the Rural areas) Selection of Cities/Towns – All the urban units in each state/group of states were stratified into the three strata & the number of CEBs (Selected from each stratum was proportional to the urban population it represents.) Stratum I : Big size cities/towns (more than fi ve lakh population): 5 CEBs Stratum II : Middle size cities/towns (one to five lakh population): 3 CEBs Stratum III : Small cities/towns (less than one lakh population): 2 CEBs Selection of CEBs – Considering the coverage of a sample of 40 interviews per CEB, the number of CEBs in each city/town were calculated. – In each selected city/town, the assigned quota of wards (equivalent to the required number of CEBs) was randomly selected using the PPS method. – From each ward one CEB was selected randomly. Selection of Target Respondents – Similar as the rural

11. Data Management and Analysis Data Scrutiny – Respective state field offices – Five data entry locations. – Trained 80 coders and 5 coding supervisors for scrutiny and coding exercise. – Research professionals Data Management – Entire data entry was handled at five centres namely Delhi, Kolkata, Lucknow, Baroda and Hyderabad where facilities to handle large volumes. – Data were entered in the Integrated System for Survey Analysis (ISSA) package. A senior system analyst with the support of a programmer monitored the data entry. – About 10 percent of the questionnaires were double entered to ensure that error levels are below 0.5 percent. Data Analysis – The core team members and the system analyst under the guidance of the team leader/core team prepared the analysis/tabulation plan.

12. Training of Research and Field Teams Orientation Meeting of Professionals and Field Executives – 3 day training workshop for entire study team – Residential training workshop was organised for all the participants. Recruitment of Field Staff – While selecting the field staff & fieldworkers it was ensured with prior experience of social research are recruited. – The field executives and supervisors, who were involved in BSS 2001, were preferably involved in BSS 2006. – Keeping in mind the dropout rate, 20 percent extra candidates were recruited and trained. A total of 116 teams, each team having one supervisor, three male interviewers and three female interviewers, were involved for the study. Training of Field Staff – 4 days intensive workshop were organised, interactive sessions at class room and field exposure visit

13. GENERAL POPULATION IndicatorUrbanRuralTotal 06Total 01 Interpersonal communication on STDs/HIV/AIDS in the last one year BSS114.714.214.4 BSS221.420.421.0 Maharashtra (BSS 2)15.727.320.910.8 Interpersonal communication on condom usage to prevent STDs/HIV/AIDS BSS112.09.410.2 BSS219.918.719.0 Maharashtra (BSS 2)14.525.820.610.9 Saw/heard/read any advertisement/ announcements on HIV/AIDS at least once in the last one month BSS183.060.767.7 BSS289.473.278.2 Maharashtra (BSS 2)95.388.991.876.1

14. GENERAL POPULATION General populationUrbanRuralTotal 06Total 01 Ever heard of either ‘HIV or AIDS or Both’ BSS186.660.667.4 BSS292.375.480.4 Maharashtra (BSS 2)98.594.596.383.6 HIV/AIDS can be transmitted through sexual contact BSS180.255.061.6 BSS285.969.374.3 Maharashtra (BSS 2)93.085.088.780.0 HIV/AIDS can be transmitted through blood transfusion BSS182.856.863.7 BSS288.370.675.9 Maharashtra (BSS 2)92.086.589.081.0

15. GENERAL POPULATION IndicatorUrbanRuralTotal 06Total 01 “HIV/AIDS can be transmitted through needle sharing ” BSS180.355.562.1 BSS287.169.274.6 Maharashtra (BSS 2)92.583.387.579.4 “HIV/AIDS can be vertically transmitted” BSS175.752.058.3 BSS278.561.866.8 Maharashtra (BSS 2)77.974.476.075.7 “HIV/AIDS can be transmitted through breast feeding” BSS158.644.648.5 BSS263.351.755.2 Maharashtra (BSS 2)55.854.855.259.9

16. GENERAL POPULATION IndicatorUrbanRuralTotal 06Total 01 “HIV/AIDS can be prevented through consistent condom use” BSS168.343.950.2 BSS278.559.565.1 Maharashtra (BSS 2)90.280.585.063.1 “HIV/AIDS can be prevented by having one faithful uninfected sex partner” BSS166.143.949.7 BSS273.757.962.6 Maharashtra (BSS 2)75.965.770.460.4 “HIV/AIDS can be prevented through sexual abstinence” BSS180.355.562.1 BSS270.457.161.3 Maharashtra (BSS 2)84.776.280.159.3

17. Methodology Similar as above Additional sample of 20 respondents aged 15- 24 years was covered in each PSU for the BSS among young people. – 10 males and 10 females The total sample covered for the BSS among young people was 78,916 – 30,791 was from the GP survey – 48,125 was the additional sample covered for the Youth survey.

18. YOUTH IndicatorUrbanRuraltotal Heard about HIV AIDS BSS195.089.884.1 BSS291.891.388.9 Maharashtra (BSS 2)98.697.498.0 Ever heard about HIV BSS284.766.271.2 Maharashtra (BSS 2)86.383.684.8 Ever heard about AIDS BSS294.674.585.7 Maharashtra (BSS 2)97.9 96.6 Aware of two important methods of prevention BSS161.453.457.6 BSS271.465.467.4 Maharashtra (BSS 2)76.160.068.0

19. YOUTH IndicatorUrbanRuralTotal Knowledge about HIV transmission and prevention BSS115.121.922.2 BSS240.828.832.9 Maharashtra (BSS 2)57.241.949 Ever heard of STDs BSS130.426.928.7 BSS240.033.835.7 Maharashtra (BSS 2)48.949.249.0 Any STD symptom (self-reported prevalence) in last 12 months BSS13.24.13.6 BSS23.84.94.5 Maharashtra (BSS 2)3.83.7

20. YOUTH IndicatorUrbanRuralTotal Aware of condoms BSS188.470.082.7 BSS289.881.584.1 Maharashtra (BSS 2)90.4 Sex with non-regular partner in last 12 months BSS16.67.26.9 BSS28.68.18.2 Maharashtra (BSS 2)9.614.612.3

21. Methodology Key indicators used – Clients of Female Sex Workers: Consistent condom use with commercial partners in last three months – Female Sex Workers: Consistent condom use with clients in last one month – Control Group for Female Sex Workers: Consistent condom use with clients in last one month Sampling procedure 1.Selection of Sites (clusters) 1.The list of sites was prepared and revalidated from the existing mapping information. 2.The sampling interval (SI) was calculated by dividing the total number of sites (M) by the number of sets to be selected (a) i.e. SI = M/a. 3.Random number table used for selection of first unit 4.Subsequent units were selected by adding the sampling interval (SI) 5.This procedure was continued until the list finished. 2.Selection of Target Respondents During peak hour & Required number of respondents were randomly selected. Sample size – Client of sex workers: 6613 and FSWs: 7417 in each sampling unit.

22. FEMALE SEX WORKER Indicators20062001 Awareness about HIV/AIDS &Knowledge on transmission Ever heard of HIV/AIDS98.193.5 Aware that a healthy looking person could be infected with HIV71.958.1 Awareness about HIV/AIDS and Knowledge on HIV Prevention HIV can be prevented by having one faithful uninfected partner88.976.1 HIV/AIDS can be prevented through consistent condom use90.382.1 knowing both the methods of HIV prevention8165.7 Awareness of STDs, Self-reported Prevalence and Treatment Seeking Behaviour Ever heard of STDs88.982.8 Atleast one STD symptom in last 12 months50.445.8 STD T/t in a govt. hospital/clinic during last episode31.927.8 Sexual Behaviour and Condom Usage last time condom use with non-regular sex partner87.576.0 consistent condom usage with paying clients in the last 3 months73.450.3 usual insistence on client using a condom86.780.5

23. CLIENT OF FEMALE SEX WORKER Indicators0601 Awareness about HIV/AIDS &Knowledge on transmission Ever heard of HIV/AIDS98.595.9 Healthy looking person could be infected with HIV50.638.5 Awareness about HIV/AIDS and Knowledge on HIV Prevention HIV/AIDS can be prevented by having one faithful uninfected77.474.2 HIV/AIDS can be prevented through consistent condom use70.768.2 Both the methods of HIV prevention8985.1 Awareness of STDs, Self-reported Prevalence and Treatment Seeking Behaviour Ever heard of STDs77.575.6 At least one STD symptom in last 12 months24.829.9 STD T/t in a govt. hospital/clinic during last episode24.927.6 Sexual Behaviour and Condom Usage Last time condom use with non-regular sex partner23.916.3 Consistent condom usage with paying clients in the last 3 mn49.632.8 Usual insistence on client using a condom39.821.8

24. Methodology Key indicators used – Men who have Sex with Men: Consistent condom use with commercial partners in last three months – Injecting Drug Users: Consistent use of needles that no one else used in the last one month Similar as in FSW Sample size – Men who have Sex with Men: 2638 – Injecting Drug Users: 2677

25. Awareness & prevention of HIV/AIDS(MSM) Ever heard of HIV/AIDS both Aware of method of prevention

26. Prevention of STD & treatment seeking(MSM) Atleast one symptom of STD in last 12 mn Saught t/t at govt hospital

27. Sexual behaviour and condom usage(MSM) Sex with any female partner in last 6 mn used condom during the last 6 mn

28. Awareness of HIV/AIDS(IDU) Ever heard of HIV/AIDS Needle sharing as a route of HIV transmission

29. Prevention of HIV/AIDS(IDU) IDUs aware of switching to non injecting drugs as means of preventing HIV infection IDUs aware of two important methods of preventing HIV infection

30. Prevalence & treatment of STD(IDU) IDUs reported to have suffered from at least one symptom of STD in last 12 mn IDUs who have not taken any T/t during last episode