India is experiencing rapid and extensive spread of HIV infection (World Health Organization, 1997). The Press Trust of India in 1997, reported a doubling of AIDS cases every 14 months. As a nation of over 900 million, an anticipated 4-5% rate of infection is leading to predictions that there will be 38 million infected persons by the year 2003 (World Bank, 1998). This will mean that there are more HIV infected persons in India than on the continents of Africa, Australia, and Latin America combined. In seven states in Northern India, the seroprevalence rates are already above 5%, with an estimated two to five million people infected with HIV in India today. The highest rates of infection occur among adults between the ages of 20 and 45 (IPS Wire, 12/97). Heterosexual contact accounts for more than 75% of all reported cases. Since the first reported case of HIV infection in 1986, HIV has spread to every state and union territory in the country with 25% of infections occurring in rural areas. Gender issues and poverty are cited as major issues in the spread of the disease.

A group that continues to be at high risk is female commercial sex workers. While the degree to which commercial sex is tolerated and regulated varies across societies in India, the majority of these women are young, have low socioeconomic status, and are at immediate risk for HIV infection and other sexually transmitted diseases. The most rapid and well-documented spread of HIV has occurred in Bombay and the State of Tamil Nadu. In Bombay, home to an estimated 100,000 commercial sex workers, HIV prevalence has reached the level of 50% among sex workers, 36% in STD patients, and 2.5% in women attending antenatal clinics.

A major means of transmission for the HIV in India is married and unmarried men visiting commercial sex workers. This is exhibited through the increasing spread of HIV infection throughout the general population as their customers, often truck drivers and migrant workers, act as vectors for carrying infections back to their wives and lovers in villages all over the country. HIV infection among women who are not commercial sex workers is increasing with reported rates of infection ranging as high as 14% (Gangakhedkar, R, et al., 1997). Some of these women in turn transmit the virus to a proportion of their children. Slowing the rate of infection among sex workers and their customers is essential to protecting the spread of infection both to the general population and among these high-risk groups.

In order to meaningfully impact the spread of the epidemic, there is: 1) a need for substantial increase in the national, state, and local capacity of the Indian professional social science and biomedical community in HIV prevention program development and research evaluation; and 2) identification and demonstration of model HIV prevention programs that can be disseminated nationally and internationally. This project, funded by the World AIDS Foundation, builds research capacity among the India team while conducting a study of HIV prevention among commercial sex workers in three communities in India.

Through a collaborative effort consisting of Dr. Jana and colleagues in India and CCH investigators, we have implemented and are evaluating the effectiveness and the long-term sustainability of the intervention with commercial sex workers in three communities in India using a sequential stepwise lagged design (see Kelly, J., et. al., 1992) and at the same time building research capacity within the India-based team. Three communities will be selected within a larger metropolitan area or region. The results of such an effort will lead to a larger attempt for broad dissemination of successful interventions across communities in India as well as other developing nations impacted by the AIDS pandemic. Additionally, it will enhance the abilities and skills of the India team in future program-building efforts by allowing the India team to "learn by doing."