The study findings showed differential effects of exposure to components of the Kavach intervention on consistent condom use with paid and non-paid female partners. For instance, trucker’s exposure to mid-media alone as compared to those who were not exposed to any intervention reported significantly higher consistent condom use with paid female partners. Whereas, truckers who visited project-run clinics as compared to those with exposure to mid-media alone have reported higher consistent condom use with non-paid female partners. Exposure only to mid-media and IPC, without being supplemented by visits to project-run clinics, did not have a significant impact on condom use behavior.
The finding that truckers’ exposure to mid-media alone has increased consistent condom use with paid female partners can be explained, to some extent, by the possible confounding effect of parallel intensive interventions among FSWs in several states of India [15
]. The national AIDS control program as well as the Avahan supported initiatives for the social marketing of condoms at ‘hotspots’ in high HIV prevalence states in India have increased the availability of condoms in high risk settings where commercial sex takes place [28
]. In the context of several intervention programs to promote condom use in commercial sex, information on the availability and importance of condom use imparted through the mid-media could lead to high rates of consistent condom use with paid female partners. However, as the study findings indicate, exposure to mid-media alone did not increase consistent condom use with non-paid female partners, which may perhaps be explained by two factors. First, the degree of intimacy and trust is higher with non-paid female partners than paid partners, and hence condom use with such partners is low [14
]. Second, non-commercial sex takes place in settings (e.g., homes) where the reach and effectiveness of HIV prevention programs may be limited.
Information on safe sexual practices provided by mid-media events coupled with counseling by a qualified counselor on safe sexual practices, correct and consistent condom use and treatment of STI by a qualified doctor in project-run clinics appear to be the most effective package of services to increase condom use with both paid and non-paid female partners. Findings suggest that visits to project-run clinics did not have an additional impact as compared to exposure to mid-media alone in terms of consistent condom use with paid female partners. However, visits to project-run clinics had an additional impact on consistent condom use with non-paid female partners compared to exposure to mid-media alone. One possible reason behind success of project-run clinics in increasing consistent condom use with non-paid female partners could be the in-depth one-to-one discussions with qualified counselors and qualified doctors. Research from developing countries indicate that HIV counseling recipients are more likely to use condom than those who do not receive it [41
]. A recent study among cross-border truck drivers in Hong Kong also found voluntary HIV counseling and testing plus the information dissemination approach to be more effective in promoting safe sex behaviors than the information dissemination approach alone [42
]. Although further studies are needed to understand the processes that motivate truckers to use condoms with non-paid female partners, this paper suggests that the provision of clinics with integrated one-to-one counseling by trained professionals promotes consistent condom use, particularly with non-paid female partners.
Findings also indicate that as compared to no exposure, exposure to only mid-media and IPC did not improve condom use behavior. This could be due to the small sample size of truckers exposed to these two intervention components, as well as the fact that truckers who were exposed to only mid-media and IPC constitute a subgroup who did not visit the project-run clinics even after being exposed to two intervention components that were aimed to motivate them to visit these clinics. As this group of truckers could not be convinced to visit clinics even after repeated efforts, it may be argued that these truckers did not give much importance to the messages on condom use provided during mid-media events and IPC sessions. Hence, though covered by the program, these truckers’ condom use behavior was similar to those who were not exposed to any intervention component. These findings suggest the need to change the IPC approach (e.g., using photographs to illustrate the consequences of STI) to motivate truckers to use condoms with non-regular female sexual partners.
The percentage of truckers exposed to the intervention as observed in this study was found to be higher than that found in a large-scale survey among long distance truck drivers conducted during 2009–10 in India [15
]. This may be because our study was limited to transshipment locations where the Kavach intervention program was being implemented whereas the above-mentioned study included transshipment locations where this program did not operate.
On the other hand, the levels of consistent condom use with paid female partners (74.1 %) and non-paid female partners (41.8 %) as found in this study are consistent with other large-scale study among long distance truckers in India which found that about 74 % of the truck drivers used condoms consistently with paid female partners whereas about 37 % of them used condom consistently with non-paid female partners [15
]. In recent past, small-scale studies in different parts of the country have found a wide range (57 %–84 %) of estimates for consistent condom use by truckers with paid female partners. This wide variation in estimates across the small-scale studies are often due to small sample size, and variation in geographic region. Differentials in sexual behaviors of truckers from different parts of the country have been documented elsewhere [15
This study has some limitations, which should be considered when interpreting the results. First, findings are based on self- reports, which are vulnerable to social desirability and recall biases. The survey measured a limited number of socio-demographic characteristics and did not include some of the important variables such as income and alcohol consumption, which may confound the results. Finally, although the PSM approach was used to establish a causal relationship between exposure to intervention and consistent condom use, this should not be considered an alternative approach to randomized trials with valid case and control groups.
In conclusion, the study documents that the Kavach intervention resulted in a significant increase in consistent condom use with both paid and non-paid female partners. Exposure to mid-media alone substantially increased consistent condom use by truckers with paid female partners whereas exposure to project-run clinics had a significant impact on increasing condom use with non-paid female partners. These findings suggest the need for intensive mid-media events to increase awareness of HIV and easily accessible clinics that provide counseling on safe sex practices and STI treatment services to truckers to increase the adoption of consistent condom use with non-regular female partners. It also highlights the need to understand truckers’ risk perceptions, needs and the barriers to the uptake of project-run clinic services even after repeated attempts to promote behavior change.