India trucking population is estimated at five to six million truck drivers and helpers, with about two to two and half million being long-distance truckers . The Indian long-distance trucking industry consists of three different segments: free agents, port operators, and express cargo operators. Truckers tend to specialize in any one of these segments, primarily because it is difficult to build business networks in more than one segment. The free agent segment which accounts for approximately 70 percent of the long-distance truckers, is fragmented with a vast majority working for small transport operators . In the late 1990s, almost 77% of India’s truck fleet was owned by operators with no more than five trucks, while only about 6% of trucks were owned by operators with more than 20 trucks . This ownership profile created middlemen (transporters and brokers) on whom small trucking operators depend to generate business. This structure of the Indian trucking industry has diluted the visibility of the industry to transport planners and policy-makers [4, 5].
Truck drivers and their helpers, particularly those who travel on highways for longer distances, have been associated with the spread of sexually transmitted infections including HIV in many parts of the world including India [6–18]. Long distance truckers are considered to be particularly vulnerable to STIs and HIV infection because they spend many days away from their families in contrast to short-distance, state-level truckers [7, 18]. Earlier reports demonstrated that in spite of high rates of STI prevalence of HIV remained lower in long distance truck drivers [19, 20]. However, because of high-risk behavior coupled with their mobility these long distance truckers are said to have potential of spreading HIV to different geographical areas [1, 7, 9]. For these reasons, truckers have been key target populations in the Indian national response since 1996 under National AIDS Control Program II and III. The three major components of the target interventions among truckers are- (1) Behavioral Change Communication (2) Condom promotion activity through social marketing and free distribution of condoms, and (3) Treatment of sexually transmitted infections (STIs) [21, 22]. Given that HIV programs in India are implemented at the state level through State AIDS Control Societies, state-level truckers were routinely covered under Targeted Interventions funded by the National AIDS Control Organization. However, long distance truckers who worked on the national highways were not targeted specifically in these interventions [23, 24].
In 2003, Avahan, the India AIDS Initiative was started in India with the aim to slow down the HIV epidemic through focused, integrated, large-scale prevention programs providing saturated coverage to high risk populations including female sex workers (FSW), men who have sex with men, transgenders, injecting drug users in the six high prevalence states in India. Potential clients of FSWs were also targeted through interventions at sex worker solicitation areas (“hot-spots”) along with long distance truck drivers (LDTD) [24, 25]. The Avahan intervention with LDTD began in 2004. To enhance accessibility of clinical services to truckers Khushi (meaning ‘happiness’ in Hindi/Urdu) clinics were established at 36 truck halt points. This intervention was redesigned in 2006 by halving the numbers of implementation sites from 36 to 17 focusing on the major truck halt points in nine Indian States. It was revamped to take advantage of the structure of the Indian trucking industry with middlemen where truckers spend time between shipments. It recruited peer educators, increased the emphasis on professional media expertise in mid-media and mass media events, improved signage and satellite clinical services at the halt points. More details about the interventions can be found elsewhere [2, 25].
A component of the evaluation design of the Avahan intervention includes two rounds of large scale cross-sectional surveys of long distance truck drivers with both a behavioral and biological component . The two rounds of the surveys are known as Integrated Behavioral and Biological Assessment (IBBA) on national highways. This paper presents an analysis of both rounds of IBBA on national highways to assess whether highways have become ‘safer’ in terms of risk of HIV transmission among truckers. By safer highways we mean increase in exposure to HIV prevention interventions and consistent condom use with non regular female sexual partners along with reduction in sexually transmitted infections (STI) including HIV among truckers. As the IBBA on national highways was conducted only among long distance truck drivers, the term trucker in this paper stands for long distance truck drivers (and not the helpers).