EPIDEMIOLOGY AND SOCIAL SCIENCE High HIV Prevalence Among a High-Risk Subgroup of Women Attending Sexually Transmitted Infection Clinics in Pune, India Shruti H. Mehta, PhD, MPH,* Amita Gupta, MD,† Seema Sahay, PhD,‡ Sheela V. Godbole, MD,‡ Smita N. Joshi, MD,‡ Steven J. Reynolds, MD,†§ David D. Celentano, PhD,* Arun Risbud, MD,‡ Sanjay M. Mehendale, MD,‡ and Robert C. Bollinger, MD, MPH† k Objective: To investigate changes over a decade in prevalence and correlates of HIV among high-risk women attending sexually trans- mitted infection (STI) clinics in Pune, India, who deny a history of commercial sex work (CSW). Design: Cross-sectional. Methods: From 1993 to 2002, 2376 women attending 3 STI clinics in Pune were offered HIV screening. Women who denied CSW were included (n = 1020). Results: Of 1020 women, 21% were HIV infected. The annual HIV prevalence increased from 14% in 1993 to 29% in 2001–2002 (P , 0.001). The change in HIV prevalence over time was paralleled by changes in clinic visitor characteristics; in later periods, women were older, more often employed, less likely to be currently married, and more likely to report condom use. In multivariate analysis, factors independently associated with HIV were calendar period (adjusted odds ratio [AOR], 1.9 for 1997–1999 vs. 1993–1996; 95% CI, 1.2– 3.0; AOR, 2.3 for 2000–2002 vs. 1993–1996; 95% CI, 1.5–3.6), lack of formal education (AOR, 2.0; 95% CI, 1.4–2.9), having been wid- owed (AOR, 3.1; 95% CI, 1.6–6.1), current employment (AOR, 1.8; 95% CI, 1.2–2.6), and genital ulcer disease on examination (AOR, 1.8; 95% CI, 1.2–2.7). Conclusions: Women attending STI clinics in India who deny a history of CSW represent a small, hidden subgroup, likely put at risk for HIV because of high-risk behavior of their male partners, generally their husbands. Educational and awareness efforts that have targeted other subgroups in India (men and CSWs) should also focus on these hard-to-reach women. Risk reduction in this subgroup of Indian women would also be expected to reduce perinatal infections in India. Key Words: HIV, AIDS, women, sexually transmitted diseases, prevalence, India (J Acquir Immune Defic Syndr 2006;41:75–80) R ecent projections suggest that approximately 5.1 million persons are living with HIV in India, 1 leading some to speculate that India has surpassed South Africa and now has more HIV cases than any other country. 2 The spread of HIV in India has predominantly been through heterosexual transmis- sion, with an estimated 38% of HIV infections occurring among women. 3,4 Initially, the Indian HIV epidemic in women was heavily concentrated among commercial sex workers (CSWs) 4 ; however, studies from several cities in India have revealed the vulnerability to HIV of married women who have had only 1 lifetime partner. 5–7 In a study from Manipur, 45% of wives of HIV-infected injection drug users were also HIV positive despite the fact that none of these women reported injection drug use themselves. 6 In Chennai, among 134 HIV-positive women who sought care for HIV infection, 82% were married, monogamous women whose only risk factor for HIV infection was unprotected intercourse with their HIV-infected spouse. 7 Finally, in Pune, a high HIV prevalence (14%) among married, monogamous women attending sexually transmitted infection (STI) clinics between 1993 and 1996 has been reported. 5 These studies suggest that these women are at risk for HIV because of the high-risk behaviors of their husbands. Over the past decade, India’s governmental organiza- tions, including the National AIDS Control Organization (NACO), nongovernmental organizations, and public–private partnerships have mounted numerous prevention and educa- tion programs directed at high-risk groups. 8 Women attending STI clinics are considered one such high-risk group, but most risk reduction efforts have focused on female CSWs and not other female clinic clients. To design interventions for women Received for publication January 20, 2005; accepted May 24, 2005. From the *Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; †Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, MD; ‡National AIDS Research Institute, Pune, India; §National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD; and k Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Supported by the Indian Council of Medical Research (Institutional Support), grants from the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) (1R21-AI3387901 and 1R01-AI41369), and the Fogarty International Center, US National Institutes of Health, Program of International Training Grants in Epidemiology Related to AIDS, D43 TW00010-AITRP, as well as a contract from the NIAID, NIH through Family Health International (FHI) (AI 35173). The views expressed in this manuscript do not necessarily represent the views of the ICMR, NIH, Fogarty International Center, FHI, or the Johns Hopkins University. Reprints: Shruti H. Mehta, 615 N. Wolfe St., E6537, Baltimore, MD 21202 (e-mail: shmehta@jhsph.edu). Copyright Ó 2005 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr  Volume 41, Number 1, January 1 2006 75 Copyright ' Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.