Geographic and socioeconomic inequalities in the coverage of contraception in Uttar Pradesh, India.

BACKGROUND: Uttar Pradesh (UP) is the most populous state in India, with a historically lower level of family planning coverage than the national average. In recent decades, family planning coverage in UP has significantly increased, yet there are considerable geographic and socio-economic inequalities. METHODS: The data used for the study is derived from a cross-sectional quantitative survey of 12,200 currently married women conducted during December 2020-February 2021 in UP by the Technical Support Unit. Univariate and bivariate analyses were performed and equiplots were used to make visualizing inequalities easy. RESULTS: The findings of the study reveal significant variation in family planning coverage indicators amongst currently married women in reproductive ages by administrative divisions in UP. For instance, in the Jhansi division, it was 72.4%, while in Faizabad, it was 39.3%. Jhansi division experienced the highest modern contraceptive coverage with the lowest inequity compared to other divisions. However, the range of coverage within the division by Accredited Social Health Activist (ASHA) areas is 25% to 75%. In fact, for some ASHA areas in the Jhansi division, the family planning demand satisfied for modern contraception ranged from more than 85% to less than 22%. On the other hand, the Gonda division with the lowest coverage and lowest inequity for demand satisfied for modern contraception has some ASHA areas with less than 5% and some with more than 36%. The study also revealed intersectionality of education, wealth, place of residence and geographic divisions in identifying inequity patterns. For instance, in case of Mirzapur and Varanasi, the demand satisfied among the illiterates was 69% and the corresponding percentage for literates was 49%. With respect to place of residence, Basti division, where the coverage for modern contraception is extremely low, demand satisfied for modern contraceptive methods is 16.3% among rural residents compared to 57.9% in the case of urban residents. CONCLUSIONS: The findings showed inequality in the modern family planning methods coverage in UP in both best and worst performing divisions. The inequalities exist even in extremely small geographies such as ASHA areas. Within the geographies as well, the socio-economic inequalities persisted. These inequalities at multiple levels are important to consider for effective resource allocation and utilization.

Programme science: a route to effective coverage and population-level impact for HIV and sexually transmitted infection prevention.

Improvements in context-specific programming are essential to address HIV and other sexually transmitted and blood-borne infection epidemics globally. A programme science approach emphasises the need for context-specific evidence and knowledge, generated on an ongoing basis, to inform timely and appropriate programmatic decisions. We aim to accelerate and improve the use of embedded research, inquiry, and learning to optimise population-level impact of public health programmes and to introduce an effective programme coverage framework as one tool to facilitate this goal. The framework was developed in partnership with public health experts in HIV and sexually transmitted and blood-borne infections through several workshops and meetings. The framework is a practice-based tool that centres on the use of data from iterative cycles of programme-embedded research and learning, as well as routine programme monitoring, to refine the strategy and implementation of a programme. This programme science approach aims to reduce programme coverage gaps, to optimise impact at the population level, and to achieve effective coverage. This framework should facilitate the generation of programme-embedded research and learning agendas to inform resource allocation, optimise population-level impact, and achieve equitable and effective programme coverage.

A cross-sectional survey exploring HIV and HCV prevalence among men who purchase sex in Dnipro, Ukraine.

BACKGROUND: HIV programming in Ukraine largely targets "key population" groups. Men who purchase sex are not directly reached. The aim of our study was to explore the prevalence of sexually transmitted and blood-borne infections (STBBIs) among men who purchase sex from female sex workers. METHODS: Following geographic mapping and population size estimation at each "hotspot", we conducted a cross-sectional bio-behavioural survey with men who purchase sex between September 2017 and March 2018 in Dnipro, Ukraine. Eligibility criteria included purchasing sex services at a "hotspot" and being ≥ 18 years. Participants completed a structured questionnaire, followed by HIV/HCV rapid testing and a dried blood spot (DBS) sample collection for confirmatory serology. RESULTS: The study enrolled 370 participants. The median age was 32 (interquartile range [IQR] = 27-38) and the median age of first purchase of sexual services was 22 (IQR = 19-27). Over half (56%) of participants reported ever testing for HIV; four participants (2%, N = 206) reported having tested positive for HIV, with three out of the four reporting being on ART. Forty percent of participants had ever tested for HCV, with three (2%, N = 142) having ever tested positive for HCV. In DBS testing, nine participants (2.4%) tested positive for HIV and 24 (6.5%) tested positive for ever having an HCV infection. CONCLUSION: Prevalence of HIV and HCV in this population was high. Given high rates of study enrolment and testing, efforts should be made to reach men who purchase sex with expanded STBBI programming.

Assessing awareness and use of HIV self-testing kits after the introduction of a community-based HIV self-testing programme among men who have sex with men in Kenya.

Men who have sex with men (MSM) bear a disproportionate burden of new HIV infections in Kenya, while experiencing discrimination, leading to suboptimal levels of HIV care. HIV self-testing (HIVST) is a tool to increase HIV screening and earlier diagnosis; however, questions remain regarding how best to scale-up HIVST to MSM in Kenya. The main objective of this study was to examine changes in knowledge and use of HIVST after implementation of a community-led HIVST project. Participants were MSM recruited from Kisumu, Mombasa, and Kiambu counties. Data were collected from two rounds (Round 1: 2019; Round 2: 2020) of serial cross-sectional integrated biological and behavioural assessments (IBBA), pre-, and post-project implementation. Two main outcomes were measured: 1) whether the respondent had ever heard of HIVST; and 2) whether they had ever used HIVST kits. Changes in outcomes between IBBA rounds were examined using modified multivariable Poisson regression models; adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) are reported. A total of 2,328 respondents were included in main analyses. The proportion of respondents who had heard of HIVST increased from 75% in Round 1 to 94% in Round 2 (aPR: 1.2, 95% CI: 1.2-1.3), while those reporting using an HIVST kit increased from 20% to 53% (aPR: 2.3, 95% CI: 2.0-2.6). Higher levels of education and HIV programme awareness were associated with both outcomes. Awareness and use of HIVST kits increased after implementation of a community-led HIVST implementation project, demonstrating the importance of integration with existing community groups.

Risk factors of HIV and variation in access to clean needles among people who inject drugs in Pakistan.

We identified key risk factors for HIV among people who inject drugs (PWID) in Pakistan and explored access to free clean needles. Multivariable logistic regression was used to investigate associations between HIV prevalence and demographic, behavioral, and socio-economic characteristics of PWID. Data came from the Government of Pakistan's Integrated Biological and Behavioral Surveillance (IBBS) Round 5 (2016-17; 14 cities). A secondary analysis investigated associations with reported access to clean needles. Unweighted HIV prevalence among 4,062 PWID (99% male) was 21.0%. Longer injecting duration (Odds ratio [OR] 1.06 [95% confidence interval: 1.02-1.10]; per year), higher injecting frequency (OR 1.67 [1.30-2.13]; per unit increase), and injecting heroin (OR 1.90 [1.11-3.25]) were positively associated with HIV prevalence. There was no association between using a used syringe at last injection and HIV. Having>10 years of education had lower odds of HIV than being illiterate (OR 0.58 [0.35-0.95]). Having a regular sexual partner (OR 0.74 [0.57-0.97]) or paying for sex with the opposite sex (OR = 0.62 [0.45-0.85]) had lower odds of HIV than not. Conversely, PWID paying a man/hijra for sex had higher odds of HIV (OR 1.20 [1.00-1.43]). Receipt of clean needles varied by city of residence (0-97% coverage), whilst PWID with knowledge of HIV service delivery programs had higher odds of receiving clean needles (OR 4.58 [3.50-5.99]). Injecting behaviors were associated with HIV prevalence among PWID, though risks related to paying for sex remain complicated. Geographical variation in access to clean needles suggests potential benefits of more widely spread public health services.

Key MessagesWhat is already known on this topicThe HIV epidemic in Pakistan is concentrated among key populations including people who inject drugs.What this study addsInjecting practices, sexual behaviors, and socio-economic factors are associated with HIV prevalence among people who inject drugs. Access to harm reduction services is varied in Pakistan.How this study might affect research, practice, or policyAccess to clean free needles, as well as service delivery programs, with a broad geographical reach remain important to curb the HIV epidemic among people who inject drugs in Pakistan.

HIV acquisition prior to entry into formal sex work: inference from next-generation viral sequencing.

OBJECTIVE: To infer the timing of HIV acquisition in relation to self-reported events in the sexual life course of adolescent girls and young women (AGYW) who self-identify as female sex workers (FSW) in Mombasa, Kenya. DESIGN: Next-generation viral sequencing of samples of AGYW living with HIV in the Transitions study, a cross-sectional bio-behavioural survey of AGYW aged 14-24 years in Mombasa, Kenya. METHOD: Dried blood spot specimens were collected from study participants ( n  = 37, all FSW). A portion of the HIV pol gene was sequenced using an in-house next-generation sequencing assay for HIV drug resistance mutation genotyping. Estimated time since infection (ETI) was inferred using the HIV EVO web-based tool ( https://hiv.biozentrum.unibas.ch/ETI/ ), and data on self-reported events were obtained from the survey. RESULTS: The median ETI among FSW was 3.4 (interquartile range = 1.7, 6.3) years, with a median ETI of 1.5 years prior to entry into formal sex work. We estimated that 74.1% (95% confidence interval = 53.7-88.9%) of participants living with HIV and who self-identified as FSW likely acquired HIV prior to self-identification as a sex worker. CONCLUSIONS: Findings suggest a large fraction of prevalent HIV infection among AGYW engaged in sex work stems from acquisition prior to entry into formal sex work. Current HIV prevention programs tailored for sex workers may miss key opportunities for HIV prevention as they are designed to reach women after entry into formal sex work, signaling a need for tailored programs to reach high-risk AGYW earlier on in their sexual life course.

Understanding the rise in traditional contraceptive methods use in Uttar Pradesh, India.

BACKGROUND: The sustainable development goals (SDG) aim at satisfying three-fourths of family planning needs through modern contraceptive methods by 2030. However, the traditional methods (TM) of family planning use are on the rise, along with modern contraception in Uttar Pradesh (UP), the most populous Indian state. This study attempts to explore the dynamics of rising TM use in the state. METHODS: We used a state representative cross-sectional survey conducted among 12,200 Currently Married Women (CMW) aged 15-49 years during December 2020-February 2021 in UP. Using a multistage sampling technique, 508 primary sampling units (PSU) were selected. These PSU were ASHA areas in rural settings and Census Enumeration Blocks in urban settings. About 27 households from each PSU were randomly selected. All the eligible women within the selected households were interviewed. The survey also included the nearest public health facilities to understand the availability of family planning methods. Univariate and bivariate analyses were conducted. Appropriate sampling weights were applied. RESULTS: Overall, 33.9% of CMW were using any modern methods and 23.7% any TM (Rhythm and withdrawal) at the time of survey. The results show that while the modern method use has increased by 2.2 percentage points, the TM use increased by 9.9 percentage points compared to NFHS-4 (2015-16). The use of TM was almost same across women of different socio-demographic characteristics. Of 2921 current TM users, 80.7% started with TM and 78.3% expressed to continue with the same in future. No side effects (56.9%), easy to use (41.7%) and no cost incurred (38.0%) were the main reasons for the continuation of TM. TM use increased despite a significant increase (66.1 to 81.3%) in the availability of modern reversible methods and consistent availability of limiting methods (84.0%) in the nearest public health facilities. CONCLUSION: Initial contraceptive method was found to have significant implications for current contraceptive method choice and future preferences. Program should reach young and zero-parity women with modern method choices by leveraging front-line workers in rural UP. Community and facility platforms can also be engaged in providing modern method choices to women of other parities to increase modern contraceptive use further to achieve the SDG goals.

In Uttar Pradesh, the use of traditional methods of contraception is on the rise, observed similarly in many other Indian states in recent times. The emphasis on modern contraceptive methods and the rise and high prevalence of traditional method use in the state call for a systematic assessment to understand the dynamics such as patterns, prevalence and reasons for traditional method use for better family planning programming. Using a state representative cross-sectional survey data from Uttar Pradesh, we attempted to understand the dynamics of increasing traditional methods use. We found no significant variations in use of traditional methods by their socio-demographic characteristics. Not only that, most current traditional method users reported that their first method was a traditional method and an overwhelming proportion of women (4/5 traditional methods users) expressed to continue with the same method in future. Also the findings reveal that more than half of the traditional method users used the method consistently over the three-years calendar period. Among those who had unmet need at the time of survey, a considerable proportion of them intend to use traditional methods in future. This emphasized the importance of initial contraceptive method choice on current contraceptive use and future preference. Traditional methods use increased in the state despite a significant increase (66.1 to 81.3% during 2018 to 2021) in availability of modern reversible methods and consistent availability of limiting method (84.0%) in public health facilities.

Declining fertility and increasing use of traditional methods of family planning: a paradox in Uttar Pradesh, India?

Uttar Pradesh (UP), with more than 220 million people, is the most populous state in India. Despite a high unmet need for modern family planning methods, the state has experienced a substantial decline in fertility. India has also seen a decline during this period which can be attributed to the increased prevalence of modern methods of family planning, particularly female sterilisation, but in UP, the corresponding increase was marginal. At the same time, Traditional Family Planning Methods (TMs) increased significantly in UP in contrast to India, where it was marginal. The trends in UP raise questions about the drivers in fertility decline and question the conventional wisdom that fertility declines are driven by modern methods, and the paper aims to understand this paradox. Fertility trends and family planning practices in UP were analysed using data from different rounds of National Family Health Surveys (NFHS) and the two UP Family Planning Surveys conducted by the UP Technical Support Unit to understand whether the use of TMs played a role in the fertility decline. As per NFHS-4, the prevalence of TM in India (6%) was less than half that of UP (13%). The UP Family Planning Survey in 25 High Priority Districts estimated that 22% of women used TMs. The analysis also suggested that availability and accessibiility of modern contraceptives might have played a role in the increased use of TMs in UP. If there are still couples who make a choice in favour of TMs, they should be well informed about the risks associated with the use of traditional methods as higher failure rate is observed among TMs users.

Improving Community Health Worker Compensation: A Case Study From India Using Quantitative Projection Modeling and Incentive Design Principles.

INTRODUCTION: Although community health workers (CHWs) are effective at mobilizing important health behaviors, there is limited evidence on how financial incentive systems can best be designed to drive their effectiveness. This study intends to bridge this evidence gap by analyzing the compensation model of India's accredited social health activist (ASHA) program and identifying areas of improvement in the system's design and implementation. METHODS: We analyze the ASHA program in Uttar Pradesh, India. ASHAs receive compensation through a mix of program-linked, performance-based, and routine activity-based incentive structures. Using multiple data sources, including a novel linked household and ASHA survey, we estimate ASHA performance-linked incentive earnings under different scenarios of ASHA actions and household behaviors. Juxtaposing statistical projection models and actual government payments, we identified which incentives promised the highest payments, which were claimed or not, which could be claimed more by increasing ASHA actions, and which were paid despite not meeting payment criteria. We also report findings on ASHA awareness of and experiences with claiming incentives. RESULTS: We find crucial gaps and implementation challenges in the ASHA incentive structure. ASHAs could double their earnings by completing certain tasks within their control. ASHAs may also be paid for partial completion of activities, as incentives are paid in lump sums for a series of activities rather than for each activity. Family planning incentives have the largest gap between potential and actual earnings. Incentivizing ASHAs for achieving certain health outcomes is inefficient, as no clear linkage was found between the achievability of such health outcomes and the claim amounts. CONCLUSION: There are several opportunities for improving CHW compensation, from improving the incentive claims process to shifting focus to achievable outcomes. Optimizing incentive system designs can further enhance CHW effectiveness globally to affect key health behaviors.

Optimizing the Health Management Information System in Uttar Pradesh, India: Implementation Insights and Key Learnings.

An effective health management information system (HMIS) that captures accurate, consistent, and relevant data in a timely fashion can enable better planning and monitoring of health programs and improved service delivery, in turn helping increase the impact of different interventions. In 2009, the Government of Uttar Pradesh (GOUP) implemented HMIS, India's national-level health information platform. However, key challenges, including difficulties in accessing the data through a web-based portal and its limited relevance to decision making and managerial needs, reduced its usability at the district and state levels. In 2015, with the support of the Uttar Pradesh Technical Support Unit, the GOUP created its own data platform, the Uttar Pradesh HMIS (UP-HMIS), to capture data elements missing from HMIS but important to UP decision makers. The UP-HMIS was redesigned to capture these data elements to holistically measure and monitor the performance of health programs and inform decision making at the district and state levels. In addition, the GOUP implemented complementary initiatives to improve data quality and data use processes. To improve HMIS data quality, the GOUP established data validation committee meetings at the block, district, and state levels. To promote the use of these validated data, in 2017, the GOUP developed and implemented the UP Health Dashboard, which ranks each of UP's 75 districts on a set of key HMIS priority health indicators. These policy guidelines have brought greater attention to UP-HMIS data quality and use; however, additional strengthening is required to improve the quality and use of HMIS data. There is a need to increase the overall capacity and understanding of HMIS data, not only for staff with specific data-related responsibilities but also for program managers and senior decision makers.

Advancing Sexual Harassment Prevention and Elimination in the Sciences: "Every ... Health Organization Must Do Something Similar".

BACKGROUND: Sexual harassment is pervasive in science. A 2018 report found that the prevalence of sexual harassment in academia in the United States is 58%. An activity held at an international scientific congress was designed to advance sexual harassment prevention and elimination and empower binary and nonbinary persons at risk for harassment, discrimination, and violence. The objective is to describe the activity and outcomes to provide a promising model for other scientific communities. METHODS: A description of the plenary and key components as well as the data collection and analysis of selected outcomes are provided. RESULTS: Among 1338 congress participants from 61 countries, 526 (39%) attended the #MeToo plenary, and the majority engaged in some way during the plenary session. Engagement included standing for the pledge (~85%), participating in the question and answer session (n = 5), seeking counseling (n = 3), and/or providing written post-it comments (n = 96). Respondents to a postcongress survey (n = 388 [24% of all attendees]) ranked the plenary as number 1 among 14 congressional plenaries. In postanalysis, the written post-it comments were sorted into 14 themes within 6 domains, including: (1) emotional responses, (2) barriers to speaking out, (3) public health priorities, (4) reframing narratives about the issue, (5) allyship, and (6) moving the issue forward. CONCLUSIONS: Scientific organizations, agencies, and institutions have an important role to play in setting norms and changing enabling policies toward a zero-tolerance culture of sexual harassment. The activity presented offers a promising model for scientific communities with similar goals. The outcomes suggest that the plenary successfully engaged participants and had a measurable impact on the participants.

Indirect effects of COVID-19 pandemic on reproductive, maternal, newborn and child health services in Pakistan.

Background: COVID-19 is having many impacts on health, economy and social life; some due to the indirect effects of closure of health facilities to curb the spread. Closures were implemented in Pakistan from March 2020, affecting provision of reproductive, maternal, newborn and child health (RMNCH) services. Aims: To appraise the effects of containment and lockdown policies on RMNCH service utilization in order to develop an early response to avoid the catastrophic impact of COVID-19 on RMNCH in Pakistan. Methods: Routine monitoring data were analysed for indicators utilization of RMNCH care. The analysis was based on Period 1 (January-May 2020, first wave of COVID-19); Period 2 (June-September 2020, declining number of cases of COVID-19); and Period 3 (October-December 2020, second wave of COVID-19). We also compared data from May and December 2020 with corresponding months in 2019, to ascertain whether changes were due to COVID-19. Results: Reduced utilization was noted for all RMNCH indicators during Periods 1 and 3. There was a greater decline in service utilization during the first wave, and the highest reduction (~82%) was among children aged < 5 years, who were treated for pneumonia. The number of caesarean sections dropped by 57%, followed by institutional deliveries and first postnatal visit (37% each). Service utilization increased from June to September, but the second wave of COVID-19 led to another decrease. Conclusion: To reinstate routine services, priority actions and key areas include continued provision of family planning services along with uninterrupted immunization campaigns and routine maternal and child services.

Remaking the Technosubject: Kenyan Men Contextualizing HIV Self-Testing Technologies.

The Kenyan government offers free HIV self-testing kits to men who have sex with men. The value of self-testing is based on the imaginary of an autonomous technosubject empowered to independently control testing services, thereby "freed," through technology, from the social conditions that might inhibit health services utilization. Following a community-centered collaborative approach, community researchers interviewed their peers who examined and reacted to the technology. Participants reframed the technosubject as intertwined with the social world and the testing kit itself as an object that exerts agency and possesses affective potential. Attending to these socio-material relationalities offers insights into program planning.

Exploring the dynamics of workplace typologies for sex workers in Eastern Ukraine.

We examine the typologies of workplaces for sex workers in Dnipro, Ukraine as part of the larger Dynamics Study, which explores the influence of conflict on sex work. We conducted a cross-sectional survey with 560 women from September 2017 to October 2018. The results of our study demonstrate a diverse sex work environment with heterogeneity across workplace typologies in terms of remuneration, workload, and safety. Women working in higher prestige typologies earned a higher hourly wage, however client volume also varied which resulted in comparable monthly earnings from sex work across almost all workplace types. While sex workers in Dnipro earn a higher monthly wage than the city mean, they also report experiencing high rates of violence and a lack of personal safety at work. Sex workers in all workplaces, with the exception of those working in art clubs, experienced physical and sexual violence perpetrated by law enforcement officers and sex partners. By understanding more about sex work workplaces, programmes may be better tailored to meet the needs of sex workers and respond to changing work environments due to ongoing conflict and COVID-19 pandemic.

Healthcare utilization among persons living with HIV in Manitoba, Canada, prior to HIV diagnosis: A case-control analysis.

BACKGROUND: Understanding care patterns of persons living with HIV prior to diagnosis can inform prevention opportunities, earlier diagnosis, and engagement strategies. We examined healthcare utilization among HIV-positive individuals and compared them to HIV-negative controls. METHODS: Data were from a retrospective cohort from Manitoba, Canada. Participants included individuals living with HIV presenting to care between 2007 and 2011, and HIV-negative controls, matched (1:5) by age, sex, and region. Data from population-based administrative databases included physician visits, hospitalizations, drug dispensation, and chlamydia and gonorrhea testing. Diagnoses associated with physician visits were classified according to International Classification of Diseases chapters. Conditional logistic regression models were used to compare cases/controls, with adjusted odds ratios (AORs) and their 95% confidence intervals (95% CI) reported. RESULTS: A total of 193 cases and 965 controls were included. Physician visits and hospitalizations were higher for cases, compared to controls. In the 2 years prior to case date, cases were more likely to be diagnosed with "blood disorders" (AOR: 4.2, 95% CI: 2.0-9.0), be treated for mood disorders (AOR: 2.4, 95% CI: 1.6-3.4), and to have 1+ visits to a hospital (AOR: 2.2, 95% CI: 1.4-3.6). CONCLUSION: Opportunities exist for prevention, screening, and earlier diagnosis. There is a need for better integration of healthcare services with public health.

Understanding the Prevalence and Geographic Heterogeneity of SARS-CoV-2 Infection: Findings of the First Serosurvey in Uttar Pradesh, India.

Population-based serological antibody test for SARS-CoV-2 infection helps in estimating the exposure in the community. We present the findings of the first district representative seroepidemiological survey conducted between 4 and 10 September 2020 among the population aged 5 years and above in the state of Uttar Pradesh, India. Multi-stage cluster sampling was used to select participants from 495 primary sampling units (villages in rural areas and wards in urban areas) across 11 selected districts to provide district-level seroprevalence disaggregated by place of residence (rural/urban), age (5-17 years/aged 18 +) and gender. A venous blood sample was collected to determine seroprevalence. Of 16,012 individuals enrolled in the study, 22.2% [95% CI 21.5-22.9] equating to about 10.4 million population in 11 districts were already exposed to SARS-CoV-2 infection by mid-September 2020. The overall seroprevalence was significantly higher in urban areas (30.6%, 95% CI 29.4-31.7) compared to rural areas (14.7%, 95% CI 13.9-15.6), and among aged 18 + years (23.2%, 95% CI 22.4-24.0) compared to aged 5-17 years (18.4%, 95% CI 17.0-19.9). No differences were observed by gender. Individuals exposed to a COVID confirmed case or residing in a COVID containment zone had higher seroprevalence (34.5% and 26.0%, respectively). There was also a wide variation (10.7-33.0%) in seropositivity across 11 districts indicating that population exposed to COVID was not uniform at the time of the study. Since about 78% of the population (36.5 million) in these districts were still susceptible to infection, public health measures remain essential to reduce further spread.

Association of identification of facility and transportation for childbirth with institutional delivery in high priority districts of Uttar Pradesh, India.

BACKGROUND: Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India. METHODS: A community-based cross-sectional survey was conducted between June-October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery. RESULTS: Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06-1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46-1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04-1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46-1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07-8.08). CONCLUSION: The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India.

Establishing evidence-based decision-making mechanism in a health eco-system and its linkages with health service coverage in 25 high-priority districts of Uttar Pradesh, India.

BACKGROUND: Achievement of successful health outcomes depends on evidence-based programming and implementation of effective health interventions. Routine Health Management Information System is one of the most valuable data sets to support evidence-based programming, however, evidence on systemic use of routine monitoring data for problem-solving and improving health outcomes remain negligible. We attempt to understand the effects of systematic evidence-based review mechanism on improving health outcomes in Uttar Pradesh, India. METHODS: Data comes from decision-tracking system and routine health management information system for period Nov-2017 to Mar-2019 covering 6963 health facilities across 25 high-priority districts of the state. Decision-tracking data captured pattern of decisions taken, actions planned and completed, while the latter one provided information on service coverage outcomes over time. Three service coverage indicators, namely, pregnant women receiving 4 or more times ANC and haemoglobin testing during pregnancy, delivered at the health facility, and receive post-partum care within 48 h of delivery were used as outcomes. Univariate and bivariate analyses were conducted. RESULTS: Total 412 decisions were taken during the study reference period and a majority were related to ante-natal care services (31%) followed by delivery (16%) and post-natal services (16%). About 21% decisions-taken were focused on improving data quality. By 1 year, 67% of actions planned based on these decisions were completed, 26% were in progress, and the remaining 7% were not completed. We found that, over a year, districts witnessing > 20 percentage-point increase in outcomes were also the districts with significantly higher action completion rates (> 80%) compared to the districts with < 10 percentage-point increase in outcomes having completion of action plans around 50-70%. CONCLUSIONS: Findings revealed a significantly higher improvement in coverage outcomes among the districts which used routine health management data to conduct monthly review meetings and had high actions completion rates. A data-based review-mechanisms could specifically identify programmatic gaps in service delivery leading to strategic decision making by district authorities to bridge the programmatic gaps. Going forward, establishing systematic evidence-based review platforms can be an important strategy to improve health outcomes and promote the use of routine health monitoring system data in any setting.

Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs in Pakistan.

BACKGROUND: Pakistan's explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations. METHODS: Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005-2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence. RESULTS: Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%-79.7%), 45.9% (95% UI, 8.1%-78.4%), and 22.2% (95% UI, 2.0%-58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%-82.0%), 53.0% (95% UI, 11.3%-80.2%), and 28.1% (95% UI, 2.7%-66.6%), respectively, over 10 years. CONCLUSIONS: Interventions should focus on these risk factors to control Pakistan's explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy.

Blocking α4ß7 integrin delays viral rebound in SHIVSF162P3-infected macaques treated with anti-HIV broadly neutralizing antibodies.

Anti-HIV broadly neutralizing antibodies (bNAbs) may favor development of antiviral immunity by engaging the immune system during immunotherapy. Targeting integrin α4ß7 with an anti-α4ß7 monoclonal antibody (Rh-α4ß7) affects immune responses in SIV/SHIV-infected macaques. To explore the therapeutic potential of combining bNAbs with α4ß7 integrin blockade, SHIVSF162P3-infected, viremic rhesus macaques were treated with bNAbs only (VRC07-523LS and PGT128 anti-HIV antibodies) or a combination of bNAbs and Rh-α4ß7 or were left untreated as a control. Treatment with bNAbs alone decreased viremia below 200 copies/ml in all macaques, but seven of eight macaques (87.5%) in the bNAbs-only group rebounded within a median of 3 weeks (95% CI: 2 to 9). In contrast, three of six macaques treated with a combination of Rh-α4ß7 and bNAbs (50%) maintained a viremia below 200 copies/ml until the end of the follow-up period; viremia in the other three macaques rebounded within a median of 6 weeks (95% CI: 5 to 11). Thus, there was a modest delay in viral rebound in the macaques treated with the combination antibody therapy compared to bNAbs alone. Our study suggests that α4ß7 integrin blockade may prolong virologic control by bNAbs in SHIVSF162P3-infected macaques.