Service utilization and cost of implementing a comprehensive HIV prevention and care program among people who inject drugs in Delhi, India.

BACKGROUND: WHO, UNODC, and UNAIDS recommend a comprehensive package for prevention, treatment, and care of HIV among people who inject drugs (PWID). We describe the uptake of services and the cost of implementing a comprehensive package for HIV prevention, treatment, and care services in Delhi, India. METHODS: A cohort of 3774 PWID were enrolled for a prospective HIV incidence study and provided the comprehensive package: HIV and hepatitis testing and counseling, hepatitis B (HB) vaccination, syndromic management of sexually transmitted infections, clean needles-syringes, condoms, abscess care, and education. Supplementary services comprising tea and snacks, bathing facilities, and medical consultations were also provided. PWID were referred to government services for antiretroviral therapy (ART), TB care, opioid substitution therapy, and drug dependence treatment/rehabilitation. RESULTS: The project spent USD 1,067,629.88 over 36 months of project implementation: 1.7% on capital costs, 3.9% on participant recruitment, 26.7% for project management, 49.9% on provision of services, and 17.8% on supplementary services. Provision of HIV prevention and care services cost the project USD 140.41/PWID/year. 95.3% PWID were tested for HIV. Of the HIV-positive clients, only 17.8% registered for ART services after repeated follow-up. Reasons for not seeking ART services included not feeling sick, need for multiple visits to the clinic, and long waiting times. 61.8% of the PWID underwent HB testing. Of the 2106 PWID eligible for HB vaccination, 81% initiated the vaccination schedule, but only 29% completed all three doses, despite intensive follow-up by outreach workers. PWID took an average of 8 clean needles-syringes/PWID/year over the project duration, with a mid-project high of 16 needles-syringes/PWID/year. PWID continued to also procure needles from other sources, such as chemists. One hundred five PWID were referred to OST services and 267 for rehabilitation services. CONCLUSIONS: A comprehensive HIV prevention, treatment, and care package is challenging to implement. Extensive efforts are needed to ensure the uptake of and retention in services for PWID; peer educators and outreach workers are required on a continuous basis. Services need to be tailored to client needs, considering clinic timing and distance from hotspots. Programs may consider provision of ART services at selected drop-in centers to increase uptake.

HIV, Hepatitis B and C among people who inject drugs: high prevalence of HIV and Hepatitis C RNA positive infections observed in Delhi, India.

BACKGROUND: India has large PWID (persons who inject drugs) population estimated at 177,000. PWIDs are at high risk for HIV, Hepatitis B (HBV) and Hepatitis C (HCV) infections. We report the prevalence of HIV, HBV and HCV infections and correlates of HIV-HCV co-infection among male PWIDs in Delhi. METHODS: 3748 male PWIDs were recruited for a longitudinal HIV incidence study. Participants were tested for HBV and HCV infections at their first follow-up visit (FV1) using serum HBV-surface antigen, and HCV-antibody tests followed by HCV RNA PCR, respectively. All PWIDs who were HIV-negative at enrollment, were re-tested for HIV at FV1. Multinomial logistic regression was employed to identify predictors of HIV, HCV and HIV-HCV co-infection. RESULTS: Overall prevalence of HIV, HBV and HCV among 2,292 participants tested at FV1 was 25.9%, 9.7% and 53.7%, respectively. 6.4% of the participants had HIV mono-infection, 34.1% had HCV mono-infection, and 19.6% had HIV-HCV co-infection. 26% of HIV-positive participants without HCV were HBsAg positive. In the regression model, having practiced at least one risky injection in the past month (relative risk ratio (RRR): 1.38; 95% CI: 1.01-1.89) and not knowing his own HIV status (RRR: 1.65, 95% CI: 1.25-2.17) were independent predictors for HIV-HCV co-infection. Longer duration of drug injections was associated with a higher likelihood of HCV mono-infection (2-5 years RRR: 2.13; 6-10 years RRR: 2.74; ≥11 years RRR: 3.14) and HIV-HCV co-infection (2-5 years RRR: 5.14; 6-10 years RRR: 8.53; >11 years RRR: 8.03). Higher frequency of injection days/month was associated with a higher likelihood of HCV mono-infection (≤10 days/month RRR: 1.61; 11-20 days/month RRR: 3.15; 21-30 days/month RRR: 3.47) and HIV-HCV co-infections (≤10 days/month RRR: 2.26; 11-20 days/month RRR: 3.46; 21-30 days/month RRR: 4.83). CONCLUSIONS: We report a high prevalence of HIV, HCV and HIV-HCV co-infection among male PWIDs in Delhi. A tenth of the participants were HBsAg positive. Targeted Intervention programs should make HBV/HCV testing, prevention and care more accessible for PWIDs.

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India.

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

High uptake of HIV testing in a cohort of male injection drug users in Delhi, India: prevalence and correlates of HIV infection.

We report baseline findings from a longitudinal cohort study to examine HIV incidence, high-risk injection and sexual behaviors of 3,792 male injection drug users (IDUs) in Delhi. The majority (95.4 %) accepted HIV testing; HIV prevalence was 21.9 %. In multivariate analysis, belonging to states adjacent to Delhi (AOR: 1.23; 95 % CI: 1.07-1.52), earning INR 500-1,500 (AOR: 2.38; 95 % CI: 1.43-3.96); duration of drug use 2-5 years (AOR: 2.02; 95 % CI: 1.09-3.73), 6-10 years (AOR: 2.81; 95 % CI: 1.55-5.11), ≥11 years (AOR: 3.35; 95 % CI: 1.84-6.11); prior HIV testing (AOR: 1.60; 95 % CI: 1.35-1.91), self-reported risky-injection behavior (AOR: 1.60; 95 % CI: 1.33-1.92), and utilization of harm-reduction services (AOR: 1.32; 95 % CI: 1.11-1.58) were positively associated with HIV infection. Alcohol use ≤2 times/week (AOR: 0.67; 95 % CI: 0.55-0.82) or ≥3 times/week (AOR: 0.74; 95 % CI: 0.54-1.01), unit increase in age (AOR: 0.99; 95 % CI: 0.98-1.00), ≥7 years of schooling (AOR: 0.82; 95 % CI: 0.66-1.02) and unsafe sex with any female partner (AOR: 0.69; 95 % CI: 0.55-0.86) were negatively associated with HIV infection. HIV prevalence remains high among male IDUs in Delhi. HIV prevention programs should include comprehensive package of services for IDUs.

Strategies for recruiting injection drug users for HIV prevention services in Delhi, India.

BACKGROUND: We utilized multiple recruitment approaches to recruit IDUs in a longitudinal cohort study to examine HIV incidence and behavior change pre- and post-introduction of comprehensive HIV prevention services. METHODS: IDUs were recruited through peer referral, targeted outreach by outreach workers (ORWs) and as walk-in clients at drop-in centers. Participants received monetary compensation for participation (USD 0.80). Participants were given recruitment coupons to recruit peers (regardless of recruitment method). For peer referral, participants received a food coupon, as secondary compensation, for each peer he/she successfully recruited. We report the profile of IDUs by recruitment method, based on the baseline behavioral survey and HIV test results. Cost per IDU recruited by recruitment method was also calculated. RESULTS: A total of 3,818 IDUs were recruited between May 2011 and October 2011. More than half of the study participants were recruited through targeted outreach (ORW: 53.6%; peer-referral: 26.3%; walk-ins: 20.1%). Of the participants who were given recruitment coupons, 92.7% recruited no peers. Those who successfully recruited at least one peer were significantly more likely to be in a stable living accommodation compared to those who did not recruit any peers (51.1% versus 42.7%; p < 0.05). Only 45.9% of the food coupons were claimed for successful recruitment of peers. Peer-referred IDUs were more likely to be living with family or relatives (50.7% versus ORW: 40.1% and walk-in: 39.8%; p < 0.001) rather than on the street or shared housings compared to the other two recruitment modes. Walk-ins were more likely than peer-referred and ORW-referred IDUs to be HIV-positive (walk-ins: 26.1%; peer-referred: 19.1%; ORW: 19.9%; p < 0.01) and have risky injection practices (walk-ins: 62.2%; ORW: 57.0%; peer-referred: 58.6%; p < 0.05). The cost per IDU recruited through ORW referral method was the most costly at USD 16.30, followed by peer-referral at USD 8.40 and walk-in at USD 7.50. CONCLUSION: When recruiting a large number of IDUs, using multiple recruitment modes is ideal with regard to diversification of IDU characteristics and risk profile. Although it was the most costly, ORW recruitment was more effective than the other two methods. Lack of monetary compensation for successful recruitment of peers may have hampered peer-referral.

Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India.

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.

Prevalence of refractive errors among school-going children in a multistate study in India.

AIM: Much existing data on childhood refractive error prevalence in India were gathered in local studies, many now dated. The aim of this study was to estimate the prevalence, severity and determinants of refractive errors among school-going children participating in a multistate vision screening programme across India. METHODS: In this cross-sectional study, vision screening was conducted in children aged 5-18 years at schools in five states using a pocket vision screener. Refractive error was measured using retinoscopy, and subjective refraction and was defined both by spherical equivalent (SE) and spherical ametropia, as myopia ≤-0.5 diopters (D), hyperopia ≥+1.0 D and/or astigmatism as >0.5 D. Data from the eye with less refractive error were used to determine prevalence. RESULTS: Among 2 240 804 children (50.9% boys, mean age 11.5 years, SD ±3.3), the prevalence of SE myopia was 1.57% (95% CI 1.54% to 1.60%) at 5-9 years, 3.13% (95% CI 3.09% to 3.16%) at 10-14 years and 4.8% (95% CI 4.73% to 4.86%) at 15-18 years. Hyperopia prevalence was 0.59% (95% CI 0.57% to 0.61%), 0.54% (95% CI 0.53% to 0.56%) and 0.39% (95% CI 0.37% to 0.41%), respectively. When defined by spherical ametropia, these values for myopia were 0.84%, 2.50% and 4.24%, and those for hyperopia were 2.11%, 2.41% and 2.07%, respectively.Myopia was associated with older age, female gender, private school attendance, urban location and state. The latter appeared to be driven by higher literacy rates. CONCLUSIONS: Refractive error, especially myopia, is common in India. Differences in prevalence between states appear to be driven by literacy rates, suggesting that the burden of myopia may rise as literacy increases.

Relationship between reported prior condom use and current self-perceived risk of acquiring HIV among mobile female sex workers in southern India.

BACKGROUND: With the evolution of Health Belief Model, risk perception has been identified as one of several core components of public health interventions. While female sex workers (FSWs) in India continue to be at most risk of acquiring and transmitting HIV, little is known about their perception towards risk of acquiring HIV and how this perception depends upon their history of consistent condom use behavior with different type of partners. The objective of this study is to fill this gap in the literature by examining this relationship among mobile FSWs in southern India. METHODS: We analyzed data for 5,413 mobile FSWs from a cross-sectional behavioral survey conducted in 22 districts from four states in southern India. This survey assessed participants' demographics, condom use in sex with different types of partners, continuation of sex while experiencing STI symptoms, alcohol use before having sex, and self-perceived risk of acquiring HIV. Descriptive analyses and multilevel logistic regression models were used to examine the associations between risky sexual behaviors and self-perceived risk of acquiring HIV; and to understand the geographical differences in HIV risk perception. RESULTS: Of the total mobile FSWs, only two-fifths (40%) perceived themselves to be at high risk of acquiring HIV; more so in the state of Andhra Pradesh (56%) and less in Maharashtra (17%). FSWs seem to assess their current risk of acquiring HIV primarily on the basis of their past condom use behavior with occasional clients and less on the basis of their past condom use behaviors with regular clients and non-paying partners. Prior inconsistent condom use with occasional clients was independently associated with current perception of high HIV risk (adjusted odds ratio [aOR)] = 2.1, 95% confidence interval [CI]: 1.7-2.6). In contrast, prior inconsistent condom use with non-paying partners was associated with current perception of low HIV risk (aOR= 0.7, 95% CI: 0.5-0.9). The congruence between HIV risk perception and condom use with occasional clients was high: only 12% of FSWs reported inconsistent condom use with occasional clients but perceived themselves to be at low risk of acquiring HIV. CONCLUSION: The association between high risk perception of acquiring HIV and inconsistent condom use, especially with regular clients and non-paying partners, has not been completely internalized by this high risk group of mobile FSWs in India. Motivational efforts to prevent HIV should emphasize the importance of accurately assessing an individual's risk of acquiring HIV based on condom use behavior with all types of partners: occasional and regular clients as well as non-paying partners; and encourage behavior change based on an accurate self-assessment of HIV risk.

Spatial, temporal, and dietary determinants of organic contaminants in nestling tree swallows in Point Pelee National Park, Ontario, Canada.

Point Pelee National Park of Canada in southwestern Ontario, an important migratory route and vital breeding area for many birds, has localized areas of organochlorine (OC) pesticide contamination from agricultural production during the 1950s and 1960s. During 2001 and 2002, we investigated movement of persistent contaminants through the food web with the insectivorous tree swallow (Tachycineta bicolor) as a sentinel. The a priori site classifications, contaminated or reference, were based on soil residues of dichlorodiphenyltrichloroethane (DDT) and its breakdown products (sigmaDDT), dieldrin, and other OC pesticides. In 2001, all nestling tissue samples were pooled by site, and residue levels did not reflect the soil contaminant status. To improve sampling accuracy in 2002, tissue residues were determined from birds in individual nests. This showed OC pesticides to be higher in samples from contaminated sites compared with reference sites (p = 0.031). Polychlorinated biphenyls (PCBs), which were not detected in soil samples, were present in the nestlings and were not related to site of origin (p = 0.422). In 2002, dietary samples were collected from nestlings and identified to taxon, and representative insects collected from nesting sites were analyzed for PCBs and other OCs. Consumption of terrestrial prey was positively correlated with tissue residues of sigmaDDT (p = 0.006), whereas PCBs came from aquatic prey, Hexagenia mayflies (p = 0.003). Dietary details proved valuable in this study of contaminant transfer in insectivorous vertebrates.

The impact of aging physiology in critical care.

Aging physiology greatly impacts care delivery in the geriatric patient population. Consideration should be given to addressing the patient-specific needs regarding the systemic changes seen in the aging patient. Each major body system presents its own unique challenges to the critical care practitioner, and a comprehensive understanding of these changes is necessary to effectively care for this patient population. This article summarizes these changes and provides key points for the practitioner to consider when caring for the aging patient in the critical care arena.

Pretreatment loss-to-follow-up after HIV diagnosis from 27 counseling and testing centers across India: findings from a cohort study.

Individuals testing HIV positive were interviewed at testing centers, followed prospectively and interviewed again when they registered at referral antiretroviral therapy (ART) centers (ARTCs). Those who did not register at ARTCs were traced and interviewed in the community. A total of 1057 newly diagnosed people living with HIV (PLHIV; 52% women; mean age, 34.7 years) were recruited. A total of 73.5% of PLHIV registered at referral ARTCs within 60 days, 17.9% did not register and were interviewed in the community, and 8.6% were not interviewed. The 2 main reasons cited for not registering were a perception of good health (30%) and work/family engagements (22%). Single clients (adjusted relative risk [ARR]: 1.54; 95% confidence interval [CI]: 1.02-2.34), participants who had not disclosed their HIV status (ARR: 2.32; 95%CI: 1.77-3.05), participants who knew a PLHIV (ARR: 1.89; 95% CI: 1.41-2.53), and participants from laborer households (ARR: 2.66; 95%CI:1.15-6.15) were more likely to not register. In conclusion, the majority of newly diagnosed PLHIV do reach ARTCs. Disclosure concerns and a perception of good health prevent PLHIV from accessing services.

High HIV incidence in a cohort of male injection drug users in Delhi, India.

BACKGROUND: India has an estimated 177,000 injection drug users (IDU) with a national HIV prevalence of 7.14%. Reliable estimates of HIV incidence are not available for this population. METHODS: We report HIV incidence in a cohort of male, HIV-negative IDUs recruited through peer-referral, targeted outreach and as walk-in clients in Delhi from May to October, 2011. Fourth-generation Antigen-Antibody tests were used to diagnose new infections and results were confirmed using Western blot tests. HIV incidence based on HIV seroconversion was calculated as number of events/person-years. Cox regression was used to identify significant (p<0.05) seroconversion predictors. RESULTS: A total of 2790 male HIV-negative IDUs were recruited at baseline; 67.4% (n=1880) returned for their first follow-up visit and 96% (n=1806) underwent HIV testing. Participants were followed for a median of 9.7 months. A total of 112 new HIV infections occurred over a cumulative 1398.5 person-years of follow-up resulting in an incidence rate of 8.01 new infections/100 person-years (95% CI: 6.65-9.64); 74% of these participants reported risky injection practices in the past month. In multivariate analysis, moderate-high risk injection behaviors (Adjusted Hazard Ratio [AHR] 2.59; 95% CI 1.45-4.62) were associated with a higher risk of new infections. CONCLUSIONS: Male IDUs in Delhi continue to practice unsafe injection practices leading to high sero-incidence despite the availability of HIV prevention services offered through targeted intervention programs.

Increasing postpartum contraception in rural India: evaluation of a community-based behavior change communication intervention.

CONTEXT: The Indian family planning program, though successful in increasing contraceptive use among couples who have achieved their desired family size, has not been equally successful in educating couples about the use of contraceptive methods for birth spacing. METHODS: An evaluation was conducted of a behavior change communication intervention integrated into the existing government program to increase knowledge and use of the lactational amenorrhea method and postpartum contraception through counseling by community workers. The intervention, which ran between September 2006 and January 2007, was conducted among 959 pregnant women aged 15-24 who lived in Uttar Pradesh, India. The evaluation used logistic regression analyses to measure differences in knowledge and contraceptive use between baseline and the four- and nine-month postpartum follow-up surveys within and between the intervention and comparison groups. RESULTS: The follow-up data show increases in knowledge of the lactational amenorrhea method and spacing methods and in use of spacing methods. At four months postpartum, women in the intervention group were more likely to know the healthy spacing messages than those in the comparison group (odds ratio, 2.1). At nine months postpartum, women in the intervention group, those with higher knowledge of healthy spacing practices and those with correct knowledge of two or more spacing methods were more likely than others to be using a contraceptive method (1.5-3.5). Use of modern contraceptives for spacing at nine months postpartum was 57% in the intervention group versus 30% in the comparison group. CONCLUSIONS: Targeted behavior change communication using community workers is an effective and feasible strategy for promoting postpartum contraception.

Promoting healthy spacing between pregnancies in India: need for differential education campaigns.

OBJECTIVE: Birth spacing intervals are relatively short in India. Healthy spacing of 3-5 years between births is an effective way to prevent maternal and child mortality and morbidities. Socio-cultural and structural barriers, including limited awareness, socio-cultural norms, and misconceptions need to be addressed for behavior change. Hence the objective was to understand these barriers and accordingly develop separate messages for young women, her husband and her mother-in-law. METHODS: Data were collected from young women, husbands and mothers-in-law using qualitative methods. Altogether 16 Focus Group Discussions and 30 in-depth interviews were conducted. Beliefs related to need of spacing, disadvantages of closely spaced pregnancies and messages considered suitable for different stakeholders were investigated. Messages were identified for women, husband and mother-in-law; communication aids prepared and community workers trained to appropriately communicate the messages to stakeholders. Quantitative data were collected to measure the effect of the intervention. RESULTS: Educational campaign resulted in higher use of contraceptives for spacing among registered pregnant women from experimental area compared to control area. CONCLUSION: Differential audience specific educational campaign is feasible and effective. PRACTICE IMPLICATIONS: For an effective communication in the community, workers should know how exactly to convey the different health messages to different target population.

PCB congener profiles in nestling tree swallows and their insect prey.

Tree swallows (Tachycineta bicolor) are widely used as indicators of local polychlorinated biphenyl (PCB) contamination in North America. Although determining total PCB residues in tissues is useful in environmental monitoring, analysis of PCB congener profiles may reveal sources of contamination and thus prove to be a more refined tool to track contaminants through the food web. To show how differences in PCB congener patterns in birds can be linked to the PCB patterns in their prey, we evaluated PCB congeners in tissues of tree swallow nestlings and their insect prey using principal component analysis and Euclidean similarities. The PC1 scores for PCB residues in nestlings fell between those of the Hexagenia (Ephemeroptera, mayflies) and Chironomidae (Diptera, midges), the two major prey groups of the nestlings. The congener pattern was not related to the location of nest boxes within the study area. However, Hexagenia insects and the nestlings that consumed them were richer in less chlorinated congeners and had higher PC1 scores than Chironomidae insect. In concordance, congener pattern of nestlings that hatched earlier and consumed more mayflies was more similar than that of other nestling to the pattern of nestings texagenia as calculated by Euclidean similarities. We point to the importance of understanding the seasonal availability of specific types of insect prey and their PCB congener pattern before these data are applied in models of trophic transfer of individual PCB congeners within a food web.

The future is now: implementation of a tele-intensivist program.

Based on overwhelming scientific evidence, The Leapfrog Group focused on 3 practices that have tremendous potential to save lives by reducing preventable mistakes in hospitals. The authors describe these practices and how they served as a driving force to create a "virtual ICU" within a Magnet hospital network. The effort combined services of a board-certified intensivist and technological advancements in telemedicine to ensure the delivery of high-quality care to all critically ill patients throughout the network. A computerized physician-order entry system, an electronic medication administration record, an electronic documentation system, and a remote ICU were the 4 programmatic phases necessary to realize the concept. The purpose of this article is to describe the process of planning and implementing the tele-intensivist program.