'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India.

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya.

BACKGROUND: The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING: This study took place in Mombasa, Kenya. METHODS: We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS: Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION: AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

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.

Boys' perspectives on girls' marriage and school dropout: a qualitative study revisiting a structural intervention in Southern India.

Girls' education has for many decades been central to the global development agenda, due to its positive impact on girls' health and wellbeing. In this paper, the authors revisit boys' attitudes, behaviours and norms related to girls' education, following the Samata intervention to prevent girls' school dropouts in Northern-Karnataka, South India. Data were collected from 20 boys in intervention villages before and after the intervention, and analysis was undertaken using a thematic-framework approach. Findings suggest that while boys did hold some attitudes and beliefs that supported girls' education and delayed-marriage, these remained within the framework of gender-inequitable norms concerning girls' marriageability, respectability/family-honour. Participants criticised peers who sought to jeopardise girls' respectability by teasing and community gossip about girls-boys' communication in public. Boys who rejected prevailing norms of masculinity were subjected to gossip, ridicule and violence by the community. Boys' attitudes and beliefs supported girls' education but were conditional on the maintenance of gendered hierarchies at household and interpersonal levels. Social norms concerning girls' honour, respectability and the role of boys as protectors/aggressors appeared to influence boys' response to girls' school dropouts. Future interventions aiming to address girls' education and marriage must invest time and resources to ensure that intervention components targeting boys are relevant, appropriate and effective.

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.

Changes in context, typology and programme outcomes between early and recent periods of sex work among young female sex workers in Mombasa, Kenya: A cross-sectional study.

INTRODUCTION: The sex work context and typology change continuously and influence HIV related risk and vulnerability for young female sex workers (YFSW). We sought to describe changes in the context and typology of sex work between the first (early) and past month (recent) of sex work among YFSW to inform HIV prevention programming for sex workers. METHODS: We used data from a cross-sectional survey (April-November 2015), administered using physical location-based sampling to 408 cis-women, aged 14-24 years, who self-identified as sex workers, in Mombasa, Kenya. We collected self-reported data on the early and recent month of sex work. The analysis focused on changes in a) sex work context and typology (defined by setting where sex workers practice sex work) where YFSW operated, b) primary typology of sex work, and c) HIV programme outcomes among YFSW who changed primary typology, within the early and recent month of sex work. We analysed the data using a) SPSS27.0 and excel; b) bivariate analysis and χ2 test; and c) bivariate logistic regression models. RESULTS: Overall, the median age of respondents was 20 years and median duration in sex work was 2 years. Higher proportion of respondents in the recent period managed their clients on their own (98.0% vs. 91.2%), had sex with >5 clients per week (39.3% vs.16.5%); were able to meet > 50% of living expenses through sex work income (46.8% vs. 18.8%); and experienced police violence in the past month (16.4% vs. 6.5%). YFSW reported multiple sex work typology in early and recent periods. Overall, 37.2% reported changing their primary typology. A higher proportion among those who used street/ bus stop typology, experienced police violence, or initiated sex work after 19 years of age in the early period reported a change. There was no difference in HIV programme outcomes among YFSW who changed typology vs. those who did not. CONCLUSIONS: The sex work context changes even in a short duration of two years. Hence, understanding these changes in the early period of sex work can allow for development of tailored strategies that are responsive to the specific needs and vulnerabilities of YFSW.

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.

Adolescent Girls and Their Family Members' Attitudes Around Gendered Power Inequity and Associations with Future Aspirations in Karnataka, India.

Intergenerational differences in inequitable gender attitudes may influence developmental outcomes, including education. In rural Karnataka, India, we examined the extent of intergenerational (adolescent girls [AGs] vs. older generation family members) dis/agreement to attitudes around gendered power inequities, including gender roles and violence against women (VAW). Unadjusted and adjusted logistic regression examined associations between intergenerational dis/agreement to attitude statements and AGs' future educational and career aspirations. Of 2,457 AGs, 90.9% had a matched family member (55% mothers). While traditional gender roles were promoted intergenerationally, more AGs supported VAW than family members. In adjusted models, discordant promotion of traditional gender roles and concordant disapproval of VAW were associated with greater aspirations. Results highlight the need for family-level programming promoting positive modeling of gender-equitable attitudes.

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.

HIV prevention programme with young women who sell sex in Mombasa, Kenya: learnings for scale-up.

INTRODUCTION: In 2018, the National AIDS and sexually transmitted infection (STI) Control Programme developed a national guidelines to facilitate the inclusion of young women who sell sex (YWSS) in the HIV prevention response in Kenya. Following that, a 1-year pilot intervention, where a package of structural, behavioural and biomedical services was provided to 1376 cisgender YWSS to address their HIV-related risk and vulnerability, was implemented. METHODS: Through a mixed-methods, pre/post study design, we assessed the effectiveness of the pilot, and elucidated implementation lessons learnt. The three data sources used included: (1) monthly routine programme monitoring data collected between October 2019 and September 2020 to assess the reach and coverage; (2) two polling booth surveys, conducted before and after implementation, to determine the effectiveness; and (3) focus group discussions and key informant interviews conducted before and after intervention to assess the feasibility of the intervention. Descriptive analysis was performed to produce proportions and comparative statistics. RESULTS: During the intervention, 1376 YWSS were registered in the programme, 28% were below 19 years of age and 88% of the registered YWSS were active in the last month of intervention. In the survey, respondents reported increases in HIV-related knowledge (61.7% vs. 90%, p <0.001), ever usage of pre-exposure prophylaxis (8.5% vs. 32.2%, p < 0.001); current usage of pre-exposure prophylaxis (5.3% vs. 21.1%, p<0.002); ever testing for HIV (87.2% vs. 95.6%, p <0.04) and any clinic visit (35.1 vs. 61.1, p <0.001). However, increase in harassment by family (11.7% vs. 23.3%, p<0.04) and discrimination at educational institutions (5.3% vs. 14.4%, p<0.04) was also reported. In qualitative assessment, respondents reported early signs of success, and identified missed opportunities and made recommendations for scale-up. CONCLUSIONS: Our intervention successfully rolled out HIV prevention services for YWSS in Mombasa, Kenya, and demonstrated that programming for YWSS is feasible and can effectively be done through YWSS peer-led combination prevention approaches. However, while reported uptake of treatment and prevention services increased, there was also an increase in reported harassment and discrimination requiring further attention. Lessons learnt from the pilot intervention can inform replication and scale-up of such interventions in Kenya.

Mapping and size estimation of men who have sex with men in virtual platforms in Delhi, India.

INTRODUCTION: In India, the HIV epidemic is concentrated among Key Populations (KPs), such as men who have sex with men (MSM), who bear a disproportionate burden of HIV disease. Conventional targeted interventions (TI) mitigate HIV transmission among MSM by focusing on physical hotspots. As increasingly, there is a shift within India's MSM community to connect with sex partners online, novel approaches are needed to map virtual platforms where sexual networks are formed. The objective of this study was to estimate the number of MSM in Delhi using virtual platforms to connect for sex and to describe patterns of their use. METHODS: The study was conducted in the state of Delhi among MSM over 18 years of age who used virtual platforms to look for sexual partners. Virtual platforms were identified through community consultations. Size estimation was carried out by enumerating the number of online users, accounting for duplication across sites and time and based on interviews with 565 MSM. RESULTS: 28,058 MSM (95% CI: range 26,455-29,817) use virtual sites to find sexual partners. We listed 14 MSM specific virtual sites, 14 general virtual sites, 19 social networking pages and 112 messenger groups, all used by MSM. Five virtual sites met feasibility criteria to be included in the virtual mapping. Of the MSM on these sites, 81% used them at night and 94% used them on Sundays, making these the peak time and day of use. Only 16% of users were aware of organizations providing HIV services and 7% were contacted by peer educators in the preceding three months. Two-fifths (42%) also visited a physical location to connect with sexual partners in the month prior to the study. DISCUSSION: TI programs that focus on physical hotspots do not reach the majority of MSM who use virtual sites. MSM active on virtual sites have a low awareness of HIV services. Virtual mapping and programmatic interventions to include them must be incorporated into current public health interventions to reach MSM at risk of HIV.

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.

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.

Estimating the burden of pediatric HIV in an 'A' category district in India: an epidemiological study.

BACKGROUND: India lacks epidemiological information on the disease burden of pediatric HIV. The National AIDS Control Program (NACP) estimates the numbers of HIV-positive children as a proportion of adult persons living with HIV. A third of HIV-positive children die before their first birthday and a half before they reach their second birthday. The early detection of HIV is crucial for the prevention of morbidities, growth delays, and death among HIV-positive children. METHODS: The study aimed to estimate the disease burden of pediatric HIV among children in 'A' category district of a high HIV prevalence state. An 'A' category district is defined by the presence of > 1% HIV prevalence among the general population, as estimated by HIV Sentinel Surveillance. The study used an innovative three-pronged strategy combining cross-sectional and longitudinal methods. The overall burden of pediatric HIV was calculated as a product of cases detected multiplied by a net inflation factor, for each of three strategies. RESULTS: The existing pool of HIV infection in the district is estimated to be 3266 (95% CI: 2621-4197) HIV positive children < 15 years of age, in a mid-year (2013) projected child population of about 1.4 million, thus giving an HIV prevalence of 0.23% (CI: 0.19-0.30) among children (0-14 years of age). The proportion of children among all people living with HIV in the district works out to 10.4% (CI: 8.6-13.5%). CONCLUSIONS: The study estimate of 0.23% HIV prevalence among children (0-14 years of age) is higher than the NACP estimates (0.02) and is 2.5 higher than the Karnataka state estimate (0.09)22. Similarly, the proportion of children among all persons living with HIV in Belgaum district is 10.4% in this study, as against 6.54% for India. The study methodology is replicable for other settings and other diseases.

Associations between community health workers' home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: a cross-sectional study.

INTRODUCTION: India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent to which exposure to ASHAs' home visits has reduced perinatal health inequalities as intended. This study aimed to examine whether ASHAs' third trimester home visits may have contributed to equitable improvements in institutional delivery and reductions in perinatal mortality rates (PMRs) between women with varying education levels in Uttar Pradesh (UP) state, India. METHODS: Cross-sectional survey data were collected from a representative sample of 52 615 women who gave birth in the preceding 2 months in rural areas of 25 districts of UP in 2014-2015. We analysed the data using generalised linear modelling to examine the associations between exposure to home visits and education-based inequalities in institutional delivery and PMRs. RESULTS: Third trimester home visits were associated with higher institutional delivery rates, in particular public facility delivery rates (adjusted risk ratio (aRR) 1.32, 95% CI 1.30 to 1.34), and to a lesser extent private facility delivery rates (aRR 1.09, 95% CI 1.04 to 1.13), after adjusting for confounders. Associations were stronger among women with lower education levels. Having no compared with any third trimester home visits was associated with higher perinatal mortality (aRR 1.18, 95% CI 1.09 to 1.28). Having any versus no visits was more highly associated with lower perinatal mortality among women with lower education levels than those with the most education, and most notably among public facility births. CONCLUSIONS: The results suggest that ASHAs' home visits in the third trimester contributed to equitable improvements in institutional deliveries and lower PMRs, particularly within the public sector. Broader strategies must reinforce the role of ASHAs' home visits in reaching the sustainable development goals of improving maternal and newborn health and leaving no one behind.