Sexual behaviours of men who inject drugs in northeast India.

BACKGROUND: Promoting safer sex behaviours among people who inject drugs is important as drug-using populations with high HIV prevalence can contribute to transition from a concentrated to a generalised epidemic. This study describes the sexual behaviours of men who inject drugs in two Northeast Indian states (Manipur and Nagaland) where HIV prevalence is high, with a focus on the HIV risks for their regular female sexual partners. METHODS: Data were obtained from two cross-sectional surveys combined (N = 3,362)-both conducted in 2009 using respondent-driven sampling to recruit men who injected drugs. Both surveys asked about demographics, drug use, sexual and injecting risk behaviours, and interventions. One survey tested participants for HIV and syphilis. Statistical analyses included logistic regression modelling to predict inconsistent condom use with regular sexual partners. RESULTS: Two thirds of participants (68.2%) had a regular female sexual partner. Of these, 78.4% had sex with their regular partner in the last month, on average five times. Only 10.7% reported consistent condom use with regular partners. Unsafe injecting was common among men with regular partners, and 40.2% had more than one sexual partner in the last year. Half of those with regular partners (51.0%) had never had an HIV test, and 14.3% of those tested were HIV positive. After controlling for confounding, inconsistent condom use with regular partners was associated with being illiterate, married, sharing needle and syringe with others, never having had an HIV test and not receiving condoms from an NGO. CONCLUSION: The findings from this study among men who inject drugs in Manipur and Nagaland highlight the risk of HIV infection for their regular female sexual partners. Promoting better uptake of HIV testing among men who inject drugs will potentially benefit both them and their regular partners. While effectively reaching regular partners is challenging, a number of strategies for improving their situation in relation to HIV prevention are available.

Opioid substitution therapy in manipur and nagaland, north-east india: operational research in action.

BACKGROUND: There is good evidence for the effectiveness of opioid substitution therapy (OST) for injecting drug users (IDUs) in middle and high-income countries but little evidence regarding the provision of OST by non-government organisations (NGOs) in resource-poor settings. This paper reports on outcomes of an NGO-based OST program providing sub-lingual buprenorphine to opiate dependent IDUs in two north-east Indian states (Manipur and Nagaland), a region where conflict, under-development and injecting of heroin and Spasmoproxyvon (SP) are ongoing problems. The objectives of the study were: 1) to calculate OST treatment retention, 2) to assess the impact on HIV risk behaviours and quality of life, and 3) to identify client characteristics associated with cessation of treatment due to relapse. METHODS: This study involves analysis of data that were routinely and prospectively collected from all clients enrolled in an OST program in Manipur and Nagaland between May 2006 and December 2007 (n = 2569, 1853 in Manipur and 716 in Nagaland) using standardised questionnaires, and is best classified as operational research. The data were recorded at intake into the program, after three months, and at cessation. Outcome measures included HIV risk behaviours and quality of life indicators. Predictors of relapse were modelled using binary logistic regression. RESULTS: Of all clients enrolled in OST during the month of May 2006 (n = 713), 72.8% remained on treatment after three months, and 63.3% after six months. Statistically significant (p = 0.05) improvements were observed in relation to needle sharing, unsafe sex, incidents of detention, and a range of quality of life measures. Greater spending on drugs at intake (OR 1.20), frequently missing doses (OR 8.82), and having heroin rather than SP as the most problematic drug (OR 1.95) were factors that increased the likelihood of relapse, and longer duration in treatment (OR 0.76) and regular family involvement in treatment (OR 0.20) reduced the likelihood of relapse. CONCLUSION: The findings from this operational research indicate that the provision of OST by NGOs in the severely constrained context of Manipur and Nagaland achieved outcomes that are internationally comparable, and highlights strategies for strengthening similar programs in this and other resource-poor settings.

My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India.

BACKGROUND: The north-east Indian states of Manipur and Nagaland are two of the six high HIV prevalence states in the country, and the main route of HIV transmission is injecting drug use. Understanding the pathways to injecting drug use can facilitate early intervention with HIV prevention programs. While several studies of initiation into injecting drug use have been conducted in developed countries, little is known about the situation in developing country settings. The aim of this study was to increase understanding of the contextual factors associated with initiation into injecting drug use in north-east India, and the influence of these factors on subsequent initiation of others. METHOD: In mid 2006 a cross-sectional survey among 200 injecting drug users (IDUs) was undertaken in partnership with local NGOs that provide HIV prevention and care services and advocacy for IDUs in Imphal, Manipur and Dimapur, Nagaland. The questionnaire elicited detailed information about the circumstances of the first injection and the contexts of participants' lives. Demographic information, self-reported HIV status, and details about initiation of others were also recorded. RESULTS: Initiation into injecting drug use occurred at 20 years of age. The drugs most commonly injected were Spasmo-proxyvon (65.5%) and heroin (30.5%). In 53.5% cases, a needle belonging to someone else was used. Two-thirds (66.7%) had used the drug previously, and 91.0% had known other IDUs prior to initiation (mean = 7.5 others). The first injection was usually administered by another person (94.5%), mostly a friend (84.1%). Initiation is a social event; 98% had others present (mean = 2.7 others). Almost 70% of participants had initiated at least one other (mean = 5 others). Initiation of others was independently associated with being male and unemployed; having IDU friends and using alcohol around the time of initiation; and having been taught to inject and not paid for the drug at the time of initiation. CONCLUSION: Targeting harm reduction messages to (non-injecting) drug users and capitalising on existing IDU social networks to promote safe injecting and deter initiation of others are possible strategies for reducing the impact of injecting drug use and the HIV epidemic in north-east India.

HIV-related knowledge, attitudes and risk perception amongst nurses, doctors and other healthcare workers in rural India.

BACKGROUND AND OBJECTIVE: People with HIV in India frequently encounter discrimination while seeking and receiving healthcare services. The knowledge and attitudes of healthcare workers (HCWs) influences the willingness and ability of people with HIV to access care, and the quality of the care they receive. Previous studies of HIV-related knowledge and attitudes amongst Indian HCWs have been conducted primarily in large urban hospitals. The objective of this study was to asses HIV-related knowledge, attitudes and risk perception among a group of rural north Indian HCWs, and to identify predictors of willingness to provide care for patients with HIV infection. METHODS: A cross-sectional survey of 266 HCWs (78% female) from seven rural north Indian health settings was undertaken in late 2002. A self-administered written questionnaire was made available in English and Hindi, and the response rate was 87 per cent. Information was gathered regarding demographic details (age, sex, duration of employment, job category); HIV-related knowledge and attitudes; risk perception; and previous experience caring for HIV-positive patients. Logistic regression modelling was undertaken to identify factors associated with willingness to care for patients with HIV. RESULTS: The HCWs in this study generally had a positive attitude to caring for people with HIV. However, this was tempered by substantial concerns about providing care, and the risk of occupational infection with HIV was perceived by most HCWs to be high. After controlling for confounding, HCWs willingness to provide care for patients with HIV was strongly associated with having previously cared for patients with HIV (P = 0.001). Knowledge of HIV transmission and perception of risk were not associated with willingness to provide care. INTERPRETATION AND CONCLUSION: The findings of this study showed a general willingness of HCWs to provide care for patients with HIV, tempered by concerns regarding provision of such care. Strategies to address HCWs concerns are likely to ameliorate the discrimination experienced by people with HIV when accessing healthcare services. These include the development of programmes to promote occupational safety of HCWs and involving people with HIV in awareness training of HCWs.

Compliance with Universal/Standard Precautions among health care workers in rural north India.

BACKGROUND: Universal Precautions (UPs) and more recently Standard Precautions have been widely promoted in high-income countries to protect health care workers (HCWs) from occupational exposure to blood and the consequent risk of infection with bloodborne pathogens. In low-income countries, the situation is very different: UPs are often practiced partially, if at all, thereby exposing the HCWs to unnecessary risk of infection. The aim of this study is to describe rural north Indian HCWs knowledge and understanding of UPs and identify predictors of compliance to target intervention programs appropriately. METHODS: A cross-sectional survey was undertaken, involving 266 HCWs (response rate, 87%) from 7 rural north Indian health care settings. Information was gathered regarding compliance with UPs and a range of other relevant variables that potentially influence compliance (eg, demographic information, perception of risk, knowledge of bloodborne pathogen transmission, perception of safety climate, and barriers to safe practice). RESULTS: Knowledge and understanding of UPs were partial, and UPs compliance was suboptimal, eg, only 32% wore eye protection when indicated, and 40% recapped needles at least sometimes. After controlling for confounding, compliance with UPs was associated with being in the job for a longer period, knowledge of bloodborne pathogen transmission, perceiving fewer barriers to safe practice and a strong commitment to workplace safety climate. CONCLUSION: Interventions to improve UPs compliance among HCWs in rural north India need to address not only their knowledge and understanding but also the safety climate created by the organizations that employ them.

Occupational exposure to blood and risk of bloodborne virus infection among health care workers in rural north Indian health care settings.

BACKGROUND: Approximately 3 million health care workers (HCWs) experience percutaneous exposure to bloodborne viruses (BBVs) each year. This results in an estimated 16,000 hepatitis C, 66,000 hepatitis B, and 200 to 5000 human immunodeficiency virus (HIV) infections annually. More than 90% of these infections are occurring in low-income countries, and most are preventable. Several studies report the risks of occupational BBV infection for HCWs in high-income countries where a range of preventive interventions have been implemented. In contrast, the situation for HCWs in low-income countries is not well documented, and their health and safety remains a neglected issue. OBJECTIVE: To describe the extent of occupational exposure to blood and the risk of BBV infection among a group of HCWs in rural north India. METHODS: A cross-sectional survey of HCWs from 7 rural health settings gathered data pertaining to occupational exposure to blood and a range of other relevant variables (eg, demographic information, compliance with Universal Precautions, perception of risk, knowledge of BBVs). A mass action model was used to estimate the risk of occupational BBV infection for these HCWs over a 10-year period. RESULTS: A total of 266 HCWs returned questionnaires (response rate, 87%). Sixty-three percent reported at least 1 percutaneous injury (PI) in the last year (mean no. = 2.3) and 73% over their working lifetime (mean no. = 4.2). Predictors of PI during the last year were hospital site, job category, perception of risk, and compliance with Universal Precautions. CONCLUSION: The high level of occupational exposure to blood found among this group of rural north Indian HCWs highlights the urgent need for interventions to enhance their occupational safety to prevent unnecessary nosocomial transmission of BBVs.