Integration of a tobacco cessation program into a rural community-based maternal and child health program in India: A stakeholders' perspective on task shifting.

INTRODUCTION: According to the Global Adult Tobacco Survey-2, India, 7.5% of pregnant women are tobacco users with a high prevalence of smokeless tobacco use in rural India. Although pregnant women may receive advice to quit tobacco, lack of knowledge on providing cessation support among healthcare workers results in missed opportunities. Community Health Workers (CHWs) play a significant role in maternal and child health (MCH) programs. Thus, task-shifting for providing cessation support by CHWs was planned and the perceptions and attitudes of concerned stakeholders were explored. METHOD: A pre-implementation qualitative study was conducted in four states of India within existing rural, community-based MCH program settings. Implementation research frameworks were used to develop data collection tools and for inductive and deductive thematic analysis. In-depth interviews were conducted with stakeholders (n=28) like coordinators, pregnant women and village functionaries of the government health system. Four focus groups were conducted with female CHWs (n=24). RESULTS: Stakeholders intended to adopt the intervention as objectives of the cessation intervention were aligned with the aims of the MCH program. CHWs related to their role in task-shifting and understood the context for implementing the intervention within the MCH program. Pregnant women expressed openness to receiving cessation support from CHWs acting as a facilitator for task-shifting. Barriers anticipated were the additional workload and time required for CHWs to implement the intervention. CONCLUSION: Task-shifting to female CHWs for screening tobacco users, providing brief advice and cessation support within the MCH program was perceived to be acceptable, adoptable and feasible. IMPLICATIONS: The study builds insight into the process of developing a grounded approach for the integration of tobacco cessation intervention into a rural, community-based antenatal care setting by task shifting to female community health workers for providing cessation support to pregnant women. The study fills gaps in the literature related to establishing tobacco cessation interventions for pregnant women. The delineated efforts in integration of the intervention and task shifting can be replicated in other developing countries, especially in rural communities within South Asian and Southeast Asian regions having cultural practices, community-based healthcare structures and tobacco consumption patterns that are comparable to India.

Sociodemographic Factors, Attitudes, and Tobacco use among Adolescent Areca-Nut Users in Mumbai, India.

Introduction: Areca nut, initiated in adolescence, is considered a gateway for tobacco use and an important cause of oral cancers in India. This study examined differences in sociodemographic factors, attitudes and beliefs, and tobacco use between current (last 30 days) areca nut users and past users, who have ever used areca but not in the last 30 days. Material and Methods: A cross-sectional survey with school students attending grades 7, 8, 9 provided data to compare differences in age, gender, beliefs, attitudes, and concurrent tobacco use among self-reported areca users. Of 1909 participants surveyed, 641 (33.57%) reported use of areca nut; of which 355 (55.38%) current users had consumed it in the last 30 days. Results: A logistic regression model revealed that male gender, using tobacco concurrently, inability to refuse a friend's request to use, and intention to use areca nuts in the next 12 months were significant predictors of current areca use. Conclusion: More research is needed to understand adolescent areca-nut use, including different types of users such as experimenters and those with established habits. This will help design targeted areca-nut prevention and cessation programs.

High Resistance to Antibiotics Recommended in Standard Treatment Guidelines in Ghana: A Cross-Sectional Study of Antimicrobial Resistance Patterns in Patients with Urinary Tract Infections between 2017-2021.

Management of urinary tract infections is challenged by increasing antimicrobial resistance (AMR) worldwide. In this study, we describe the trends in antimicrobial resistance of uropathogens isolated from the largest private sector laboratory in Ghana over a five-year period. We reviewed positive urine cultures at the MDS Lancet Laboratories from 2017 to 2021. The proportions of uropathogens with antimicrobial resistance to oral and parenteral antimicrobials recommended by the Ghana standard treatment guidelines were determined. The proportion of multi-drug resistant isolates, ESBL and carbapenemase-producing phenotypes were determined. Of 94,134 urine specimens submitted for culture, 20,010 (22.1%) were culture positive. Enterobacterales was the most common group of organisms, E. coli (70.6%) being the most common isolate and Enterococcus spp. the most common gram-positive (1.3%) organisms. Among oral antimicrobials, the highest resistance was observed to ciprofloxacin (62.3%) and cefuroxime (60.2%) and the least resistance to fosfomycin (1.9%). The least resistance among parenteral antimicrobials was to meropenem (0.3%). The highest multi-drug resistance levels were observed among Klebsiella spp. (68.6%) and E. coli (64.0%). Extended-spectrum beta-lactamase (ESBL) positivity was highest in Klebsiella spp. (58.6%) and E. coli (50.0%). There may be a need to review the Ghana standard treatment guidelines to reflect increased resistance among uropathogens to recommended antimicrobials.

Using the Theory of Planned Behavior to Explain and Predict Areca Nut Use Among Adolescents in India: An Exploratory Study.

Context: Areca nut, used alone or in combination with tobacco, contributes to the high oral cancer burden in India. Used widely by adolescents, who perceive it as a harmless substance, areca nut is addictive and considered a precursor to tobacco use. Given its serious implications for addictiveness and physical health, urgent preventive interventions for areca nut use are required in India and South-East Asia. Studies examining the role of health behavior theory in explaining and predicting areca nut use and for development of its prevention among adolescents are scarce. Aim: This study explored the role of the components of Theory of Planned Behavior (TPB) such as attitudes, subjective norms, perceived behavioral control, and intention in predicting areca nut use among adolescents. Settings and Design: Observational study with cross-sectional design conducted with 1884 male and female adolescents attending low-income schools in Mumbai, India. Methods and Material: Self-administered surveys were used to gather data on age, gender, behavioral factors and areca nut use. Statistical Analysis Used: Chi-square and Mann Whitney test for bivariate and logistic regression for multivariate analysis. Results: Around 27.2% of 1884 participants were areca nut users. The mean age of users was 13.75 years. Intention-to-use and perceived behavioral control were statistically significant predictors of actual areca nut use (p<0.001). The components of TPB such as attitude, perceived subjective social norms, and perceived behavioral control had a statistically significant effect on the intention-to-use areca nut (p<0.05). Conclusion: This exploratory study indicates that constructs from TPB could help us understand and predict areca nut use. However, more rigorous future research is required to generate insights that help craft effective theory-based behavioral interventions for areca nut prevention and cessation in adolescents.

Adolescents and E-cigarettes in India: A Qualitative Study of Perceptions and Practices.

PURPOSE: Global Youth Tobacco Survey-4, India conducted in 2019 showed 'ever use' of e-cigarettes among adolescents to be 2.8%. However, there is dearth of qualitative data on adolescent use of e-cigarettes in the country. This study was conducted to explore and gain better understanding on adolescents' perceptions and practices about e-cigarette use. METHODS: In-depth interviews were conducted with 24 adolescents who self-reported use of e-cigarettes. The participants were recruited from ten municipal schools of Mumbai, India that cater to students from lower socio-economic background. Participants were from 7th to 9th grades, and aged 11-16 years. Data from in-depth interviews were analyzed using inductive thematic analysis. RESULTS: Adolescents referred to 'e-cigarette' as 'pen-hookah.'  E-cigarettes were perceived as relatively harmless compared to regular hookahs and conventional cigarettes. Initiation was influenced by a friend, peer, or sibling. A variety of flavors, the after-taste, the ability to perform playful tricks with smoke, and fun-time spent with friends were cited as reasons for continued use. Social media influenced both initiation and continuation. Most adolescents' regular use was with a group of friends; the device was shared with or obtained from friends or siblings. Adolescents were unclear about the presence of nicotine in refill liquids and the harmful health effects. CONCLUSION: Increasing awareness among adolescents about the harms of e-cigarettes is urgently required through comprehensive tobacco-prevention programs. More research is needed to examine the role of flavors in increasing acceptability of e-cigarettes and how it affects perceived harmfulness of tobacco products.

How Do Adolescents Assess and Rank the Risk of Areca Nut Use? Findings from a Study in Mumbai, India.

OBJECTIVE: Areca nut use, along with tobacco, is a contributor to India's high rates of oral cancer. Areca nut use is culturally accepted, often initiated early in adolescence, and said to lead to later tobacco use. Unlike tobacco prevention, there are scarce prevention or harm-reduction programmes or campaigns specifically targeted at areca nut. METHODS: A participative ranking method was used to understand adolescents' assessment of risks of areca nut. Five focus group discussions were conducted with 31 adolescents, 19 fe-male and 12 male, non-users and users of chewing tobacco, water-pipe (hookah) and areca nut. Participants categorized and ranked the risk of 16 activities, including the use of areca nut and various tobacco-products, and discussed reasons for these risk-rankings. RESULTS: Despite differences between groups on the assessment of risks associated with the 16 different activities, all the groups, user and non-user, rated cigarette smoking as having the highest risk, chewing fennel and using mouth fresheners as no risk, and areca nut as low risk. The other activities were ranked differently by each group. Adolescents' perceptions of smoking or online games as risky was influenced by greater exposure to messaging on harmful consequences of the activity through multiple channels such as mass media, interpersonal networks including parents, and classroom health-education sessions. Inadequate knowledge about the harmful consequences of areca nut use, greater social and cultural acceptability, and the sweet taste of commercially packaged areca nut influenced low-risk perceptions. CONCLUSION: Perceptions of risk from an activity often determines preventive behaviors. Presently, adolescents do not perceive areca use as risky. In comparison to smoking they con-sider it less harmful. More research is required to better understand areca nut use and its cul-tural determinants. However, targeted health communication messages and prevention poli-cies and programmes have to be initiated to reduce areca nut use and associated burden of oral cancer.

A Qualitative Study of Perceptions and Practices Related to Areca Nut Use Among Adolescents in Mumbai, India.

INTRODUCTION: Areca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country. METHODS: This qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India. RESULTS: Respondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child's supari use was often muted in comparison to extreme reactions associated with the child's tobacco use. CONCLUSIONS: Perceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents' use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers. IMPLICATIONS: The study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

Factors Influencing Implementation of a Workplace Tobacco Cessation Intervention in India: A Qualitative Exploration.

BACKGROUND: Tobacco use is projected to cause more than 8 million deaths annually worldwide by 2030 and is currently linked to 1 million annual deaths in India. Very few workplaces provide tobacco cessation as a part of occupational health in India. In this study, we examined promoters and barriers to implementing an evidence-based tobacco cessation program in a workplace setting in India. METHODS: In-depth interviews were conducted with all facilitators (two program coordinators and four counselors) of a workplace tobacco cessation intervention covering implementation efforts in five organizations, including three manufacturing units and two corporate settings. FINDINGS: The identified promoters for implementation of the program were as follows: (a) workplaces that provided access to many individuals, (b) high prevalence of tobacco use that made the intervention relevant, (c) core components (awareness sessions, face-to-face counseling and 6-months follow-up) that were adaptable, (d) engagement of the management in planning and execution of the intervention, (e) employees' support to each other to quit tobacco, (f) training the medical unit within the workplace to provide limited advice, and (g) efforts to advocate tobacco-free policies within the setting. Barriers centered around (a) lack of ownership from the workplace management, (b) schedules of counselors not matching with employees, (c) nonavailability of employees because of workload, and (d) lack of privacy for counseling. CONCLUSION/IMPLICATIONS FOR PRACTICE: This study provided practical insights into the aspects of planning, engaging, executing and the process of implementation of a tobacco cessation intervention in a workplace setting. It provided guidance for an intervention within occupational health units in similar settings.

How has the COVID-19 pandemic affected tobacco users in India: Lessons from an ongoing tobacco cessation program.

INTRODUCTION: Tobacco use is detrimental at any time. However, it is proving to be more dangerous during the COVID-19 pandemic. Tobacco use may increase the risk of being infected, increases the chances of complications, and also increases the probability of its spread. We assessed the awareness about this association and the impact of the lockdown on tobacco use among tobacco users registered before the lockdown for LifeFirst, a tobacco dependence treatment program. METHODS: 1016 tobacco users were under active follow-up in their course of the 6-month counselling program. From 14 to 28 May 2020, 650 (64%) of these registered users were contacted by counsellors for follow-up sessions over the telephone. Semi-structured questionnaires were filled in during the calls. RESULTS: Two-thirds (67%) of tobacco users were unaware of the association between tobacco and COVID-19. Only 30% of the users felt that the current situation had affected their tobacco use, the commonest impacts being unavailability and increased prices of tobacco products. While this was seen as an opportunity to quit by some users, some reported increased tobacco use due to increased stress. Of the 219 (34%) tobacco users who quit tobacco during the lockdown, 51% quit because of the lockdown and their concern over COVID-19. Abstinence among those who were aware of the association between the coronavirus and tobacco was twice that among those who were not aware. CONCLUSIONS: Awareness activities about the harmful effects of tobacco during the coronavirus pandemic have to be strengthened. Measures to motivate and support tobacco users to quit have to be provided through cessation services.

Why do Adolescents Initiate and Continue Using Tobacco and Areca Nut?: A Qualitative Study Tracing Pathways of Use Among School-Going Adolescents in Mumbai, India.

BACKGROUND: Tobacco and areca-nut use among adolescents has been reported from different parts of India. Multiple factors influence initiation of tobacco use among adolescents. Initiation of one product gradually extends to multiple products. Studies on initiation lack documentation of the pathways and experiences post-initiation, which is required to holistically understand behavior patterns of adolescents for planning timely intervention. This study was conducted to trace pathways and identify factors influencing the initiation and continuation of tobacco and areca-nut among adolescents. METHODS: In this two-staged study, we conducted 14 focus group discussions (FGDs) with 166 adolescents studying in grades 7-9 (11-18 years) from six municipal schools in Mumbai, India. They had self-reported areca-nut or smoked or smokeless tobacco (SLT) use. Pathways of initiation were traced through in-depth interviews for 60 adolescents. RESULTS: Four multi-linear pathways of use were identified: (1) areca-nut only, (2) areca-nut to tobacco, (3) initiation with SLT, and (4) initiation with smoking. Raw or sweetened areca-nut, betel leaf, gutka, masheri, mawa, hookah, cigarette, bidi, and e-cigarettes were products reported to be used. Curiosity, easy access to tobacco products and normalization of tobacco use influenced initiation. Areca-nut acted as a precursor to tobacco use. CONCLUSION: Tracing pathways in tobacco use helped to understand reasons for initiation, influences in continuation of use, and experiences of significance to the adolescents. Experiences of adolescents play a critical role in shaping the pathways of tobacco use. Understanding the pathways and influencers will further help to build effective health promotion communication, policies for sale to minors, and school-based cessation interventions. IMPLICATIONS: Findings of the study provide an insight into unknown areas of information regarding products used by adolescents, their patterns of consumption, perceptions, and their pathways of initiation and continuation of primary and secondary products. This will help in developing specific public health awareness messages, policies regarding packaging and sale of areca-nut to children and interventions targeted for the adolescents and their specific products of use not just in India but for the South-East Asia region as areca-nut and tobacco use among adolescents is common in the region. The exercise of tracing the pathways provides basis for cessation counseling among adolescents.

Tobacco Use and Subsequent Cessation Among Hospitalized Patients in Mumbai, India: A Longitudinal Study.

INTRODUCTION: Hospitalization is an important setting to address tobacco use. Little is known about post-discharge cessation and treatment use in low- and middle-income countries. Our objective was to assess tobacco use after hospital discharge among patients in Mumbai, India. METHODS: Longitudinal observational study of inpatients (≥15 years) admitted at one hospital from November 2015 to October 2016. Patients reporting current tobacco use were surveyed by telephone after discharge. RESULTS: Of 2894 inpatients approached, 2776 participated and 15.7% (N = 437) reported current tobacco use, including 5.3% (N = 147) smokers, 9.1% (N = 252) smokeless tobacco (SLT) users, and 1.4% (N = 38) dual users. Excluding dual users, SLT users, compared to smokers, were less likely to report a plan to quit after discharge (42.6% vs. 54.2%, p = .04), a past-year quit attempt (38.1% vs. 52.7%, p = .004), to agree that tobacco has harmed them (57.9% vs. 70.3%, p = .02) or caused their hospitalization (43.4% vs. 61.4%, p < .001). After discharge, 77.6% of smokers and 78.6% of SLT users reported trying to quit (p = .81). Six-month continuous abstinence after discharge was reported by 27.2% of smokers and 24.6% of SLT users (p = .56). Nearly all relapses to tobacco use after discharge occurred within 30 days and did not differ by tobacco type (log-rank p = .08). Use of evidence-based cessation treatment was reported by 6.5% (N = 26). CONCLUSIONS: Three-quarters of tobacco users in a Mumbai hospital attempted to quit after discharge. One-quarter reported continuous tobacco abstinence for 6 months despite little use of cessation treatment. Increasing post-discharge cessation support could further increase cessation rates and improve patient outcomes. IMPLICATIONS: No prior study has measured the patterns of tobacco use and cessation among hospitalized tobacco users in India. Three-quarters of tobacco users admitted to a hospital in Mumbai attempted to quit after discharge, and one-quarter remained tobacco-free for 6 months, indicating that hospitalization may be an opportune time to offer a cessation intervention. Although smokers and SLT users differed in socioeconomic status, perceived risks and interest in quitting, they did not differ in their ability to stay abstinent after hospital discharge.

Short-term nutrition and growth indicators in 6-month- to 6-year-old children are improved following implementation of a multidisciplinary community-based programme in a chronic conflict setting.

OBJECTIVE: We investigated short- and long-term indicators of malnutrition and diet before and after the community-based 'Breaking the Cycle of Poverty' multidisciplinary intervention. DESIGN: A historically and geographically controlled study using data collected in 2013 and 2016. We compared the prevalence of short-term indicators (anaemia, breast-feeding duration and minimum dietary diversity) and long-term indicators (stunting and wasting) in exposed communities at two time points. We then compared these factors in geographic areas exposed or not exposed to intervention. We conducted logistic regression analyses on the 2016 sample to measure associations between living in intervention communities and child growth indicators. SETTING: Berd region, a chronic conflict zone near the north-eastern border of Armenia and Azerbaijan. PARTICIPANTS: Children aged 6 months to 6 years. RESULTS: Analyses included data from 2013 comprising 382 children, and data from 2016 comprising 348 children living in communities where the programme was implemented, and 635 children from unexposed communities. Anaemia prevalence in exposed communities was significantly lower in 2016 v. 2013 (10·9 v. 19·1 %, P < 0·01). Minimum dietary diversity (79·0 v. 68·1 %, P < 0·001) and breast-feeding duration (13·0 v. 11·5 months, P < 0·002) were significantly improved in exposed communities. Prevalences of stunting (11·5 v. 10·2 %, P = 0·57) and wasting (4·8 v. 2·0 %, P = 0·07) were not significantly different. Odds of anaemia were significantly lower (OR = 0·24, 95 % CI 0·16, 0·36) in intervention communities. CONCLUSIONS: Exposure to a community-based multidisciplinary intervention reduced the rate of anaemia and improved dietary indicators.

Change in TB diagnostic profile after introduction of GeneXpert MTB/RIF assay in National TB Program of Armenia, 2013-2017.

INTRODUCTION: In 2013, the National Tuberculosis (TB) Program of Armenia introduced GeneXpert MTB/RIF (Xpert) assay to address World Health Organization (WHO) target of 80% (2020) of notified new and relapse TB cases to be tested with WHO recommended rapid diagnostic methods. This study aimed to assess the change in laboratory diagnostic profile of Mycobacterium tuberculosis after introduction of the Xpert assay from 2013 to 2017. METHODOLOGY: Retrospective cohort analysis of all presumptive TB patients' records retrieved from the National Reference Laboratory database was performed. RESULTS: This study showed increased trend of Xpert coverage for suspected TB cases from 25% in 2013 to 86% in 2017 which is in line with WHO TB global strategy's target of 80% in 2020. In 4.7% cases, Xpert tested positive while microscopy showed negative results. There was also an improved detection of Rifampicin resistance with increased concordance from 99.1% to 99.4% and decreased discordance from 6.7% to 1.4% between culture and Xpert results. CONCLUSION: Armenia has achieved the 2020 target; in terms of utilizing the GeneXpert it is on track to achieve the End TB strategy target of 100% by 2025. The next step of this research will be assessment of the impact of GeneXpert and other TB tests utilization on the treatment outcomes in Armenia.

Integrating screening for non-communicable diseases and their risk factors in routine tuberculosis care in Delhi, India: A mixed-methods study.

BACKGROUND: Evidence supports the integration of prevention and management for tuberculosis (TB) with non-communicable diseases (NCDs). Bi-directional screening for TB and diabetes mellitus (DM) is already implemented in India, a country with a dual burden of TB and NCDs. However, very limited programmatic data are available on the feasibility of adding other NCDs and their risk factors in such screening programme. OBJECTIVE: To assess the yield, feasibility, and acceptability of a two-stage integrated screening for NCDs and risk factors for NCDs among patients with TB ≥20 years and treated in DOTS centres of two medical colleges in Delhi, between October 2016 and March 2017. METHODS: It was a mixed-methods, triangulation study with a quantitative component (cross-sectional study using questionnaires, anthropometric measurements and records review) and a qualitative component (descriptive study using interview data). RESULTS: Amongst 403 patients screened, the prevalence of hypertension was 7% (n = 28) with 20 new cases detected and 8% for DM (n = 32) with 6 new cases diagnosed. The number needed to screen to find a new case was 20 and 63 for hypertension and DM respectively. The most frequent NCD-risk factors were inadequate vegetable (80%) and fruits (72%) intake, alcohol use (34%), use of smokeless tobacco (33%) and smoking (32%). Clustering of four or more risk factors was associated with increasing age and male sex (p<0.05). Both patients and health providers considered the screening relevant and acceptable. However, waiting time and costs involved in blood tests were considered as bothersome by the patients, while health providers perceived increased workload, inadequate medical supplies and inadequate skills and knowledge as key challenges in implementation of the screening. CONCLUSION: Integrating screening for NCDs and their risk factors in the existing TB programme produces high yield and it is feasible and acceptable by patients and health providers provided the challenges are overcome.

"They don't like us .": Barriers to antiretroviral and opioid substitution therapy among homeless HIV positive people who inject drugs in Delhi: A mixed method study.

BACKGROUND: Provision of Anti-Retroviral Therapy (ART) and Opioid Substitution Therapy (OST) are important components of the targeted intervention (TI) programme for people who inject drugs (PWID). Homeless HIV positive PWIDs in Delhi is a key population experiencing gaps in uptake of these services, especially the ART uptake which is reportedly far from 90%, UNAIDS' 90-90-90 target to end the AIDS epidemic. OBJECTIVE: To assess the gaps and barriers in accessing the ART and OST services uptake among HIV positive homeless PWID in Delhi and to explore experiences and perspectives of the PWIDs and service providers. METHODOLOGY: We used a convergent parallel mixed methods design which included a cross-sectional quantitative survey and a qualitative study. Two hundred thirty five homeless HIV positive PWID were interviewed and in-depth interviews were conducted with five PWIDs and nine health providers. RESULTS: While only 12% of PWIDs were on ART, 80% were availing OST services. The top individual, health system related and structural barriers for ART service access were insufficient and incorrect knowledge (63%), long waiting time (86%) and lack of family support (44%) respectively. Inconvenient timings, stringent registration requirements and negative attitude of health providers were expressed as major barriers of accessing ART services during the interviews while these were not a concern in OST services. Homelessness, poverty, stigma were common barriers for both services. Integrated, 'single window' service and provision of additional support like nutrition and shelter were suggested as measures to improve access by both health providers and the PWIDs themselves. CONCLUSION: There is an urgent need for structural and health systems changes to improve access to ART and OST services. These include integrated service delivery, flexibility in timing of the centers, accelerated ART initiation, simplification of bureaucratic procedures, nutritional and social support to all homeless HIV positive PWIDs.