Facilitating person-centred care: integrating an electronic client feedback tool into continuous quality improvement processes to deliver client-responsive HIV services in the Democratic Republic of Congo.

INTRODUCTION: Engaging communities in the design, implementation and monitoring of health services is critical for delivering high-quality, person-centred services that keep people living with HIV engaged in care. The USAID-funded Integrated HIV/AIDS Project in Haut-Katanga (IHAP-HK) integrated an electronic client feedback tool into continuous quality improvement (CQI) processes. We aimed to demonstrate this system's impact on identifying and improving critical quality-of-care gaps. METHODS: Through stakeholder and empathy mapping, IHAP-HK co-designed a service quality monitoring system-comprising anonymous exit interviews and ongoing monitoring through CQI cycles-with people living with HIV, facility-based providers and other community stakeholders. IHAP-HK trained 30 peer educators to administer oral, 10- to 15-minute exit interviews with people living with HIV following clinic appointments, and record responses via the KoboToolbox application. IHAP-HK shared client feedback with facility CQI teams and peer educators; identified quality-of-care gaps; discussed remediation steps for inclusion in facility-level improvement plans; and monitored implementation of identified actions. IHAP-HK tested this system at eight high-volume facilities in Haut-Katanga province from May 2021 through September 2022. RESULTS: Findings from 4917 interviews highlighted wait time, stigma, service confidentiality and viral load (VL) turnaround time as key issues. Solutions implemented included: (1) using peer educators to conduct preparatory tasks (pre-packaging and distributing refills; pulling client files) or escort clients to consultation rooms; (2) limiting personnel in consultation rooms during client appointments; (3) improving facility access cards; and (4) informing clients of VL results via telephone or home visits. Due to these actions, between initial (May 2021) and final interviews (September 2022), client satisfaction with wait times improved (76% to 100% reporting excellent or acceptable wait times); reported cases of stigma decreased (5% to 0%); service confidentiality improved (71% to 99%); and VL turnaround time decreased (45% to 2% informed of VL results 3 months after sample collection). CONCLUSIONS: Our results showed the feasibility and effectiveness of using an electronic client feedback tool embedded in CQI processes to collect client perspectives to improve service quality and advance client-responsive care in the Democratic Republic of Congo. IHAP-HK recommends further testing and expansion of this system to advance person-centred health services.

Losses along the tuberculosis sputum sample referral cascade for Mpongwe District, Zambia.

BACKGROUND: In resource limited-settings, timely tuberculosis (TB) diagnosis depends upon referral of sputum samples from non-diagnostic to diagnostic facilities for examination. The TB programme data for 2018 suggested losses in Mpongwe District's sputum referral cascade. AIM: This study aimed to identify the referral cascade stage where loss of sputum specimen occurred. SETTING: Primary health care facilities in Mpongwe District, Copperbelt Province, Zambia. METHODS: Data were retrospectively collected from one central laboratory and six referring health facilities between January and June 2019, using a paper-based tracking sheet. Descriptive statistics were generated in SPSS version 22. RESULTS: Of the 328 presumptive pulmonary TB patients found in presumptive TB registers at referring facilities, 311 (94.8%) submitted sputum samples and were referred to the diagnostic facilities. Of these, 290 (93.2%) were received at the laboratory, and 275 (94.8%) were examined. The remaining 15 (5.2%) were rejected for reasons such as 'insufficient sample'. Results for all examined samples were sent back and received at referring facilities. Referral cascade completion rate was 88.4%. Median turnaround time was six days (IQR = 1.8). CONCLUSION: Losses in the sputum referral cascade for Mpongwe District mainly occurred between dispatch of sputum samples and receipt at diagnostic facility. Mpongwe District Health Office needs to establish a system to monitor and evaluate the movement of sputum samples along the referral cascade to minimize losses and ensure timely TB diagnosis.Contribution: This study has highlighted, at primary health care level for resource limited settings, the stage in the sputum sample referral cascade where losses mainly occur.

Mortality among persons receiving tuberculosis treatment in Itezhi-Tezhi District of Zambia: A retrospective cohort study.

Itezhi-Tezhi District in southern Zambia has been reporting tuberculosis (TB) mortality rates that are fourfold higher than the national average of six percent. We conducted a retrospective cohort study to establish the demographic and clinical characteristics associated with mortality among persons under treatment for TB in Itezhi-Tezhi District, as well as the likely causes and time to death. We reviewed medical records for persons with TB registered in 19 public health facilities in Itezhi-Tezhi District between January 2015 and December 2018. Of the 506 persons with TB registered in the study period, 426 were included in the analysis. Of these, 71 (16.7%) died before completing treatment. The overall mortality rate was 31.8 per 1,000 person-months of observation. Most of the deaths (53 [74.7%]) occurred in the first month of treatment (median: 16 days; interquartile range: 5-52 days). In a multivariate Cox regression model, type of TB was found to be an independent predictor of mortality while on TB treatment. The risk of dying was more than twice higher for persons with clinically diagnosed PTB compared to those with bacteriologically confirmed PTB (adjusted hazard ratio = 2.2, 95% CI: 1.4-3.6). In a sub-analysis of persons with clinically diagnosed PTB, persons with TB who were on a community-based DOT plan were more than twice more likely to die compared to those on facility-based DOT plan (adjusted hazard ratio = 2.21, 95% CI: 1.1-4.8). Common likely causes of death were pulmonary TB disease (66.0%), anemia (12.8%), cardiac failure (4.3%), pneumocystis jiroveci pneumonia (4.3%), and gastroenteritis (4.2%). These findings show that most deaths occurred during the first month of treatment. Clinical evaluation at initiation of anti-TB treatment and during follow-up care, especially in persons with clinically diagnosed PTB, should include screening and treatment of other conditions.

Losses in the Sputum Specimen Referral Cascade in Mpulungu District, Zambia: A Cross-Sectional Study.

Sputum specimen referral cascades in resource-limited settings are characterized by losses of specimens, resulting in delays in tuberculosis (TB) diagnosis. Mpulungu District Health Office in Zambia conducted a quantitative based cross-sectional study using both primary and secondary data to identify points at which loss of specimens occurred in the sputum referral cascade. Primary data were collected through observations and interviews with 22 TB service providers. Secondary data were collected through examination of patient files and presumptive TB and laboratory registers to retrospectively track sputum specimens referred by ten health centers from April to September 2018. Proportions of specimens/laboratory results at every stage of the referral cascade were calculated using Epi Info v7. Only 49 (23%) out of 209 sputum specimens completed the referral cascade. The remaining 160 (76%) were lost at various stages of the referral cascade. The largest loss (51%) occurred between the release of laboratory results by the diagnostic facility and their receipt at referring facilities. Barriers included an inadequate number of staff oriented in sputum specimen referral, negative staff attitudes, and lack of specimen packaging material and specimen transportation. The district health office should strengthen the sputum specimen referral system by providing transport and specimen packaging material and by training staff in sputum collection transportation and tracking.

Urban-rural disparity in sociodemographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women and their perspectives on their male sexual partners: A cross-sectional study in Zimbabwe.

We conducted a cross sectional survey in Zimbabwe to describe urban-rural disparity in socio-demographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women (AGYW) and their male sexual partners. Between September and November 2016, we interviewed 360 sexually active HIV positive AGYW, aged 15--24 years attending ART and PMTCT clinics in urban and rural health facilities in Harare and Mazowe district respectively. HIV positive AGYW in rural areas as compared to those in urban areas were older, less educated, more frequently married or cohabiting, had lower number of male sexual partners in their lifetime and in the last 12 months preceding the survey. They were mostly heterosexually infected, more likely to disclose their status to a family member and to be more adherent to ART (OR = 2.5-95% CI = 1.1-5.5). Most recent male sexual partners of HIV positive AGYW in urban areas as compared to those from rural areas were mainly current or former boyfriends, single, more educated, less likely to have a child with them and to engage in couple voluntary counseling and testing (CVCT). They were more likely to patronize dancing and drinking venues and involved in transactional sex (OR = 2.2-95% CI: 1.2-4). They were also more likely to be circumcised (OR = 2.3-95% CI: 1.3-4.1) and to use condom more consistently in the last 12 months preceding the survey. Our study findings called for the strengthening of HIV prevention interventions in urban areas among HIV positive AGYW who had more than one partner in their lifetime or are patronizing dancing and drinking venues. In Zimbabwe, promotion of CVCT, index testing, male circumcision and condom use should be sustained to engage male sexual partners of both urban and rural HIV positive AGYW in HIV prevention.

Prevalence and determinants of unprotected sex in intimate partnerships of men who inject drugs: findings from a prospective intervention study.

Unprotected sex, common among people who inject drugs, puts them and their partners at risk of sexually transmitted infections including human immunodeficiency virus (HIV). This analysis assesses the changes in sexual risk behavior with regular female partners (RFPs), among married men who inject drugs, before and after implementation of a HIV prevention intervention, and identifies correlates of unprotected sex. People who inject drugs (PWID) were assessed at three points: baseline, preintervention follow-up visit (FV)1, and postintervention FV2. Descriptive analysis was used for reporting changes in sexual behavior over time. Generalized estimating equation assessed the population-averaged change in self-reported unprotected sex with an RFP, attributable to intervention uptake. Multivariable logistic regression determined correlates of self-reported unprotected sex with an RFP at FV2. Findings suggest that the proportion of men reporting any unprotected sex remained high (baseline = 46.0%, FV1 = 43.5%, FV2 = 37.0%). A reduction was observed in unprotected sex after the intervention phase, but this could not be attributed to uptake of the intervention. Higher odds of self-reported unprotected sex with an RFP in the past three months at FV2 were associated with self-reported unprotected sex at baseline, living with family, and being HIV-negative. Married male PWID should receive counseling for safe sex with RFPs, especially those who are HIV-negative and live with their families.

HIV testing and counselling couples together for affordable HIV prevention in Africa.

BACKGROUND: The impact and cost-effectiveness of couples' voluntary HIV counselling and testing (CVCT) has not been quantified in real-world settings. We quantify cost-per-HIV-infection averted by CVCT in Zambia from the donor's perspective. METHODS: From 2010 to 2016, CVCT was established in 73 Zambian government clinics. The cost-per-HIV-infection averted (CHIA) of CVCT was calculated using observed expenditures and effectiveness over longitudinal follow-up. These observed measures parameterized hypothetical 5-year nationwide implementations of: 'CVCT'; 'treatment-as-prevention (TasP) for discordant couples' identified by CVCT; and 'population TasP' for all HIV+ cohabiting persons identified by individual testing. RESULTS: In all, 207 428 couples were tested (US $52/couple). Among discordant couples in which HIV+ partners self-reported antiretroviral therapy (ART), HIV incidence was 8.5/100 person-years before and 1.8/100 person-years after CVCT (79% reduction). Corresponding reductions for non-ART-using discordant and concordant negative couples were 63% and 47%, respectively. CVCT averted an estimated 58% of new infections at US $659 CHIA. In nationwide implementation models, CVCT would prevent 17 times the number of infections vs 'TasP for discordant couples' at 86% of the cost, and nine times the infections vs 'population TasP' at 28% of the cost. CONCLUSIONS: CVCT is a cost-effective, feasible prevention strategy in Zambia. We demonstrate the novel, added effectiveness of providing CVCT to ART users, for whom ART use alone only partially mitigated transmission risk. Our results indicate a major policy shift (supporting development of CVCT indicators, budgets and targets) and have clinical implications (suggesting promotion of CVCT in ART clinics as a high-impact prevention strategy).

Willingness to Pay for Condoms among Men in Sub-Saharan Africa.

HIV/AIDS and other sexually transmitted infections (STIs) continue to be among the greatest public health threats worldwide, especially in sub-Saharan Africa (SSA). Condom use remains an essential intervention to eradicate AIDS, and condom use is now higher than ever. However, free and subsidized condom funding is declining. Research on how to create healthy markets based on willingness to pay for condoms is critically important. This research has three primary aims: (1) willingness of free condom users in five African countries to pay for socially marketed condoms; (2) the relationship between specific population variables and condom brand marketing efforts and willingness to pay; and (3) potential opportunities to improve condom uptake. Nationally representative samples of at least 1200 respondents were collected in Kenya, Nigeria, South Africa, Zambia, and Zimbabwe. We collected data on a range of demographic factors, including condom use, sexual behavior, awareness of condom brands, and willingness to pay. We estimated multivariate linear regression models and found that free condom users are overwhelmingly willing to pay for condoms overall (over 90% in Nigeria) with variability by country. Free users were consistently less willing to pay for condoms if they had a positive identification with their free brand in Kenya and Zimbabwe, suggesting that condom branding is a critical strategy. Ability to pay was negatively correlated with willingness, but users who could not obtain free condoms were willing to pay for them in Kenya and Zimbabwe. In a landscape of declining donor funding, this research suggests opportunities to use scarce funds for important efforts such as campaigns to increase demand, branding of condoms, and coordination with commercial condom manufacturers to build a healthy total market approach for the product. Free condoms remain an important HIV/AIDS prevention tool. Building a robust market for paid condoms in SSA is a public health priority.

Sexual behavior experiences and characteristics of male-female partnerships among HIV positive adolescent girls and young women: Qualitative findings from Zimbabwe.

BACKGROUND: New HIV infections among sub-Saharan Africa's adolescent girls and young women (AGYW, ages 15-24) greatly exceed those of their male peers. In addition, AGYW tend to acquire HIV at a much earlier age. Understanding the factors associated with HIV infection in AGYW could inform effective prevention and treatment interventions for these populations and their male sexual partners. METHODS: This qualitative study, conducted October-November 2016, was a follow on to a quantitative survey that sought to characterize male sexual partners and sexual behaviors of sexually active HIV positive AGYW in Zimbabwe. The qualitative study explored sexual behavior experiences and characteristics of male-female partnerships among the same participants. We conducted in-depth interviews with purposively sampled AGYW (16-24 years). Audio recorded qualitative data were transcribed, translated into English, and thematically coded using NVivo. RESULTS: 28 AGYW (n = 14 urban, n = 14 rural) took part in the in-depth interviews. 50% were 16-19 years old. Discussions with 10/11 (91%) AGYW who were reportedly infected through sex suggested that they had acquired HIV from their husbands or romantic partners. Accounts also suggested that the age difference between respondents and their male sexual partners was ≥5 years. Overall, respondents described two types of male partners: those older (''sugar daddies'', men ≥35 years old) and younger (<35 years). Respondents felt unable to suggest condom use to both older and younger partners. Evident in respondents' accounts was a general low HIV risk perception, particularly with younger men, which was largely due to poor HIV knowledge. Discussions suggested that an AGYW's relationship with either male partner was characterized by some form of violence. CONCLUSIONS: Discussions highlighted the nature and characteristics of relationships between AGYW and their male sexual partners. Findings could inform interventions to engender risk perception among AGYW, promote female-controlled HIV prevention efforts and, foster risk-reduction among men.

A Cluster Randomised Trial to Determine the Efficacy of the "Feeding Buddies" Programme in Improving Exclusive Breastfeeding Rates Among HIV-Infected Women in Rural KwaZulu-Natal, South Africa.

This cluster randomised trial in KwaZulu-Natal South Africa, evaluated the implementation of a Feeding Buddies (FB) programme to improve exclusive breastfeeding (EBF) amongst human immunodeficiency virus infected mothers. Eight clinics were randomly allocated to intervention and control arms respectively. Pregnant women attending the prevention of mother-to-child transmission program and intending to EBF were enrolled: control (n = 326), intervention (n = 299). Intervention mothers selected FBs to support them and they were trained together (four sessions). Interviews of mothers occurred prenatally and at post-natal visits (day 3, weeks 6, 14 and 22). Breastfeeding results were analysed (Stata) as interval-censored time-to-event data, with up to four time intervals per mother. EBF rates at the final interview were similar for control and intervention groups: 44.68% (105/235) and 42.75% (109/255) respectively (p = 0.67). In Cox regression analysis better EBF rates were observed in mothers who received the appropriate training (p = 0.036), had a community care giver visit (p = 0.044), while controlling for other factors. Implementation realities reduced the potential effectiveness of the FBs.

Women and substance use: a qualitative study on sexual and reproductive health of women who use drugs in Delhi, India.

OBJECTIVES: To explore contextual factors that increase vulnerabilities to negative sexual and reproductive health (SRH) outcomes and possible differences in SRH-related behaviours and the needs of women who use drugs (WUD) through non-injecting and injecting routes. DESIGN: Qualitative study design using semi-structured in-depth interviews. PARTICIPANTS: Twenty women who injected drugs in the past 3 months and 28 women who reported using drugs through non-injecting routes in the past 1 month. SETTING: Interviews were conducted at community-based, drop-in centres in Delhi, India. RESULTS: Study findings illustrate that WUD were sexually active and had multiple sex partners including clients of sex work. Transient relationships were reported and many participants engaged in unsafe sex. Factors which affected safe sex behaviours included: gender power imbalance, limited agency for decision-making, lack of accurate information for correct self-risk assessment, and being under the influence of drugs. Despite high awareness, low and inconsistent contraceptive use was reported. Some participants were coerced to conceive while a few others reported their inability to conceive. Violence was a key determinant for SRH outcomes. Perception of certain adverse health outcomes (such as infertility) to be 'common and expected among WUD' influenced access to healthcare. Further, healthcare providers' stigmatising attitudes and lack of women-centric services deterred women from uptake of healthcare services. CONCLUSION: Findings highlight that SRH-related behaviours and needs of this group are a complex interplay of multiple determinants which need to be addressed at all levels: individual, family, community and institutional. It is imperative to roll out a 'one-stop-shop' for a comprehensive package of health services. Expansion of existing drop-in-centres could be considered for setting-up community-based women-centric services with appropriate linkage to drug dependence treatment and reproductive health services.

Transitioning couple's voluntary HIV counseling and testing (CVCT) from stand-alone weekend services into routine antenatal and VCT services in government clinics in Zambia's two largest cities.

INTRODUCTION: Most HIV infections in Africa are acquired by married/cohabiting adults and WHO recommends couple's voluntary HIV counseling and testing (CVCT) for prevention. The handover from NGO-sponsored weekend CVCT to government-sponsored services in routine weekday antenatal care (ANC) and individual voluntary testing and counseling (VCT) services in Zambia's two largest cities from 2009-2015 is described. METHODS: Government clinic counselors were trained to provide CVCT, and along with community health workers they promoted CVCT services in their clinic and surrounding areas. When client volume exceeded the capacity of on-duty staff in ANC and VCT, non-governmental organization (NGO) subsidies were offered for overtime pay. RESULTS: Implementation of routine CVCT services varied greatly by clinic and city. The 12 highest volume clinics were examined further, while 13 clinics had CVCT numbers that were too low to warrant further investigation. In Lusaka, the proportion of pregnant women whose partners were tested rose from 2.6% in 2009 to a peak of 26.2% in 2012 and 24.8% in 2015. Corresponding reports in Ndola were 2.0% in 2009, 17.0% in 2012 and 14.5% in 2015. Obstacles to CVCT included: limited space and staffing, competing priorities, record keeping not adapted for couples, and few resources for promotion and increasing male involvement. Conflicting training models for 'partner testing' with men and women separately vs. CVCT with joint post-test counseling led to confusion in reporting to district health authorities. DISCUSSION: A focused and sustained effort will be required to reach a meaningful number of couples with CVCT to prevent heterosexual and perinatal HIV transmission. Establishing targets and timelines, funding for dedicated and appropriately trained staff, adoption of standardized data recording instruments with couple-level indicators, and expansion of community and clinic-based promotions using proven models are recommended.

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.

Effects of a High Protein Food Supplement on Physical Activity, Motor Performance and Health Related Quality of Life of HIV Infected Botswana Children on Anti-Retroviral Therapy (ART).

OBJECTIVE: Despite existing evidence about the benefits of nutrition, physical activity (PA) and sport to the overall health and wellbeing of children, knowledge gaps remain on this relationship in children living with chronic conditions like HIV/AIDS. Such knowledge should inform context specific programs that could enhance the quality of life of children. The purpose of this study was to examine the effects of integrating a nutrition intervention (culturally tailored food supplement) into antiretroviral therapy (ART) on psychosocial outcomes and physical activity among HIV-positive children in Botswana. METHOD: 201 HIV-positive children (6-15 years; M = 9.44, SD = 2.40) were recruited and randomly assigned (stratified by age and gender) to two groups. The intervention group (n = 97) received a high protein (bean-sorghum plus micronutrients) food supplement, while the control group (n = 104) received a sorghum plus micronutrients supplement. Participants were followed over 12 months. Anthropometric measures, PA, motor performance, and health related quality of life (HRQL) were collected at baseline, 6 and 12 months. RESULTS: Mixed repeated-measures ANOVA revealed a significant time effect of the food supplement on target variables except body fat percentage, speed, and school functioning. Time × treatment interaction was found for physical functioning, psychosocial functioning and total quality of life score. Scores on physical functioning and total of quality life in the intervention group significantly increased from baseline to 6 months compared with the control group (p = 0.015). CONCLUSION: A combination of ART and nutritional intervention had a positive effect on physical functioning and total quality of life of HIV-positive children in this study. There were also improvements to physical activity and motor performance tests over time. More research is needed on long term effects of nutrition and PA interventions on HRQL in children living with HIV.

The aetiology of diarrhoea, pneumonia and respiratory colonization of HIV-exposed infants randomized to breast- or formula-feeding.

BACKGROUND: Diarrhoea and pneumonia are common causes of childhood death in sub-Saharan Africa but there are few studies describing specific pathogens. OBJECTIVES: The study aimed to describe the pathogens associated with diarrhoea, pneumonia and oropharyngeal colonization in children born to HIV-infected women (HIV-exposed infants). METHODS: The Mashi Study randomized 1200 HIV-infected women and their infants to breastfeed for 6 months with ZDV prophylaxis or formula-feed with 4 weeks of ZDV. Children were tested for HIV by PCR at 1, 4, 7, 9 and 12 months and by ELISA at 18 months. Pre-defined subsets of children were sampled during episodes of diarrhoea (n = 300) and pneumonia (n = 85). Stool was tested for bacterial pathogens, rotavirus and parasites. Children with pneumonia underwent bacterial blood culture, and testing of nasopharyngeal aspirates for viral pathogens by PCR. Oropharyngeal swabs were collected from a consecutive subset of 561 infants at the routine 3-month visit for bacterial culture. RESULTS: The median age (range) at sampling was 181 days for diarrhoea (0-730) and 140 days for pneumonia (2-551). Pathogens were identified in 55 (18%) children with diarrhoea and 32 (38%) with pneumonia. No differences in pathogens by child HIV status (HIV-infected vs HIV-uninfected) or feeding strategy were identified. Campylobacter was the most common diarrhoeal pathogen (7%). Adenovirus (22%) and other viruses (19%) were the primary pathogens isolated during pneumonias. More formula-fed infants had oropharyngeal colonization by pathogenic Gram-negative bacteria (16.8% vs 6.2%, P = 0.003), which was associated with a non-significant increased risk of pneumonia (OR 2.2, 95% CI 0.8-5.7). CONCLUSION: A trend toward oropharyngeal bacterial colonization was observed in formula-fed infants. Although viruses were most commonly detected during pneumonia, respiratory colonization by Gram-negative bacteria may have contributed to pneumonia in formula-fed infants.

A Protocol for a Cluster Randomized Trial on the Effect of a "feeding buddy" Program on adherence to the Prevention of Mother-To-Child-Transmission Guidelines in a Rural Area of KwaZulu-Natal, South Africa.

BACKGROUND: The uptake of prevention of mother-to-child-transmission (PMTCT) services has improved in South Africa but challenges remain, including adherence to the World Health Organization's (WHO) PMTCT recommendations of exclusive breastfeeding (EBF), taking antiretroviral medication (ARV); testing for early infant diagnosis; and reducing stigma. Women who practice EBF for the first 6 months are less likely to transmit HIV to their infants, yet only 7% of women EBF for 6 months in South Africa. Adherence to these recommendations remains challenging because of difficulties relating to disclosure and stigma. To address this challenge, the feeding buddy concept was developed based on studies where ARV buddies have proved effective in providing support for women living with HIV. Buddies have demonstrated a positive effect on providing emotional and social support to adhere to PMTCT guidelines. METHODS: A cluster randomized controlled trial was conducted in 16 selected randomly assigned clinics in uMhlathuze and uMlalazi districts of KwaZulu Natal, South Africa. HIV-positive pregnant women (n = 625) who intended to breastfeed were enrolled at 8 control clinics and 8 intervention clinics. The clinics were stratified on the basis of urban/rural/periurban locale and then randomly allocated to either intervention or control. In the intervention clinics, the mother chose a feeding buddy to be enrolled alongside her. Quantitative interviews with mothers and their chosen buddies took place at enrollment during pregnancy and at routine postdelivery visits at day 3 and weeks 6, 14 and 22. Women in the control clinics were followed using the same evaluation schedule. The trial evaluated the effect of a voluntary PMTCT feeding buddy program on HIV-infected women's adherence to PMTCT recommendations and stigma reduction. The proportion of women exclusively feeding at 5.5 months postpartum was the primary end-point of the trial. In-depth interviews were conducted among a convenience sample of PMTCT counselors, community caregivers, mothers, and buddies from intervention clinics and control clinics to document their overall experiences. DISCUSSION: The information collected in this study could be used to guide recommendations on how to build upon the current South Africa. PMTCT "buddy" strategy and to improve safe infant feeding. The information would be applicable to many other similar resource poor settings with poor social support structures.

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.

Implementation of a confidential helpline for men having sex with men in India.

BACKGROUND: In India, men who have sex with men (MSM) often face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual identity, especially if they are married to women and have families. Due to pervasive stigma and discrimination, human immunodeficiency virus (HIV) prevention programs are unable to reach many MSM effectively. OBJECTIVE: The objective of this paper was to describe the design, operations, and monitoring of the Sahaay helpline, a mHealth intervention for the MSM population of India. METHODS: We established the "Sahaay" mHealth intervention in 2013; a MSM-dedicated helpline whose main goal was to increase access to comprehensive, community-based HIV prevention services and improve knowledge, attitudes, and behaviors of MSM towards HIV and sexually transmitted infections (STI) in three states of India (Chhattisgarh, Delhi, and Maharashtra). The helpline provided a 24x7 confidential and easy to use interactive voice response system (IVRS) to callers. IVRS function was monitored through an online dashboard of indicators. The system also provided real-time reporting on callers and services provided. RESULTS: The helpline received more than 100,000 calls from 39,800 callers during the first nine months of operation. The helpline maintained an operational uptime of 99.81% (6450/6462 hours); and answered more than 81.33% (83,050/102,115) of all calls. More than three-fourths of the calls came between 9:00 am-12:00 pm. The most successful promotional activity was "interpersonal communication" (reported by 70.05%, 27,880/39,800, of the callers). Nearly three-fourths of the callers self-identified as MSM, including 17.05% (6786/39,800) as rural MSM and 5.03% (2001/39,800) as a married MSM. Most callers (93.10%, 37,055/39,800) requested information, while some (27.01%, 10,750/39,800) requested counseling on HIV/acquired immune deficiency syndrome (AIDS), STIs, and other health and nonhealth issues. There were 38.97% (15,509/39,800) of the callers that were provided contacts of different HIV/AIDS referral services. Many MSM clients reported increased self-esteem in dealing with their sexual identity and disclosing the same with their family and spouse; and an increase in HIV/AIDS risk-reduction behaviors like consistent condom use and HIV testing. CONCLUSIONS: National HIV/AIDS prevention interventions for MSM in India should consider scaling-up this helpline service across the country. The helpline may serve as an important mechanism for accessing hard-to-reach MSM, and thus improving HIV prevention programing.

'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 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.