Health impacting behaviour & morbidity: Implications for adolescent & youth health programmes in India.

BACKGROUND OBJECTIVES: In Himachal Pradesh (HP), a comprehensive health survey was conducted to assess the prevalent health affecting habits and issues among young individuals aged 10 to 24 yr. The study was aimed to evaluate key factors such as nutrition, substance use (including tobacco and alcohol), mental health concerns such as anxiety and depression, sexual behaviours and personal hygiene, as well as incidents of violence and injury (including road traffic and other injuries). METHODS: A cross-sectional survey was conducted in HP on 2895 individuals aged between 10 and 24 yr. The survey encompassed four districts, namely Shimla, Kinnaur, Kangra, and Sirmaur, and 12 blocks (three in each district). To ensure a representative sample, a stratified multistage cluster sampling approach was used. Districts and blocks were selected purposively so as to represent the diverse sociodemographic and cultural characteristics of this region. Within each block, thirty clusters were chosen using a probability proportional to size method. Clusters were defined as villages in rural areas and wards in urban areas. The World Health Organization 30 × 7 cluster technique was employed to identify households and individuals for the study. RESULTS: Underweight (44.39%), risk of cell phone addiction (19.62%), feeling anxious (15.54%), unintentional injuries (14.72%) and violence (8.19%) were the top five health impacting problems among young people in HP. INTERPRETATION CONCLUSIONS: The leading health impacting problems identified are preventable and/or modifiable factors affecting the overall health and development of young people in HP. These need to be addressed as priority health problems for interventions with a focus on maintaining positive health through integrated approaches including care provision, risk reduction and health promotion related to these health impacting behaviours. Such interventions are likely to yield better results towards the overall health and development of young people in HP.

Assessment of resources for physical activity and understanding people's perception and practices regarding physical activity in an Indian city.

BACKGROUND: Promoting physical activity in urban India is imperative considering the burden of non-communicable diseases in the country. Planning for improving population level physical activity needs sound understanding of availability and quality of resources/facilities for physical activity and knowing people's perception and practices regarding the physical activity. METHODS: A cross-sectional study was undertaken in Kolar city of Karnataka state in India. All the resources/facilities required for supporting physical activity were mapped and their quality was assessed utilizing adapted version of physical activity resource assessment questionnaire. The information regarding latitude, longitude and approximate size of the resource was obtained using a hand-held GPS tracker. 495 individuals aged ≥ 18 years, selected by two stage cluster random sampling with probability proportionate to population size technique, were interviewed to assess their perception and practices regarding physical activity using semi-structured questionnaire and global physical activity questionnaire. RESULTS: Kolar city has 36.3 physical activity resources per lakh population and per person availability of park and playground area was 0.4 Sq. meters. Available resources were concentrated in the center of the city. Half of the sports facilities and 14 of the 17 recreational facilities in the city were of poor to mediocre quality. 38.2% of adults in Kolar city were found to be physically active. Only 19.2% of the study participants had accessed sports/fitness facilities/playgrounds in past 3 months and only 18.8% of the study participants accessed parks in the previous 3 months. 28.6% to 59.1% of the participants preferred 'walking' for work, college and shopping. Less than 5% of the participants preferred and used cycle as a mode of transport. 1/3rd of the study participants felt that Kolar city is safe of walking and 44.6% felt that the city is safe for cycling. CONCLUSION: Creating enabling environment by increasing the number and quality of resources/facilities for physical activity along with their equitable distribution is required to promote and improve population level physical activity in Kolar city. Urban planning with a focus on non-motorized transport including walking would contribute to improved people's perception and practices regarding physical activity in the city.

Youth focused life skills training and counselling services program-An inter-sectoral initiative in India: Program development and preliminary analysis of factors affecting life skills.

OBJECTIVES: This paper describes the methodology of developing and implementation of a youth focused life skills training and counselling services programme (LSTCP) and assessment of factors associated with life skills of participants pre-training. DESIGN: Development of all aspects of LSTCP (modules, methods and evaluation) was through a consultative process. Experiential learning based facilitation was decided as the approach for training participants. A quasi-experimental design with pre, post and follow-up assessment post-training was finalised. Data collection was done using specifically developed semi-structured self-administered questionnaire. RESULTS: Multivariable logistic regression with life skills as outcome and various exposure variables was performed. About 2/3rd of participants had high level of life skills (68%). Increased score of extraversion (AOR = 1.57,95% CI = 1.32-1.85), agreeableness (AOR = 1.42,95% CI = 1.16-1.73), conscientiousness (AOR = 1.9,95% CI = 1.55-2.33), physical (AOR = 1.03,95% CI = 1.01-1.04), environmental (AOR = 1.02,95% CI = 1.004-1.03) and social quality of life (AOR = 1.01,95% CI = 1.006-1.02) were associated with high life skills score. Higher score of neuroticism (AOR = 0.66,95% CI = 0.53-0.79) was associated with low life skills score. CONCLUSION: The results presented provide an opportunity to understand the evolution of factors affecting life skills during the follow-up of this study. This study throws light on development of LSTCP for apparently healthy population in a setting like India and its states.

Youth and suicidality: Correlates among clients attending youth mental health promotion clinics in India.

BACKGROUND: Suicidality among youth is one of the most challenging public health issues. A thorough understanding of the risk factors that contribute to youth suicidality is necessary. The main aim of the study is to estimate the proportion of suicidality and understand factors associated with suicidality amongst clients attending youth mental health promotion clinics in Karnataka, India. METHODS: A retrospective cross-sectional case record analysis was performed utilising data from real-time digitised management information system specifically developed for the programme. All case records of clients aged 15 to 35 years who received mental health promotion (MHP) services between January 2017 and December 2020 across 30 districts of Karnataka were included in this analysis. Multivariate logistic regression analysis was performed with suicidality among clients as outcome. Socio-demographic characteristics, issues reported, feelings/emotions that indicate underlying mental health issue/crisis, being aware of suicidality among friends and family and personal habits (smoking/chewing tobacco and drinking alcohol) were considered potential exposure variables. FINDINGS: Overall proportion of suicidality among youth presenting to youth mental health promotion clinics in Karnataka was 3.5% (357/10,340). Among factors associated with suicidality, the strongest association was found among those clients who reported attempted suicide among friends (AOR 8.94; 95% CI 5.95-13.45), family members (AOR 5.50; 95% CI 3.66-8.29), being anxious (AOR 4.90; 95% CI 3.43-6.99), inability to trust anyone (AOR 4.07; 95% CI 2.75-6.03), had issues of Gender, Sex and Sexuality (AOR 3.16; 95% CI 1.93-5.17) and relationship issues (AOR 2.77; 95% CI 2.05-3.73). CONCLUSION: The results alert all institutions, organisations and departments that cater to services and development of youth, to be sensitive towards risk factors of suicidality. The study advocates youth mental health promotion clinics to be equipped with measures/interventions to identify and manage such risk factors. This study has implications for Youth mental health promotion in India and other similar South-East Asian countries.

A bird's eye view of the mental health systems in India.

Background: A staggering 85% of the global population resides in low- and middle-income countries (LAMICs). India stands as an exemplary pioneer in the realm of mental health initiatives among LAMICs, having launched its National Mental Health Program in 1982. It is imperative to effectively evaluate mental health systems periodically to cultivate a dynamic learning model sustained through continuous feedback from mental healthcare structures and processes. Materials and Methods: The National Mental Health Survey (NMHS) embarked on the Mental Health Systems Assessment (MHSA) in 12 representative Indian states, following a pilot program that contextually adapted the World Health Organization's Assessment Instrument for Mental Health Systems. The methodology involved data collection from various sources and interviews with key stakeholders, yielding a set of 15 quantitative, 5 morbidity, and 10 qualitative indicators, which were employed to encapsulate the functional status of mental health systems within the surveyed states by using a scorecard framework. Results: The NMHS MHSA for the year 2015-16 unveiled an array of indices, and the resultant scorecard succinctly encapsulated the outcomes of the systems' evaluation across the 12 surveyed states in India. Significantly, the findings revealed considerable interstate disparities, with some states such as Gujarat and Kerala emerging as frontrunners in the evaluation among the surveyed states. Nevertheless, notable gaps were identified in several domains within the assessed mental health systems. Conclusion: MHSA, as conducted within the framework of NMHS, emerges as a dependable, valid, and holistic mechanism for documenting mental health systems in India. However, this process necessitates periodic iterations to serve as critical indicators guiding the national mental health agenda, including policies, programs, and their impact evaluation.

Profile of Acute Encephalitis Syndrome Patients from South India.

Introduction: Encephalitis is a major public health problem worldwide that causes huge emotional and economic loss to humanity. Encephalitis, being a serious illness, affects people of all ages. The aim is to describe the sociodemographic, clinical, etiological, and neuroimaging profile among 101 acute encephalitis syndrome (AES) patients visiting a tertiary neuro-specialty care hospital in India. Methods: Record review of medical records of all patients attending neurology emergency and outpatient services at NIMHANS Hospital, diagnosed with AES in 2019, was conducted. Data were collected using standardized data collection forms for all cases in the study. Descriptive analyses (mean and standard deviation for continuous variables and proportions for categorical variables) were conducted. The Chi-square test/Fisher's exact test was used for the comparison of independent groups for categorical variables, and t-test for comparing means for continuous variables. Results: About 42.6% of AES patients had viral etiology, while in 57.4%, etiology was not ascertained. Common presenting symptoms were fever (96%), altered sensorium (64.4%), seizures (70.3%), headache (42.6%), and vomiting (27.7%). Herpes simplex was the most common (21.8%) identified viral encephalitis, followed by chikungunya (5%), arboviruses (chikungunya and dengue) (4%), Japanese encephalitis (4%), rabies (3%), dengue (1%), and varicella virus (1%). About 40% of AES patients showed cerebrospinal fluid pleocytosis (44%), increased protein (39.6%), abnormal computed tomography brain (44.6%), and magnetic resonance imaging abnormalities (41.6%). Conclusion: The study highlights the need to ascertain etiology and importance of evidence-based management of AES patients. A better understanding of opportunities and limitations in the management and implementation of standard laboratory and diagnostic algorithms can favor better diagnosis and management of AES.

Mental health morbidities in Kerala, India: Insights from National Mental Health Survey, 2015-2016.

Background: The National Mental Health Survey was borne out of the felt need for a comprehensive epidemiological survey on mental health to understand the magnitude of psychiatric morbidities in India to aid in mental health policymaking, service planning, and delivery. Kerala was one of the 12 surveyed states, representing southern India. Aims: To estimate the prevalence and pattern of various mental illnesses and substance use disorders in a representative sample from Kerala state. Settings and Design: A household survey using a multi-stage, stratified, random cluster sampling technique, with selection based on probability proportionate to size at each stage. Materials and Methods: The community-based survey was carried out by trained field staff on individuals from systematically selected households from three randomly selected districts of Kerala. The instruments used in the survey included M.I.N.I adult version 6.0, a modified version of the Fagerström Nicotine Dependence Scale and questionnaires to screen for epilepsy, intellectual disability, and autism spectrum disorders. Results: A total of 2479 respondents aged >18 years were interviewed. The lifetime and current prevalence of mental morbidity (excluding tobacco use disorders) was 14.14% and 11.36%, respectively. Neurotic/stress-related disorders and depressive disorders were 5.43% and 2.49%, respectively, while severe mental disorders were prevalent in 0.44% of the sample. The prevalence of high risk for suicide was 2.23%. Conclusions: The survey revealed high rates of common mental illnesses and suicide risk in the state when compared to national estimates.

Smoked tobacco dependence and its correlates among participants attending life skills training and counselling services programme across Karnataka (2017-2022).

Introduction: Indian National Mental Health Survey reports an alarming prevalence of 20.9% for tobacco dependence in India. Dependence on smoked tobacco can be prevented by thorough knowledge of the risk factors associated with it. Objectives: To estimate the prevalence and identify the factors associated with smoked tobacco dependence among participants attending the life skills training and counselling services programme (LSTCSP) across Karnataka from 2017 to 2022. Materials and Methods: Pretraining data of 3104 participants from training programmes between 2017 and 2022 were utilised. Univariate and multivariable logistic regression analysis was performed based on a conceptual framework with various hypothesised exposure variables and smoked tobacco dependence as outcome. Results: The overall prevalence of smoked tobacco dependence among LSTCSP participants who used smoked tobacco products was 59.4%. Ever use of smokeless tobacco products (Adjusted odds ratio (AOR) =2.05, 95% CI: 1.11-3.78) and screening positive for symptoms of generalised anxiety (AOR = 2.53, 95% CI: 1.32-4.84) significantly increased the odds of smoked tobacco dependence, whereas making decisions collectively in the family (AOR = 0.35, 95% CI: 0.18-0.66) and individuals with increased score for neurotic personality traits (AOR = 0.64, 95% CI: 0.44-0.93) were the factors associated with reduced odds of smoked tobacco dependence. Conclusion: The identified risk factors associated with smoked tobacco dependence are important to develop tobacco control programmes as well as in preventing its onset. With the risk factors for smoked tobacco dependence identified, the results of this study have implications for health promotion and prevention programmes as well as cessation programmes related to smoked tobacco dependence, within India and similar countries.

Prevalence and factors associated with tobacco use among beneficiaries attending the youth mental health promotion clinics (Yuvaspandana Kendra) in India: A case-record analysis.

INTRODUCTION: Chewing tobacco and smoking among youth leads to poor health outcomes. Understanding the factors associated with chewing tobacco and smoking is thus important for interventions. METHODS: A case-record analysis among 10340 youth (aged 15-35 years) attending a unique mental health promotion program, Yuva Spandana, across the state of Karnataka in southern India, was performed to assess prevalence of chewing tobacco and smoking. Multiple logistic regression was applied to determine the factors associated with their use. RESULTS: Overall, the prevalence of chewing tobacco and smoking among beneficiaries was 3% and 2.1%, respectively. The risk of tobacco chewing and smoking increased with age and risk was higher among males, married individuals and among all occupational categories, other than students. Adjusted odds ratios of chewing tobacco were found to be highest among business/salaried beneficiaries (AOR=3.48; 95% CI: 2.27-5.34), followed by ever married beneficiaries (AOR=3.41; 95% CI: 1.27-9.17). Adjusted odds ratios of smoking tobacco were highest among males (AOR=12.89; 95% CI: 7.5-22.14), followed by emotional experience of feeling worthless (AOR=4.19; 95% CI: 2.78-6.32), beneficiaries with poor relationship with family members (AOR=3.79; 95% CI: 1.38-10.44), and business/salaried beneficiaries (AOR=2.90; 95% CI: 1.79-4.7). Strength of association of males with smoking was much higher (AOR=12.89; 95% CI: 7.5-22.14) than compared with chewing tobacco (AOR=2.49; 95% CI: 1.89-3.28). CONCLUSIONS: Early identification of these factors associated with chewing tobacco and smoking will help in focusing on youth specific health promotion and interventions to improve their overall health and wellbeing.

Certificate Course in Occupational Safety and Health: A Capacity Building Program for Primary Care Physicians based on Adult Learning Model.

Context: The need for physicians qualified in the field of occupational safety and health (OSH) is growing with the growth of manufacturing and service sectors where maximum number of work-related morbidity and mortality occur. Aims: This article aims to assess the effectiveness and feasibility of the certificate course in occupational safety and health for training and capacity building of primary care physicians in OSH. Methods and Material: Guideline for reporting evidence-based practice educational interventions and teaching (GREET) was used for describing educational interventions. The outcome was assessed by comparing the mean scores. t test with P < 0.005 was considered a level of significance. Results: The result showed significant improvement in the cumulative pre- and post-test scores after each module. The certificate course is suitable for adult learning as there was no intergroup difference in knowledge after the program. Consistent with the findings, the improvement scores indicate that training has made a difference in the knowledge and learning of the trained physicians. Conclusions: This customized training intervention has high potential for scaling up while optimally addressing the scarcity of trained physicians in the OSH in high population density settings like India where a high number of vulnerable workforces work in the informal economy.

Effectiveness and Factors Associated with Improved Life Skill Levels of Participants of a Large-Scale Youth-Focused Life Skills Training and Counselling Services Program (LSTCP): Evidence from India.

(1) Background: To empower and facilitate mental health promotion for nearly 18 million youth, a pioneering state-wide Life Skills Training and Counselling Services Program (LSTCP) was implemented in Karnataka, India. This study assesses the changes in life skills scores, level of life skills and factors associated with increased life skills among participants of the LSTCP. (2) Method: This pre-post study design was conducted on 2669 participants who underwent a six-day structured LSTCP. Changes in mean life skills scores and level of life skill categories pre- and post-LSTCP were assessed. Multivariate logistic regression was performed to assess the factors associated with increases in life skills. (3) Results: The LSTCP resulted in significant changes in life skill scores and level of life skills, indicating the effectiveness of the training. All life skill domains, except empathy and self-awareness, increased post-training. There was a positive shift in the level of life skills. Age (AOR = 1.34, CI = 1.11-1.62), gender (AOR = 1.39, CI = 1.15-1.68), education (AOR = 1.44, CI = 1.05-1.97) and physical (AOR = 1.02, CI = 1.01-1.03) and psychological (AOR = 1.02, CI = 1.01-1.03) quality of life was associated with an increase in life skills among participants. (4) Conclusions: The LSTCP is effective in improving the life skills of participants. The LSTCP modules and processes can be used to further train youth and contribute to mental health promotion in the state.

Factors affecting relationship issues among clients attending youth mental health promotion services in India.

BACKGROUND: India today is home for the largest youth population in the world. Youth is a formative phase transitioning from childhood to adulthood. Relationship is fundamental for a healthy and satisfactory life. Relationships assume importance and maturity during adolescence and youth. Relationships and mental health have a bidirectional effect. The effect of relationships on mental health is stronger than vice versa. MATERIALS AND METHODS: Two-year case record analysis of 8595 beneficiaries aged 15-35 years attending youth guidance centers (Yuva Spandana Kendras) in Karnataka, India, was undertaken to understand factors affecting relationship issues among them. Multivariate logistic regression was performed with any beneficiary having a relationship issue as outcome. RESULTS: Being a student (adjusted odds ratio [AOR] = 1.49; 95% confidence interval [CI] = 1.18-1.89), occupation (AORbusiness/salaried = 3.04; 95% CI = 2.10-4.40 and AORothers = 1.72; 95% CI = 1.22-2.44), marital status (AORmarried = 1.42; 95% CI = 1.06-1.90 and AORothers = 3.44; 95% CI = 1.45-8.15), having health and lifestyle issues (AOR = 3.61; 95% CI = 3.05-4.27), personality issues (AOR = 2.88; 95% CI = 2.43-3.41), safety issues (AOR = 6.28; 95% CI = 5.01-7.87), gender, sex, and sexuality issues (AOR = 3.10; 95% CI = 1.93-4.98), suicidality (AOR = 1.82; 95% CI = 1.17-2.85), alcohol use (AOR = 5.43; 95% CI = 3.92-7.41), and different emotions experienced (AOR ranging from 0.37 to 3.50), had significant association with relationship issues. CONCLUSION: Investing in health promotion interventions focusing on these precursors of relationship issues among youth seems strategic. Our findings have implications for other states in India and other low-middle-income countries like India.

Incidence and Risk for Hypertension among Regular Medical Examination Attendee Cohort in an Automobile Industry. A Cox- Regression Analysis Model.

Introduction: With nearly 1,612,505 industrial workers in Karnataka, controlling hypertension among them is necessary to reduce subsequent non-communicable diseases (NCDs). However, information on prevalence, incidence, and risk for hypertension among industrial workers is limited. Objectives: To estimate the prevalence, incidence proportion, incidence rate, and risk for hypertension among annual medical examination [AME] attendee cohort between 2010 and 2014 in an automobile industry in India. Materials and Methods: Longitudinal record analysis (cohort approach) of 640 regular AME attendees between 2010 and 2014 was performed to estimate incidence and incidence rates. Cox regression was conducted to estimate the risk for hypertension in the study period. Necessary permission and ethics clearance was obtained. Results and Conclusion: The prevalence of hypertension significantly increased from 8.8% in 2010 to 26.6% in 2014. The small increase in mean blood pressure (BP) resulted in large increases in the prevalence of hypertension. The incidence rate increased from 6.5 per 1000 person-months of observation in 2012 to 14.5 in 2014. No significant risk for hypertension was observed for the work department and type of plant. Results indicate a rising burden of hypertension with no specific risks associated with different work departments or types of plants. AME data is a utility value to monitor hypertension trends among employees and evaluate the effectiveness of worksite health programs to reduce hypertension.

The burden of active infection and anti-SARS-CoV-2 IgG antibodies in the general population: Results from a statewide sentinel-based population survey in Karnataka, India.

OBJECTIVE: To estimate the burden of active infection and anti-SARS-CoV-2 IgG antibodies in Karnataka, India, and to assess variation across geographical regions and risk groups. METHODS: A cross-sectional survey of 16,416 people covering three risk groups was conducted between 3-16 September 2020 using the state of Karnataka's infrastructure of 290 healthcare facilities across all 30 districts. Participants were further classified into risk subgroups and sampled using stratified sampling. All participants were subjected to simultaneous detection of SARS-CoV-2 IgG using a commercial ELISA kit, SARS-CoV-2 antigen using a rapid antigen detection test (RAT) and reverse transcription-polymerase chain reaction (RT-PCR) for RNA detection. Maximum-likelihood estimation was used for joint estimation of the adjusted IgG, active and total prevalence (either IgG or active or both), while multinomial regression identified predictors. RESULTS: The overall adjusted total prevalence of COVID-19 in Karnataka was 27.7% (95% CI 26.1-29.3), IgG 16.8% (15.5-18.1) and active infection fraction 12.6% (11.5-13.8). The case-to-infection ratio was 1:40 and the infection fatality rate was 0.05%. Influenza-like symptoms or contact with a COVID-19-positive patient were good predictors of active infection. RAT kits had higher sensitivity (68%) in symptomatic people compared with 47% in asymptomatic people. CONCLUSION: This sentinel-based population survey was the first comprehensive survey in India to provide accurate estimates of the COVID-19 burden. The findings provide a reasonable approximation of the population immunity threshold levels. Using existing surveillance platforms coupled with a syndromic approach and sampling framework enabled this model to be replicable.

Yuva spandana - A youth mental health promotion model in India - Design, methods and progress.

A unique youth mental health promotion program called Yuva Spandana is implemented and functional across all districts within Karnataka. Trained guidance providers named Yuva Parivarthakas (YPs) and Yuva Samalochakas (YS) provide support to youth having issues at Yuva Spandana Kendras (YSKs). We highlight the process of development of the program "Yuva Spandana" into a sustainable community-based youth mental health promotion model addressing youth issues across Karnataka and describe the profile of beneficiaries attending YSKs in Karnataka between 2017 and 2019. Yuva Spandana has evolved over time and got established in local-self-governments and communities.

Awareness and compliance to anti-smoking law in South Bengaluru, India.

INTRODUCTION: Tobacco smoke affects the health of non-smokers by exposure to second-hand smoke (SHS). The Indian Cigarettes and Other Tobacco Products (COTPA) Act 2003 Section 4 aims to reduce exposure to SHS. Awareness and compliance to COTPA are key to achieving its intended outcome. We assessed: a) awareness among persons responsible for compliance (PRC) and authorized officers (AO), and b) compliance of public places to COTPA in South Bengaluru, India. METHODS: A cross-sectional assessment of public places in South Bengaluru was conducted using time-location sampling. The Johns Hopkins Bloomberg School of Public Health's observational and interview checklist was used to assess compliance of public places to COTPA and awareness of COTPA among PRC/AO, respectively. RESULTS: Among 359 public places, one-third of the public places showed complete (1.9%) or partial compliance (28.1%). The majority (93%) of the PRCs and all AOs were aware of COTPA. However, they lacked information on the different provisions of the Act. Violations like persons smoking (3.9%), visible ashtrays (6%) and cigarette butts (13%) were noted more among eateries compared to other public places. Among those public places supposed to have designated smoking-areas, only 19% complied. CONCLUSIONS: This is the first representative survey of awareness and compliance of COTPA in Bengaluru City. Low compliance, coupled with the lack of appropriate awareness among PRCs and AOs about COTPA, demands a comprehensive strategy to enhance awareness. Comprehensive efforts towards making all stakeholders understand the health impacts of smoking, and strict enforcement, might facilitate effective implementation of COTPA.

Multilevel Analysis of the Predictors of HIV Prevalence among Pregnant Women Enrolled in Annual HIV Sentinel Surveillance in Four States in Southern India.

BACKGROUND: Heterogeneity of the HIV epidemic across districts of south India is reflected in HIV positivity among antenatal clinic (ANC) attendees. Along with individual factors, contextual factors also need consideration for effective HIV interventions. Thus, identifying district and individual level factors that influence ANC HIV positivity assumes importance to intervene effectively. METHODS: Data on HIV sentinel surveillance among the ANC population were obtained from the National AIDS Control Organization (NACO) between years 2004 and 2007. Data from serial cross-sectional studies among female sex workers (FSWs) conducted during this time period in 24 districts were used to generate district level variables corresponding to parameters concerning this high risk population. Other district level data were obtained from various official/governmental agencies. Multilevel logistic regression was used to identify individual and district level factors associated with ANC-HIV positivity. RESULTS: The average ANC-HIV prevalence from 2004 to 2007 in the 24 integrated biological and behavioural assessments (IBBA) districts ranged from 0.25 to 3.25%. HIV positivity was significantly higher among ANC women with age ≥ 25 years [adjusted odds ratio (AOR):1.49; 95% confidence interval (95%CI):1.27 to 1.76] compared to those with age<25 years; illiterate (AOR:1.62; 95%CI:1.03 to 2.54) compared to literate; employed in agriculture (AOR:1.34; 95%CI:1.11 to 1.62) or with occupations like driver/helper/industry/factory workers/hotel staff (AOR:1.59; 95%CI:1.26 to 2.01) compared to unemployed. District level HIV prevalence among FSWs (AOR:1.03; 95%CI:1.0 to 1.05) and percentage women marrying under 18 years were significantly associated with ANC-HIV positivity (AOR:1.02; 95%CI:1.00 to 1.04). CONCLUSION: Illiteracy of the woman, higher HIV prevalence among FSWs and early marriage were associated with HIV positivity among pregnant women in southern India. In addition to targeted HIV preventive interventions among FSWs, studying and changing the behavior of FSW clients and addressing structural drivers of the epidemic might indirectly help reduce HIV infection among women in southern India.

Two cross-sectional studies in south India assessing the effect of an HIV prevention programme for female sex workers on reducing syphilis among their clients.

OBJECTIVE: To assess the impact of the Avahan HIV prevention programme for female sex workers (FSWs) in south India on reducing syphilis prevalence among their clients, by comparing rates of syphilis over time as reported in two large-scale surveys of FSWs' clients. METHODS: A random-effect multilevel logistic regression analysis was performed using syphilis as the dependent variable, with individual independent variables (from the two survey rounds) at level 1 and the district-level programme (from the Avahan computerised monitoring and information system) and contextual variables (from Indian government datasets) at level 2. Programme variables included their 2006 value and their difference in value between 2008 and 2006, as well as the interaction between the latter and the study round. The analysis also controlled for baseline syphilis prevalence and its interaction with the study round. RESULTS: Syphilis decreased significantly among FSWs' clients, from 4.8% (round 1) to 2.6% (round 2), p<0.001. The OR of the interaction term between the difference in programme coverage of FSWs and the round was 0.98 (p=0.023), suggesting that increased coverage was associated with a reduced incidence of syphilis. CONCLUSIONS: This study suggests that the Avahan intervention programme among FSWs reduced syphilis rates among their clients.

Increased HIV prevention program coverage and decline in HIV prevalence among female sex workers in south India.

BACKGROUND: As one way of assessing the impact of Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation, we examined the association between HIV prevention program indicators and changes in HIV prevalence among female sex workers (FSWs) between 2005 and 2009. METHODS: We conducted a secondary data analysis from 2 large cross-sectional surveys (2005-2006 and 2008-2009) across 24 districts in south India (n = 11,000 per round). A random-effect multilevel logistic regression analysis was performed using HIV as the outcome, with individual independent variables (from both surveys) at level 1 and district-level FSW-specific program indicators and contextual variables at level 2. Program indicators included their 2006 value, the difference in their values between 2008 and 2006, and the interaction between this difference and study round. RESULTS: HIV prevalence among FSWs decreased from 17.0% to 14.2% (P < 0.001). This decline varied significantly (P = 0.006) across levels of difference in program coverage (% of FSWs contacted by the program in a given year). Odds ratios comparing HIV prevalence between rounds changed with the level of increase in coverage and were statistically significant with coverage increase ≥ quartile (Q) 1: odds ratio, 0.85 at Q1; 0.78 at Q2; 0.66 at Q3; and 0.51 at Q4. CONCLUSIONS: These findings suggest that increased program coverage was associated with declining HIV prevalence among FSWs covered by the Avahan program. The triangulation of our results with those from other approaches used in evaluating Avahan suggests a major impact of this intervention on the HIV epidemic in southern India.

Population-level impact of Avahan in Karnataka state, south India using multilevel statistical modelling techniques.

OBJECTIVE: To assess the population-level impact of "Avahan," the India AIDS Initiative of the Bill & Melinda Gates Foundation, between 2003 and 2008 in Karnataka state, India. DESIGN: Secondary data analysis using all consistent data collection sites from antenatal clinic (ANC) sentinel surveillance data from 2003 to 2008 in Karnataka. METHODS: A multilevel logistic regression model considering individual- and district-level variables was developed to compare time trends in HIV prevalence among young ANC women (younger than 25 years of age) between Avahan (18) and non-Avahan (9) districts. District-level random effects were considered for the intercept and time. The impact was assessed using interaction terms between district type (Avahan vs. non-Avahan) and time. The number of cases averted was estimated, comparing predicted ANC HIV prevalence in the presence versus the absence of Avahan. Data from the National Family Health Survey Round 3 (2006) were used to extrapolate these numbers to the general population. RESULTS: HIV prevalence among young ANC women declined from 1.46% (2003) to 0.83% (2008). The HIV prevalence trend was significantly different between Avahan and non-Avahan districts (P = 0.046). Overall, 87,035 cases of HIV infection were estimated to have been averted in the Karnataka general population because of Avahan during the 2003-2008 period (range under varying assumptions: 55,160-150,784). CONCLUSIONS: Our results suggest that Avahan has had a significant impact on the HIV epidemic in the general population of Karnataka. These results suggest that targeted interventions similar to Avahan should be implemented and scaled up in all concentrated and mixed HIV epidemics.