Identifying gaps in the continuum of care for hypertension and diabetes in two Indian communities.

BACKGROUND: Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur. METHODS: We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members. RESULTS: Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG <200 mg/dl. Lower-level health facilities were noted to have limited capacity to measure blood glucose as well as significant gaps in the availability of first-line pharmaceuticals for both hypertension and diabetes. CONCLUSIONS: We found high rates of uncontrolled diabetes and undiagnosed and uncontrolled hypertension. Lower level health facilities were constrained by capacity to test, monitor and treat diabetes and hypertension. Interventions aimed at improving patient outcomes will need to focus on the expanding access to quality care in order to accommodate the growing demand for NCD services.

Impact of targeted interventions on heterosexual transmission of HIV in India.

BACKGROUND: Targeted interventions (TIs) have been a major strategy for HIV prevention in India. We evaluated the impact of TIs on HIV prevalence in high HIV prevalence southern states (Tamil Nadu, Karnataka, Andhra Pradesh and Maharashtra). METHODS: A quasi-experimental approach was used to retrospectively compare changes in HIV prevalence according to the intensity of targeted intervention implementation. Condom gap (number of condoms required minus condoms supplied by TIs) was used as an indicator of TI intensity. Annual average number of commercial sex acts per female sex worker (FSW) reported in Behavioral Surveillance Survey was multiplied by the estimated number of FSWs in each district to calculate annual requirement of condoms in the district. Data of condoms supplied by TIs from 1995 to 2008 was obtained from program records. Districts in each state were ranked into quartiles based on the TI intensity. Primary data of HIV Sentinel Surveillance was analyzed to calculate HIV prevalence reductions in each successive year taking 2001 as reference year according to the quartiles of TI intensity districts using generalized linear model with logit link and binomial distribution after adjusting for age, education, and place of residence (urban or rural). RESULTS: In the high HIV prevalence southern states, the number of TI projects for FSWs increased from 5 to 310 between 1995 and 2008. In high TI intensity quartile districts (n = 30), 186 condoms per FSW/year were distributed through TIs as compared to 45 condoms/FSW/year in the low TI intensity districts (n = 29). Behavioral surveillance indicated significant rise in condom use from 2001 to 2009. Among FSWs consistent condom use with last paying clients increased from 58.6% to 83.7% (p < 0.001), and among men of reproductive age, the condom use during sex with non-regular partner increased from 51.7% to 68.6% (p < 0.001). A significant decline in HIV and syphilis prevalence has occurred in high prevalence southern states among FSWs and young antenatal women. Among young (15-24 years) antenatal clinic attendees significant decline was observed in HIV prevalence from 2001 to 2008 (OR = 0.42, 95% CI 0.28-0.62) in high TI intensity districts whereas in low TI intensity districts the change was not significant (OR = 1.01, 95% CI 0.67-1.5). CONCLUSION: Targeted interventions are associated with HIV prevalence decline.

Process evaluation of community care centers providing care, support, and treatment to people living with human immunodeficiency virus in India.

CONTEXT: Since 2007, the concept of community care centers (CCC) has evolved to provide care, support, and treatment services to the people living with human immunodeficiency virus in a community-based environment so as to bridge the gap between secondary/tertiary level institutional and home-based care. Monitoring and evaluation, including process evaluation (PE), are integral parts of this scheme. OBJECTIVE: This article presents the design of the "PE" for CCC and the results pertaining to the gaps and constraints in the implementation of the scheme. DESIGN: The CCC PE was conducted in 197 of the 273 CCCs that have been functioning for at least 1 year as on November 30, 2009. Data were collected by structured observations and individual interviews through checklists and semistructured tools. PARTICIPANTS: The targeted population for PE was inpatient/outpatient beneficiaries, caregivers, and service providers of CCCs. RESULTS: The findings revealed that of 197 CCCs evaluated, 55, 57, 52, and 33 were graded as A, B, C, and D, respectively. Of the 33 grade-D CCCs, 22 were from 4 high-prevalence states (Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu). There was dearth of good nongovernment organizations in the Northeastern region of the country with more nongovernment organizations in C and D category. The PE indicated some critical constraints in the services, such as shortage of medicines for treatment of opportunistic infections, poor coordination with anti-retroviral treatment centers, and transportation for referral cases. In spite of various constraints in the scheme, the majority of the patients were satisfied with the services available at CCC. CONCLUSION: The PE had provided an invaluable base to improve the CCC scheme, which will enhance the quality of service delivery system. The results of our experience may help other researchers and managers plan similar and more improved assessment.

Predisposing, enabling, and need factors associated with utilization of HCV testing services among PWID in two settings in India.

BACKGROUND: The Hepatitis C virus (HCV) is very common among people who inject drugs (PWID), yet PWID in India have suboptimal access to HCV testing and treatment. This study sought to identify HCV risk factors among male PWID who utilized a free needle and syringe exchange program and to examine the predisposing, enabling, and need factors associated with utilization of HCV testing services by those PWID reporting that they had been tested. METHODS: A cross-sectional study was conducted in Imphal, Manipur and Amritsar, Punjab. These two settings have high HCV prevalence and large numbers of PWID. A team of 18 field investigators obtained data through face-to-face interviews using a structured multiple-choice questionnaire. The questionnaire was administered to 1241 of 2644 male PWID aged 15 years and above enrolled in the needle and syringe program of India's AIDS Control Program, with study participants selected through consecutive sampling. Statistical analyses included descriptive statistics and multivariate regression. RESULTS: Twenty-four percent of PWID in our study sample reported having been tested for HCV. Unlike PWID in Imphal, more than half of PWID in Amritsar reported unprotected sex and use of alcohol or non-injecting drugs as being among their HCV risk factors (67.1 and 77.8 %, respectively). However, opioid substitution therapy non-adherence was reported more often in Imphal than in Amritsar. Education, marital status, place of residence and duration of injecting drug use were found to significantly enable access to HCV testing while alcohol use, frequent mobility and unprotected sex were found to significantly inhibit access to HCV testing for PWID after controlling for other explanatory variables. CONCLUSIONS: Predisposing and enabling determinants provide an area for developing effective interventions to improve HCV testing practices among PWID. HCV prevention programs that address safe injecting and sexual practices, OST adherence and frequent mobility customized for PWID by age are strongly recommended.

Pretreatment loss-to-follow-up after HIV diagnosis from 27 counseling and testing centers across India: findings from a cohort study.

Individuals testing HIV positive were interviewed at testing centers, followed prospectively and interviewed again when they registered at referral antiretroviral therapy (ART) centers (ARTCs). Those who did not register at ARTCs were traced and interviewed in the community. A total of 1057 newly diagnosed people living with HIV (PLHIV; 52% women; mean age, 34.7 years) were recruited. A total of 73.5% of PLHIV registered at referral ARTCs within 60 days, 17.9% did not register and were interviewed in the community, and 8.6% were not interviewed. The 2 main reasons cited for not registering were a perception of good health (30%) and work/family engagements (22%). Single clients (adjusted relative risk [ARR]: 1.54; 95% confidence interval [CI]: 1.02-2.34), participants who had not disclosed their HIV status (ARR: 2.32; 95%CI: 1.77-3.05), participants who knew a PLHIV (ARR: 1.89; 95% CI: 1.41-2.53), and participants from laborer households (ARR: 2.66; 95%CI:1.15-6.15) were more likely to not register. In conclusion, the majority of newly diagnosed PLHIV do reach ARTCs. Disclosure concerns and a perception of good health prevent PLHIV from accessing services.

Integrating adolescent-friendly health services into the public health system: an experience from rural India.

BACKGROUND: Although India's health policy is directed toward improving adolescent reproductive health, adolescent-friendly health services are scarce. The intervention for "integrating adolescent-friendly health services into the public health system" is an effort to improve the health status of adolescents in rural areas of the Varanasi (Arajiline) and Bangalore (Hosakote) districts in India. The purpose of this article is to describe the features of the intervention and investigate the impact on improving awareness and utilization of services by adolescent as well as quality of ARSH services in the intervention districts. METHODS: Data from project monitoring, community survey (737 adolescents), exit interviews (120 adolescents), assessment of adolescent sexual and reproductive health clinics (n = 4), and health service statistics were used. Descriptive analyses and paired t-tests were used to compare the two intervention districts. RESULTS: Overall, the percentage of adolescents who were aware of the services being offered at a health-care facility was higher in Hosakote (range: 56.2% to 74.7%) as compared to Arajiline (range: 67.3% to 96.9); 23.3% and 42.6% of adolescents in Arajiline and Hosakote typically sought multiple services at any one visit. A large percentage of clients (Arajiline: 81.7%; Hosakote: 95.0%) were satisfied with the services they received from the facility. The relative change in uptake of services from the first quarter (January to March 2009) to the last quarter (October to December 2010) was significantly higher in Arajiline (7.93, P = 0.020) than in Hosakote (0.78, P = 0.007). CONCLUSION: The intervention had positive results for the public health system and the services are being scaled up to different blocks of the districts, under a public-private partnership.

Assessment of ART centres in India: client perspectives.

Drug adherence and quality of antiretroviral therapy (ART) services are the keys for the successful ART programme. Hence, an attempt has been made to assess ART centres in India from client perspectives that are receiving services from the centres. Data were gathered through exit interviews with 1366 clients from 27 ART centres that were selected on the basis of drug adherence and client load. Analyses revealed that more than 80 per cent of the clients reported overall satisfaction with the services availed from the centre and 60 per cent reported that the quality of life has improved to a great extent after getting ART. Most of the clients strongly demanded to open ART centre in each district for better access as that will increase drug adherence and eventually control the HIV progression. It has been found that as many as 14% of respondents, ever been on ART, reported non-adherence and 70% of them cited distance and economic factors as the reasons for non-adherence. Study concludes that while majority of the clients were satisfied with ART services, shortage of staff, high level of non-drug adherence, long distances and poor referring system are the weak areas requiring attention.

Are persons living with HIV timely accessing ART services in India?

CD4+ T-cell level is one of the important criteria for categorising HIV-related clinical conditions to determine initiation of antiretroviral therapy (ART). The present study is undertaken to analyse baseline CD4 count at which persons living with HIV/AIDS (PLHA) were getting registered for ART in India. It also examines the profile of the PLHA with baseline CD4 count over a period of time. Data of 1,10,974 registered PLHAs at ART centres were analysed for the last three years (April 2005 to March 2008) in the computerised management information system. It was revealed that 85 per cent of PLHA were registered when their baseline CD4 count was less than 250 cells/mm3 and thus were eligible for initiation of ART. No significant change in the proportion of PLHA by CD4 categories was observed in the last three years. These findings suggest that registration for ART at early stages of infection is still uncommon. Significant decline in the proportion of PLHA in the age group of 21-30 years, literate and employed was noticed. The proportion of PLHA referred by counselling and testing centres has increased from 62.6% in 2005-06 to 71.3% in 2007-08. Sexual transmission, followed by mother to child transmission has been reported as two major modes of HIV transmission by PLHA registered at ART centres in the last three years. Though the number of ART centres has increased in India which in turn has increased the number of PLHAs registered and on ART, it is evident from this study that the programme is still far behind to achieve the goal of early detection for timely ART.