Search

Background: Even though quantitative studies have described barriers to anti-retroviral therapy (ART), a more exploratory approach will provide in-depth information on these issues, and potential suggestions to address these issues at individual as well as structural level. We designed this qualitative study to examine the barriers and facilitators for antiretroviral therapy adherence in key population (KP) in Mumbai, India. We also wanted to understand the strategies adopted by these groups and get suggestions to improve adherence to ART., Methods: This is a qualitative analysis of seven focus group discussions (FGDs) conducted with four KP subgroups in Mumbai. We conducted two FGDs each with female sex workers (FSW), men who have sex with men (MSM), male-to-female transgendered people/Hijras (TGH) each, and one FGD with people who inject drugs (IDU). We transcribed the audio-recorded electronic records of these FGDs. We also added the notes of the observers on the group dynamics to the transcribed data. We used the Framework Approach to analyse these data., Results: Some experiences-such as side effects to ART medicines-were common across groups. However, incarceration as a reason for stopping ART was reported by FSWs but not by other KPs. Friends and family (including Guru) are important support systems for HIV infected individuals and adherence to ART. Stigma and discrimination by community members and general community prevent regular access of ART centres and other health care facilities. Additional factors which led to missed doses were mental health issues, alcohol use, and misplacing the ART tablets during police raids or during robbery attempts at the cruising sites. Since a common source of discrimination among peers and the community was the presence of 'Green book' (or their treatment book); the key population wanted the AIDS program to change it to digital cards so that labelling one as 'HIV positive' for being seen with the book can be avoided., Conclusions: The qualitative study helped us explore the barriers to ART among key population and the community provided specific suggestions to address them. In addition to Key Population centric enhanced adherence counselling, some administrative guidelines and procedures may need to be altered to improve adherence to ART in these populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Acharya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Knowledge of factors associated with TB mortality during treatment and post treatment will help us develop better monitoring and implementation strategies for TB control. We designed the present study to examine the factors associated with mortality in HIV-TB co-infected patients during and after the course of TB treatment., Methods: This study is a cohort analysis of secondary data collected from 1804 HIV-TB co-infected individuals from 16 anti-retroviral therapy (ART) centres affiliated with the Mumbai Districts AIDS Control Society, Mumbai, India. We used Kaplan Meier survival curves and hazard ratios to estimate the mortality in patients., Results: The overall mortality rate in this cohort was 1.14 per 100 per month. The mortality proportion was 18% (95% CI: 16.1%, 20.1%) during treatment and 10.6% (95% CI: 8.9%, 12.5%) in the post-treatment period. Mortality was significantly higher in those with a CD4 count 0-200 cells/mm 3 (HR: 3.04, 95% CI: 2.13, 4.15; p < 0.001), and in patients who were ART naïve and referred to the ART centre with a diagnosis of TB (HR: 1.39, 95% CI: 1.06, 1.82; p = 0.016). Mortality was also significantly higher in the first 6 months after initiation of ART (HR: 1.36, 95% CI: 1.06, 1.75; p = 0.016). A decrease in the CD4 counts from initial levels at start of TB treatment to end of TB treatment was associated with higher mortality in the post-treatment period., Discussion: The overall mortality remains high; early identification of TB and HIV disease, and use of rapid point of care tests for diagnosis of TB are needed across all health care facilities. Post-treatment follow-up and monitoring is important in HIV-TB co-infected patients, and post-treatment mortality should also be considered as one of the indicators for successful TB control programmes., (© 2023 John Wiley & Sons Ltd.)

Background: It is important to understand the current internet-related sexual behaviours of high-risk groups such as men who have sex with men (MSM). We designed the present study to understand the types of online/mobile apps used by MSM and male-to-female transgendered people/hijras [TGH] in Mumbai, India. We also compared the internet-related 'partner seeking' and 'sexual behaviours' in MSM and TGH in Mumbai, India., Methods: This is a cross-sectional analysis of secondary data collected (April to June 2020) from 8582 MSM and 4163 TGH from five targeted intervention programmes each in Mumbai, Maharashtra, India. Data on demographics, years of association with the intervention, number and type of online/mobile apps used, sexual behaviours including partners from virtual space and non-virtual (physical) space, group sex, attending parties, mobility for sexual partners, and HIV status were collected., Results: MSM were more likely to have mobile phone (88% vs 51%, p < 0.001) and internet access over the phone (78% vs 27%; p < 0.001) compared with TGH. The common apps used by MSM were Grindr (48%), Facebook (42%), and Blued (36%). MSM were more likely to have partners from virtual space (91% vs 67%; p < 0.001). A higher proportion of MSM had attended parties (28% vs 2%; p < 0.001), had group sex (16% vs 6%; p < 0.001), and were mobile for sex (25% vs 4%). MSM and TGH who had partners from virtual space were significantly more likely to report 'missed a condom at least once during penetrative sex in the past one week' (17% vs 12%; p<0.001). In HIV positive MSM, group sex, parties, and mobility for sex, were only in those who reported partners from the virtual space., Conclusions: Internet-based interventions for MSM should be incorporated in the existing targeted intervention programme and outreach workers should be trained in virtual outreach services. Among TGH, given the low reach and use of smartphones and apps, internet-based interventions may not be such a useful option, and the existing physical targeted intervention programmes should be strengthened., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Acharya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: People with Advanced HIV Disease (AHD) are at higher risk of TB coinfection and mortality. However, there are challenges in TB diagnosis with the currently recommended diagnostic tools. WHO recommends lateral flow urine lipoarabinomannan (LF-LAM) assay to assist TB diagnosis among AHD patients. We assessed the utility and acceptability of using urine LF-LAM assay for TB diagnosis among patients at public Antiretroviral Therapy (ART) Centres in Mumbai., Methods: The cross-sectional study was conducted among adult AHD patients accessing care from 17 ART centres during November,2020-June, 2021. Urine LF-LAM was offered as routine care for eligible patients in combination with standard diagnostic tests. We calculated the proportion of positive LF-LAM results by CD4 categories and TB symptoms and performed multivariable logistic regression to determine the factors associated with LF-LAM positivity., Results: Among 2,390 patients, the majority (74.5%) had CD4 between 101-200 cells/mm3. The mean age was 43.7 years (SD:10.6), 68.6% were male, 8.4% had TB symptoms and 88.0% were on ART. The overall proportion of patients with urine LF-LAM positive results was 6.4%. Among PLHIV with CD4≤100 cells/mm3, the positivity was 43.0% and 7.7% in symptomatic and asymptomatic patients, respectively. Among PLHIV with a CD4>100 cells/mm3, the positivity was 26.7% and 2.7% in symptomatic and asymptomatic patients respectively. Urine LF-LAM positivity was higher among inpatients, ART naïve, patients on treatment for <6 months, symptomatic and in WHO clinical stage III/IV of HIV disease as compared to the reference categories. We detected an additional 131 TB cases with urine LF-LAM in combination with the standard diagnostic tests., Conclusion: The study demonstrated the utility of urine LF-LAM for TB diagnosis among AHD patients and the simple, user-friendly test was acceptable as part of routine care. Inclusion of urine LF-LAM test in the current diagnostic algorithm may facilitate early TB diagnosis among AHD patients., Competing Interests: The authors have declared that no competing interests exist.

Background: The Pediatric HIV Telemedicine Initiative is a video-linked delivery of expert services, designed to reach those previously unable to access expert HIV care. The present qualitative study was designed to understand the acceptability of telemedicine [TM] by patients, their caregivers and health care providers in the anti-retroviral therapy (ART) centers in Maharashtra., Methods: We conducted focus group discussions with caregivers at six ART centres (three linked with TM facilities and three not linked with TM). We also conducted in-depth interviews with medical officers, counselors, and pharmacists at each centre. The data from the interviews were transcribed and translated into English for analysis. The qualitative data were analyzed using thematic framework approach., Results: Children and caregivers who had participated in telemedicine consultation through video conference found the process acceptable, were comfortable communicating during these sessions, and did not have any specific problem to report. The advantages of TM were: consultation without having to travel to other cities; economic advantage; and prompt consultation. The total time spent during the process and technical difficulties during the TM sessions were some of the challenges. The medical officers had the opportunity to discuss difficult cases with the expert during the TM session. Some sessions were also considered a 'group counseling' session, wherein several children and caregivers were able to interact and learn from each other and motivate each other. The health care providers at the three centers that did not currently have TM facilities expressed a desire to have these services at their centers as well. According to them, these facilities will help them address complicated and difficult pediatric HIV cases. Currently, they send their patients to referral centers or other hospitals. Since, many of these referral hospitals are situated in bigger cities, less than 50% of patients access care at these centers This is mostly due to the time constraints and finances (travel/stay) required for accessing these centres., Discussion: TM was a feasible, acceptable, and desired approach for care of children living with HIV/AIDS. It provides support to their caregivers as well as their care providers. The ART staff from the telemedicine-linked peripheral centers were supportive of the use of TM and wanted these services to be initiated in the non-linked centers., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To understand the survival in a cohort of children living with HIV/AIDS (CLHAs) and to study the factors associated with survival in CLHAs in government antiretroviral therapy (ART) centres in Mumbai, India., Design: This is a retrospective cohort analysis., Setting: Data from electronic ART records of children from 15 ART centres in Mumbai, Maharashtra, India., Participants: 2224 CLHAs registered in one of these ART centres from 2004 until October 2019. CLHAs up to the age of 18 at the time of registration were considered for these analyses., Primary and Secondary Outcomes: We accessed the following data: date of test, date of initiation of ART, date of last follow-up, age at the time of registration, gender, potential route of infection, baseline CD4 counts, ART regimen, adherence and presence of co-infection (TB). We estimated the survival probabilities, plotted the Kaplan-Meier survival graphs and estimated HRs for mortality., Results: The mortality rate in our population was 22.75 (95% CI 20.02 to 25.85) per 1000 person-years. The 1-year survival was 0.92 (95% CI 0.91 to 0.93), 0.89 (95% CI 0.88 to 0.91) at 5 years and 0.85 (95% CI 0.83 to 0.87) at 10 years after initiation of ART. Children with adherence less than 80% had lowest survival in the first year (0.54, 95% CI 0.46 to 0.61). It reduced drastically at 5 and 10 years. After adjusting for demographic and clinical parameters, mortality was associated with poor adherence (<80%) (HR 11.70, 95% CI 8.82 to 15.53; p<0.001). However, CD4 counts of greater than 200 and age more than 1 year were protective., Conclusions: Poor adherence to ART and low CD4 counts were significantly associated with higher mortality. Adherence counselling should be an important component of CLHA monitoring in all ART centres. It is also important to identify children early in the infection and start ART medications appropriately., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To evaluate the effectiveness of telemedicine in the clinical management of children living with HIV/AIDS in resource-limited settings ; Background: Telemedicine is an important mechanism for service delivery in health care settings, both in resource-rich and resource-poor settings. Such service delivery mechanisms have shown to be associated with virologic suppression and higher CD4 counts. These services are also associated with improved access, shorter visiting times, and higher patient satisfaction. ; Objective: We designed the present two-group comparison study to compare the clinical evaluation and management of children in the anti-retroviral therapy (ART) centres linked to telemedicine facility with those who are not linked to this facility in Maharashtra, India. ; Methods: We analysed clinical records from six ART centres in Maharashtra; of these, 250 children were in the linked ART centres and 301 were in the non-linked ART centres. The outcomes were classified according to investigations, management, and monitoring. For management, we evaluated: 1) Initiation of cotrimoxazole prophylaxis; 2) Children not initiated on ART when required; 3) ART regime after appropriate investigations; and 4) Change of regime (if immunologically indicated). For monitoring, we assessed the haematological monitoring of children on ART. ; Results: The mean (SD) ages of children in linked and non-linked ART centres were 10.8 (4.6) and 10.9 (4.6) years, respectively (p=0.80). After adjusting for individual and structural level variables, physical examination (OR: 2.0, 95% CI; 1.2, 3.2), screening for tuberculosis (OR: 12.9, 95% CI: 2.0, 82.9) and cotrimoxazole prophylaxis were significantly more likely in the linked centres compared with non-linked centres (OR: 1.8, 95% CI: 1.4, 2.2). A higher proportion of children eligible for ART were not initiated on treatment in the non-linked centres compared with linked centres (26% vs. 8%, p=0.06). Children were less likely to be initiated on zidovudine-based regimens without baseline haemoglobin or with baseline haemoglobin of less than 9 gm% in linked centres (OR: 0.7, 95% CI: 0.6, 0.8). Similarly, children in the linked centres were less likely to have been started on nevirapine-based regimens without baseline liver enzymes (OR: 0.8, 95% CI: 0.7, 0.9). ; Conclusion: Thus, the overall clinical management of Children Living with HIV/ AIDS (CLHA) was better in ART centres linked with the telemedicine initiative compared with those who were not linked. Children in the linked ART centres were more likely to have a complete baseline assessment (physical, hematological, radiological, and screening for TB); the presence of a pediatrician in the centres was helpful., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

A key recommendation of the National AIDS Control Programme-IV of India was to develop new strategies for geo-prioritization of the human immunodeficiency virus (HIV) epidemic. We conducted this study to categorize the districts in Maharashtra (India) based on a multidimensional framework for geo-prioritization of services. Programmatic data on trends of HIV prevalence, coverage of marginalized populations and vulnerability factors were included. A composite indicator based on these was developed, and the cumulative score was calculated for each district. HIV prevalence among general population has declined steadily from 0.60% in 2007 to 0.33% in 2017. The programme coverage was stable but inadequate for men who have sex with men (MSM). The coverage for female sex workers (FSWs) was inadequate and reduced over time. Nine districts were categorized as high priority, 13 as moderate priority and 11 were classified as low-priority districts based on burden and vulnerability for HIV. The high-priority districts were Pune, Solapur and Yavatmal for FSW interventions and Pune, Thane and Latur for MSM interventions. This multidimensional indicator is based on existing programmatic data, dynamic and can be made state-specific. It is useful to categorize and prioritize districts for allocation of resources and geo-prioritization of services in resource limited settings., (© 2020 John Wiley & Sons Ltd.)

Background: India has recently introduced telemedicine initiatives to enhance access to specialized care at a low cost for the pediatric HIV patients, who face multiple challenges due to growing disease burden and limited preparedness of the health system to address it. There are limited evidences on the cost-effectiveness of these interventions. This study was undertaken in Maharashtra, a province, located in the western region of the country, to inform policy regarding the effectiveness of this programme. The objective was to estimate the unit cost of ART services for pediatric HIV patients and examine the efficiency in the use of resource and treatment compliance resulting from telemedicine initiatives in pediatric HIV compared to usual ART services., Methods: We selected 6 ART centers (3 from linked centers linked to Pediatric HIV Centre of Excellence (PCoE) and 3 from non-linked centers) randomly from three high, middle and low ART centers, categorized on the basis of case load in each arm. A bottom up costing methodology was adopted to understand the unit cost of services. Loss to follow up and timeliness of the visits were compared between the two arms and were linked to the cost., Results: The average cost per-visit was INR 1803 in the linked centers and that for the non-linked centers was INR 3412. There has been 5 percentage point improvement in lost to follow-up in the linked centers compared to non-linked centers against a back-drop of a reduction in per-pediatric patient cost of INR 557. The linkage has resulted in increase in timeliness of the visits in linked centers compared to non-linked centers., Discussion and Conclusion: The telemedicine linkage led to an increase in the case load leading to a decrease in cost. The evidence on efficiency in the use of resource and improvement in treatment compliance as suggested by this study could be used to scale up this initiative., Competing Interests: The authors have declared that no competing interests exist.

Background: The present study describes an assessment of a large-scale intervention, "Avahan", using an evaluation framework that assesses the program coverage, changes in injection patterns, condom use, and STI and HIV prevalence among People Who Inject Drugs (PWID) in two states of India - Manipur and Nagaland., Methods: Program monitoring data and results from two rounds of a cross sectional biological and behavioural surveys in 2006 (Round 1) and 2009 (Round 2) were used. The sample included 839 and 860 PWIDs from Manipur and 821 and 829 PWIDs from Nagaland in Round 1 and Round 2 respectively for current analysis. Bivariate and multivariate analyses were done to measure the changes in behavioural and biological outcomes between the two rounds and to examine the association between programme exposure and behavioural outcomes., Results: In Manipur, about 77% of the PWIDs were contacted by the peer educators/outreach workers every month and about 18% of the PWIDs visited the clinic every month by March 2010. In Nagaland, however, the proportion of PWIDs visiting the clinic monthly remained low (11% in March 2010). PWIDs in both states were more likely to report 'consistent safe injection practice in the last six months' in Round 2 compared to Round 1 (Manipur: adjusted odds ratio (aOR): 1.88, 95% confidence intervals (CI): 1.46-2.43; Nagaland: aOR: 2.35, 95% CI: 1.86-2.80) PWIDs were also more likely to report consistent condom use with regular partners in Round 2. The prevalence of Hepatitis B virus (HBV) increased in Round 2 in Manipur (11% vs 6%, p<0.001) and Nagaland (8% vs 6%, p=0.05). The prevalence of Hepatitis C virus (HCV) was high and did not change, either in Manipur (67.3% vs 69.9%, p=0.42) and Nagaland (14.7% vs 15.1%, p=0.82). Similarly, the prevalence of HIV did not change significantly between the two Rounds either in Manipur (27.8% in Round 1 vs 29.2% in Round 2, p=0.59) or in Nagaland (1.2% in Round 1 and 1.6% in Round 2 of the IBBA, p=0.82)., Conclusion: Improvements in safe injection practices and consistent condom use with regular partners suggest effectiveness of prevention efforts. However, increase in HBV prevalence and non-decline in HCV and HIV prevalence in both the states also underscore the need to continue and intensify targeted interventions (such as Hepatitis B vaccination, needle exchange programmes, condom distribution) for long term risk reduction among PWID population., (Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: The present study compared the sexual behaviours of married and unmarried men, in Mumbai, India, who have sex with men., Methods: We conducted a cross-sectional analysis (comparing socio-demographic, behavioural and clinical data) of 88 married and 423 unmarried MSM., Results: Even though MSM are single at younger ages, they are more likely to be married later in life and carry their risky sexual behaviours to this changed social milieu., Conclusions: Married MSM had high-risk behaviours with both men and women; they form an important intervention group for HIV prevention. The interventions will not only reduce the transmission in the male-to-male sexual group, but will also have an effect on the male-to-female transmission of HIV.

Background: Men who have sex with men and transgenders are an important risk group for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). They have risky sexual behaviors but low risk perception., Objectives: To assess the sexual behavior, STIs, HIV and identify factors associated with HIV in men who have sex with men (MSM) and transgenders (TGs) in Mumbai., Methods: Participants were enrolled from two clinics in Mumbai. They completed an interviewer-administered questionnaire and were evaluated for STIs and HIV infection., Results: A total of 150 participants, 122 MSM and 28 TGs were evaluated; 17% of MSM and 68% of the TGs were HIV infected. HIV infection in MSM was associated with serological positivity for HSV2 IgG [adjusted odds ratio (aOR), 95% confidence interval (CI): 9.0 (2.2-36.9)], a positive Treponema pallidum hemagglutination assay (TPHA) [aOR (95% CI): 6.0 (1.5-24.0)], greater than five acts of receptive anal sex in the past six months [aOR (95% CI): 4.3 (1.2-15.0)] and per category increase in age (18-24 yrs, 25-29 yrs, > 30 yrs) [aOR (95% CI): 3.1 (1.3-7.1)] in multivariate analysis. Consistent condom use during receptive anal sex in the past six months was low (27%). Many MSM were married (22%) or had sex with females and may act as a 'bridge population'. HIV infection in TGs was associated with a positive TPHA [OR (95% CI): 9.8 (1.5-63.9)] and HSV 2 IgG [OR (95% CI): 6.7 (1.1-40.4)] in univariate analysis., Conclusion: Prior STIs were strongly associated with HIV infection in MSM and TGs. These groups should be the focus of intensive intervention programs aimed at STI screening and treatment, reduction of risky sexual behavior and promotion of HIV counseling and testing.

Cohort design is a type of nonexperimental or observational study design. In a cohort study, the participants do not have the outcome of interest to begin with. They are selected based on the exposure status of the individual. They are then followed over time to evaluate for the occurrence of the outcome of interest. Some examples of cohort studies are (1) Framingham Cohort study, (2) Swiss HIV Cohort study, and (3) The Danish Cohort study of psoriasis and depression. These studies may be prospective, retrospective, or a combination of both of these types. Since at the time of entry into the cohort study, the individuals do not have outcome, the temporality between exposure and outcome is well defined in a cohort design. If the exposure is rare, then a cohort design is an efficient method to study the relation between exposure and outcomes. A retrospective cohort study can be completed fast and is relatively inexpensive compared with a prospective cohort study. Follow-up of the study participants is very important in a cohort study, and losses are an important source of bias in these types of studies. These studies are used to estimate the cumulative incidence and incidence rate. One of the main strengths of a cohort study is the longitudinal nature of the data. Some of the variables in the data will be time-varying and some may be time independent. Thus, advanced modeling techniques (such as fixed and random effects models) are useful in analysis of these studies. [ABSTRACT FROM AUTHOR]

This study systematically reviews the existing literature on sexually transmitted infections (STIs) including human immunodeficiency virus (HIV) infection in the men who have sex with men (MSM) in India. After a comprehensive literature search of Medline (1950-June 2008), Embase (1980-June 2008), and the Cochrane Library (1950-June 2008), 12 published studies met the inclusion criteria. The link between sexual identity and sexual behavior is a complex phenomenon strongly embedded in a very specific context in India. MSM in India are an important risk group for acquiring STIs/HIV and effective culturally sensitive prevention programs should be designed for them. The combined estimate of HIV prevalence in theMSM population in India calculated from 5 included studies was 16.5% (95% confidence intervals: 11% to 22%). The review also identifies the lacunae in existing literature and provides future directions for research in the MSM community in India. [ABSTRACT FROM AUTHOR]