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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: India started its vaccination programme for Coronavirus-19 infection (COVID-19) on 16 January 2021 with CovishieldTM (Oxford/Astra Zeneca vaccine manufactured by Serum Institute of India) and Covaxin ® (Bharat Biotech, India). We designed the present study to study the effectiveness of vaccines for COVID-19 in prevention of breakthrough infections and severe symptomatic cases among health care workers in a real-life scenario in Mumbai, India. Furthermore, we also wanted to study the factors associated with this effectiveness. Methods: This is cohort analysis of secondary data of 2762 individuals working in a tertiary health care setting in Mumbai, India (16 January 2021 to 16 October 2021). Vaccination records of all groups of health care staff (including the date of vaccination, type of vaccine taken, and date of positivity for COVID-19) were maintained at the hospital. The staff were tested for COVID-19 at least once a week and when symptomatic. The observation time for everyone was divided into unvaccinated, partially vaccinated (14 days after the first dose); and fully vaccinated (14 days after the second dose). If the individual was found to be positive, the day of positivity was considered the 'day of the event' for that individual. We combined unvaccinated/partially vaccinated into one group and completely vaccinated in the other group. We estimated hazard ratios (HR) and their 95% confidence intervals. The vaccine effectiveness (VE) was assessed as (1-HR)*100. Results: The mean age (SD) of the study participants was 32.3 (8.3) years; majority of these individuals had taken Covishield TM (99.0%) and only 0.9% (n = 27) had taken Covaxin ®. The incidence rate in the overall population was 0.067/100 person-days (PD). The incidence rate was significantly higher in the unvaccinated/partially vaccinated group compared with the fully vaccinated group (0.0989 / 100 PD vs 0.0403/100 PD; p < 0.001). The adjusted HR (aHR) in the fully vaccinated group compared with the unvaccinated/partially vaccinated group in the complete cohort was 0.30 (95% CI: 0.23, 0.39). Thus, the vaccine effectiveness (VE) for full vaccination was 70% (95% CI: 61%, 77%). It remained the same in the Covishield TM only cohort. The VE in completely vaccinated and with a history of previous infection was 88% (95% CI: 80%, 93%). Only 11 health care workers required hospitalization over the entire observation period; the incidence rate in our cohort was 0.0016 / 100 PD. None of the HCWs reported any severe adverse events after vaccination. Conclusions: In this real-world scenario, we did find that complete vaccination reduced the rate of infection, particularly severe infection in health care personnel even during the severe delta wave in the country. Even among those infected, the hospitalisation rates were very low, and none died. We did not record any major side effects of vaccination in these personnel. Previous infection with COVID-19 and complete vaccination had a significantly higher effectiveness in prevention of infection. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: India started its vaccination programme for Coronavirus-19 infection (COVID-19) on 16 January 2021 with CovishieldTM (Oxford/Astra Zeneca vaccine manufactured by Serum Institute of India) and Covaxin ® (Bharat Biotech, India). We designed the present study to study the effectiveness of vaccines for COVID-19 in prevention of breakthrough infections and severe symptomatic cases among health care workers in a real-life scenario in Mumbai, India. Furthermore, we also wanted to study the factors associated with this effectiveness., Methods: This is cohort analysis of secondary data of 2762 individuals working in a tertiary health care setting in Mumbai, India (16 January 2021 to 16 October 2021). Vaccination records of all groups of health care staff (including the date of vaccination, type of vaccine taken, and date of positivity for COVID-19) were maintained at the hospital. The staff were tested for COVID-19 at least once a week and when symptomatic. The observation time for everyone was divided into unvaccinated, partially vaccinated (14 days after the first dose); and fully vaccinated (14 days after the second dose). If the individual was found to be positive, the day of positivity was considered the 'day of the event' for that individual. We combined unvaccinated/partially vaccinated into one group and completely vaccinated in the other group. We estimated hazard ratios (HR) and their 95% confidence intervals. The vaccine effectiveness (VE) was assessed as (1-HR)*100., Results: The mean age (SD) of the study participants was 32.3 (8.3) years; majority of these individuals had taken Covishield TM (99.0%) and only 0.9% (n = 27) had taken Covaxin ®. The incidence rate in the overall population was 0.067/100 person-days (PD). The incidence rate was significantly higher in the unvaccinated/partially vaccinated group compared with the fully vaccinated group (0.0989 / 100 PD vs 0.0403/100 PD; p < 0.001). The adjusted HR (aHR) in the fully vaccinated group compared with the unvaccinated/partially vaccinated group in the complete cohort was 0.30 (95% CI: 0.23, 0.39). Thus, the vaccine effectiveness (VE) for full vaccination was 70% (95% CI: 61%, 77%). It remained the same in the Covishield TM only cohort. The VE in completely vaccinated and with a history of previous infection was 88% (95% CI: 80%, 93%). Only 11 health care workers required hospitalization over the entire observation period; the incidence rate in our cohort was 0.0016 / 100 PD. None of the HCWs reported any severe adverse events after vaccination., Conclusions: In this real-world scenario, we did find that complete vaccination reduced the rate of infection, particularly severe infection in health care personnel even during the severe delta wave in the country. Even among those infected, the hospitalisation rates were very low, and none died. We did not record any major side effects of vaccination in these personnel. Previous infection with COVID-19 and complete vaccination had a significantly higher effectiveness in prevention of infection., Competing Interests: The authors have declared that no competing interests exist.