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Background: Lifestyle modifications (LM) are crucial in managing comorbid Tuberculosis (TB) and Diabetes Mellitus (DM) patients, significantly impacting treatment outcomes and overall health. In view of this, a study was conducted to clarify sociocultural features associated with LM among TB–diabetes comorbid patients. Methods: A cross-sectional descriptive study among randomly selected 180 adult TB–diabetes-comorbid-patients was conducted using a semi-structured interview schedule. Mann–Whitney-U-test was used to examine differences in means between patterns of distress (PDs) and perceived causes (PCs) regarding TB and Diabetes for two identified LM strategies among comorbid patients. Stepwise logistic regression was used to study factors associated with these LM strategies. Results: TB–diabetes-comorbid-patients reporting physical symptoms as PDs preferred to follow the LM-1 strategy for TB and LM-2 for Diabetes. In contrast, patients reporting health-illness-injury-related causes follow LM-2 for TB and LM-1 for Diabetes. Further patients reporting hypertension for Diabetes (AOR = 2.916, 95% CI 0.9262–9.1788) and concerns-about-the-course-of-TB-illness (AOR = 3.746, 95% CI 1.4683–9.5593) as PDs were 3–4 times more likely to follow LM-1. While those reporting prior illnesses (AOR = 4.255, 95% CI 1.3941–12.9837) and sanitation (AOR = 5.242, 95% CI 1.2028–22.8446) as PCs for TB were 4–5 times follow LM-2. Patients who perceived consumption of alcohol as PCs of Diabetes were 10 times more likely to stop addictions (AOR = 9.680, 95% CI 2.5555–36.6639) and follow the LM-2 strategy. Conclusion: Given significant associations of sociocultural features with LM strategies, consideration of sociocultural features vis-à-vis these strategies is indispensable for managing TBDM comorbidity, emphasizing the need for developing comprehensive, patient-centred self-management interventions to enhance adherence and improve health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Childhood pneumonia, if identified early, is readily treatable through low-cost antibiotics. The study aimed to understand the family caregivers' knowledge and care-seeking behavior for the management of childhood pneumonia. The study was cross-sectional, with mixed methods assessing knowledge, perceptions, and practices of caregivers of under-five children on pneumonia using a vignette. Methodology: Systematic random sampling was used to select the participants. Of 107, more than half of the respondents were 18–25 years old. Results: Less than one-fourth were illiterate. Cough, flu, and stomach distention were the commonly reported symptoms. Food ingestion was reported as a main perceived cause; private doctors and traditional healers were the most reported source of help-seeking. Friend/family were reported as leading sources of information. Health education is to be imparted using local knowledge regarding childhood pneumonia. Traditional healers and private practitioners sensitize in early management and referral of childhood pneumonia cases. Conclusions: Information, education and communication messages need to be prepared in the local languages. Strengthening the public health sector is suggested. [ABSTRACT FROM AUTHOR]

Background: India is a major contributor to the global burden of leprosy and tuberculosis (TB), which adversely affects the poorest tribal communities. Despite prioritisation by disease control programmes, programme performance for leprosy and TB in tribal communities continues to be a challenge. In addition to access to services and infrastructural limitations, socio-cultural concepts of illness causation and related help seeking (HS) rooted in distinct features of tribal culture need to be addressed to improve programme outcomes. Methods: A cultural epidemiological survey of leprosy and TB patients was carried out using a locally adapted, semi-structured explanatory model interviews. A total of 100 leprosy and 50 TB patients registered for treatment at government health facilities were selected randomly from tribal dominant blocks of the Thane district, Maharashtra state. The perceived causes (PCs) of leprosy and TB in patients were compared based on prominence categories. The relationship between PCs as predictors, and disease conditions and HS preferences as outcome variables were assessed using multivariate logistic regression. Results: In the multivariate logistic regression model with disease conditions as outcome variables, TB patients were significantly more likely to report PCs in the categories of ingestion; health, illness and injury; and traditional, cultural and supernatural. Tuberculosis patients more frequently first sought help from private facilities as compared to leprosy patients who preferred government health facilities. In a combined analysis of leprosy and TB patients employing multivariate logistic regression, it was found that patients who reported PCs in the environmental and contact-related categories were more likely to visit traditional rather than non-traditional practitioners. In another multivariate combined model, it was found that patients who reported PCs in the traditional, cultural and supernatural category were significantly more likely to visit private rather than public health facilities. Conclusion: Cultural concepts about illness causation and associated HS behaviours should be considered as priorities for action, which in turn would provide the necessary impetus to ensure that tribal patients seek help in a timely and appropriate manner, and could facilitate improvement in programme performance in general. [ABSTRACT FROM AUTHOR]

Background: Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied.Methods: This retrospective cohort study conducted between 1st March 2009 and 1st March 2017 aimed to evaluate rate of incident TB in individuals initiated on ART at 3 private sector ART clinics in Pune, India. Individuals more than 12 years of age with ART duration of atleast 6 months were included. Patients were classified as having prevalent TB if they had a TB episode within the year prior to ART initiation or if they developed TB within 6 months of starting ART. Individuals who were diagnosed with TB after 6 months of starting ART were classified as incident TB cases. A recurrent episode of TB after treatment completion or cure of prevalent TB was also regarded as incident TB. Patients were classified as definitive TB if Mycobacterium tuberculosis was grown in culture from a biological sample or a positive rapid molecular test. Patients were classified as probable TB if there was radiologic evidence of TB in absence of confirmatory culture or PCR.Results: 1904 patients with a median duration of follow up on ART of 57 (IQR = 32.0, 84.0) months were included. Of these, 182 developed incident TB (22% definitive TB, 38% recurrent cases). TB incidence at 6-12 months, 13-24 months, 25-60 months and > 60 months of ART was 24.32, 5.46, 2.54 and 0.75 cases per 100 person years respectively. Current time updated CD4 count < 500 cells/mm3 (p < 0.0001), virologic failure on ART (adjusted Hazard Ratio (aHR): 3.05 (95% CI: 2.094, 4.454), p < 0.0001) and receipt of ART without IPT (aHR: 8.24 (95% CI, 3.358, 20.204), p < 0.0001) were associated with higher risk of incident TB.Conclusion: Starting ART early in treatment naïve individuals, prompt detection of virologic failure on ART and providing IPT along with ART will be useful in reducing incident TB. Efforts from private sector are crucial in achieving Sustainable Development Goals set by Government of India and attaining the vision of a TB free India. [ABSTRACT FROM AUTHOR]

Background & objectives: Respondent Driven Sampling (RDS) method is increasingly being used for surveys among hard to reach populations. It essentially relies on the networking among the target population. Key behavioural indicators, HIV and sexually transmitted infection (STI) prevalence were measured under Integrated Behavioural and Biological Assessment (IBBA), designed to study the impact of Avahan India AIDS Initiative. RDS surveys were conducted in 2006 and 2007 among high risk populations. Methods: Four separate surveys covered female sex workers (FSW) (Mumbai, Parabhani), Bar Girl (Mumbai) and injecting drug users (IDU) (Mumbai-Thane) population through RDS. Respondents were recruited through the personal and social networks of the initially selected "seeds". Successive recruitments were done through snowball effect. Duel compensation for participation and recruitment was given. Three uniquely numbered coupons were given to recruit peers from network. Through subsequent waves of recruitment desirable sample was achieved. Informed and voluntary consent was obtained. Results: A total of 338 bar girls, 403 FSWs (Mumbai), 367 FSW (Parbhani) and 376 IDUs (Mumbai/Thane) were recruited through RDS. The desired samples were achieved within three months period. Average seeds recruited for each survey ranged from 22 to 35. Average reported network size ranged from 4.8 to 13.2. Homophily index for each survey group was found to be 0.0 except for bar girl survey (0.3). Some seeds yielded multiple waves of recruitment while many failed to go beyond first wave. Interpretation & conclusions: Our findings suggest that RDS does not appear to recruit more marginalized or undercovered section of the targeted group. Greater preparatory activity and better understanding of networks may be required for setting up appropriate venues across geographical boundaries. Further indepth network analysis is needed in diverse regional structures and population coverage in conducting RDS surveys locally. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis(TB) and Diabetes comorbidity is an emerging public health problem in India. Delays in diagnosing TB or Diabetes would lead to adverse outcomes among comorbid patients, and attempts must be made to reduce these delays. Against this background, the study has been undertaken to clarify the role of sociocultural factors in determining diagnostic delays for TB and Diabetes among comorbid patients., Methods: A cross-sectional cultural epidemiological survey of the randomly selected 180 TB-Diabetes comorbid patients was carried out. The study examined sociocultural factors of delayed diagnosis of TB and Diabetes among urban and rural TB-Diabetes comorbid patients registered under TB-Diabetes collaborative activities under the National TB Elimination Programme (NTEP) in the Satara district of Maharashtra by using a semi-structured interview schedule. The patterns of distress (PDs) and perceived causes(PCs) of TB and Diabetes were compared with patients' and providers' diagnostic delays of TB and Diabetes based on prominence categories. In addition, the relationship between PDs and PCs as explanatory variables and TB and Diabetes diagnostic delays as outcome variables were assessed using stepwise multiple logistic regression., Results: Of the 180 TB-Diabetes comorbid patients, the proportion of men was higher, and they were 4.7 times more likely to get a delayed Diabetes diagnosis. Those who reported side effects of drugs and stigma reduced social status as the PDs were 2-3 times more likely to delay reaching TB facilities/providers (patients' diagnostic delay). Those who perceived inadequate diet and mental-emotional stress as the causes of TB were about three times more likely to reach the TB providers/facilities after two weeks. Also, those who perceived TB as a cause of punishment for prior deeds were two times more likely to reach TB facilities/providers after two weeks. Patients who reported fever and chest pain as the symptoms of TB were two times more likely to delay the diagnosis of TB. Patients who reported tobacco consumption, unhealthy lifestyles, thoughts, worries, tension, and germs or infection as perceived causes of TB were about two times more likely to be diagnosed after two weeks. Patients who reported excessive thirst as a diabetes symptom were about two times more likely to get delayed >2 weeks to reach diabetes facilities/providers. Patients who perceived environmental/occupational exposure as the cause of Diabetes were two times more likely to reach the diabetes facilities/providers after two weeks. Patients who reported excessive thirst and stroke as the physical problems of Diabetes were 3.2 and 9.6 times more likely to get delayed in the diagnosis of Diabetes (providers' diagnostic delay). Patients who perceived violation of taboo or misbehaviour as the perceived cause of Diabetes were 6.7 times more likely to get a delayed diagnosis of Diabetes., Conclusions: The sociocultural factors associated with TB and Diabetes diagnostic delays among comorbid patients are essential considerations in the evolving context of implementing TB-Diabetes collaborative activities. Therefore, acknowledging sociocultural factors concerning delayed diagnosis and minimising delays would strengthen joint TB-Diabetes collaborative activities under the National framework locally and nationally., Competing Interests: Conflict of interest The authors have none to declare., (Copyright © 2023 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Objectives: Over-the-counter (OTC) antibiotic use can cause antibiotic resistance, threatening global public health gains. To counter OTC use, this study used machine learning (ML) methods to identify predictors of OTC antibiotic use in rural Pune, India., Methods: The features of OTC antibiotic use were selected using stepwise logistic, lasso, random forest, XGBoost, and Boruta algorithms. Regression and tree-based models with all confirmed and tentatively important features were built to predict the use of OTC antibiotics. Five-fold cross-validation was used to tune the models' hyperparameters. The final model was selected based on the highest area under the curve (AUROC) with a 95% confidence interval (CI) and the lowest log-loss., Results: In rural Pune, the prevalence of OTC antibiotic use was 35.9% (95% CI, 31.6 to 40.5). The perception that buying medicines directly from a medicine shop/pharmacy is useful, using antibiotics for eye-related complaints, more household members consuming antibiotics, and longer duration and higher doses of antibiotic consumption in rural blocks and other social groups were confirmed as important features by the Boruta algorithm. The final model was the XGBoost+Boruta model with 7 predictors (AUROC, 0.934; 95% CI, 0.891 to 0.978; log-loss, 0.279) log-loss., Conclusions: XGBoost+Boruta, with 7 predictors, was the most accurate model for predicting OTC antibiotic use in rural Pune. Using OTC antibiotics for eye-related complaints, higher consumption of antibiotics and the perception that buying antibiotics directly from a medicine shop/pharmacy is useful were identified as key factors for planning interventions to improve awareness about proper antibiotic use.

Background: The second COVID-19 wave in India has been associated with an unprecedented increase in cases of COVID-19 associated mucormycosis (CAM), mainly Rhino-orbito-cerebral mucormycosis (ROCM)., Methods: This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all-cause mortality due to CAM., Results: 59 patients were diagnosed with CAM. Median duration from the first positive COVID-19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID-19. 56% patients were prescribed steroids for non-hypoxemic, mild COVID-19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID-19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death., Conclusions: CAM is a rapidly progressive, angio-invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases., (© 2022 Wiley-VCH GmbH.)

Abstract: Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Symptomatic cerebrospinal fluid (CSF) viral escape (sCVE) is reported in people with HIV, who are on ritonavir-boosted protease inhibitor (PI/r) containing antiretroviral therapy (ART). Management of sCVE includes performing genotypic HIV-1 resistance testing (GRT) on CSF and plasma HIV and changing ART accordingly. Neither GRT nor newer drugs (Dolutegravir and Darunavir/ritonavir) are routinely available in India. As a result, management of sCVE includes 2 modalities: a) ART intensification by adding drugs that reach therapeutic concentrations in CSF, like Zidovudine, to existing ART or b) Changing to a regimen containing newer boosted PI/r and integrase strand transfer inhibitor (INSTI) as per GRT or expert opinion. In this retrospective study, we report the outcomes of above 2 modalities in treatment of sCVE in Pune, India.Fifty-seven episodes of sCVE in 54 people with HIV taking PI/r-containing ART were identified. Clinical, demographic, laboratory and ART data were recorded. Forty-seven cases had follow-up data available after ART change including measurement of plasma and CSF viral load (VL).Of the 47 cases, 23 received zidovudine intensification (Group A, median VL: plasma- 290, CSF- 5200 copies/mL) and 24 received PI/INSTI intensification (Group B, median VL: plasma- 265, CSF-4750 copies/mL). CSF GRT was performed in 16 participants: 8 had triple class resistance. After ART change, complete resolution of neurologic symptoms occurred in most participants (Group A: 18, Group B: 17). In Group A, follow-up plasma and CSF VL were available for 21 participants, most of whom achieved virologic suppression (VL < 20 copies/mL) in plasma (17) and CSF (15). Four participants were shifted to the PI/INSTI intensification group due to virologic failure (plasma or CSF VL > 200 copies/mL). In Group B, follow-up plasma and CSF VL were available for 23 participants, most of whom also achieved virologic suppression in plasma (21) and CSF (18). Four deaths were noted, 2 of which were in individuals who interrupted ART.This is a unique sCVE cohort that was managed with 1 of 2 approaches based on treatment history and the availability of GRT. At least 75% of participants responded to either approach with virologic suppression and improvement in symptoms.

Objective: To evaluate cost-effectiveness of second HIV test in pregnancy., Background: Current strategy of single HIV test during pregnancy in India can miss new HIV infections acquired after the first test or those HIV infections that were missed in the first test due to a false-negative HIV test., Methods: Between August 2011 and April 2013, 9097 pregnant HIV uninfected women were offered a second HIV test near term (34 weeks or beyond) or within 4 weeks of postpartum period. A decision analysis model was used to evaluate cost-effectiveness of a second HIV test in pregnant women near term., Primary and Secondary Outcome: Our key outcome measures include programme cost with addition of second HIV test in pregnant women and quality-adjusted life years (QALYs) gained., Results: We detected 4 new HIV infections in the second test. Thus HIV incidence among pregnant women was 0.12 (95% 0.032 to 0.297) per 100 person women years (PWY). Current strategy of a single HIV test is 8.2 times costlier for less QALYs gained as compared to proposed repeat HIV testing of pregnant women who test negative during the first test., Conclusions: Our results warrant consideration at the national level for including a second HIV test of all pregnant women in the national programme. However prior to allocation of resources for a second HIV test in pregnancy, appropriate strategies will have to be planned for improving compliance for prevention of mother-to-child transmission of HIV and reducing loss-to-follow-up of those women detected with HIV., Trial Registration Number: CTRI/2013/12/004183., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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.

An overview of social responses to AIDS, characterized by high levels of stigma, discrimination central to the global AIDS challenge, as related to human dignity is described. Stigma is conceptualized as a problem of 'they' and 'us', or interactions perspective. Causes and consequences to enable the varied perspectives in understanding this third epidemic of social impact of HIV/AIDS are described. In the absence of an effective medical intervention, the social factors like stigma and discrimination attached to HIV/AIDS are a major obstacle in the curtailment of the disease requiring urgent action. The different forms of stigma associated with other diseases are compared. Ignorance about the disease, fear of discrimination and consequent denial for testing and treatment, contribute to spread of the disease. The disease status adds to vulnerability especially in women. The disease is often identified with groups like intravenous drug users (IDUs), and homosexuals who face a double stigma as a result of HIV. Research scenario on stigma associated with HIV/AIDS is reviewed to understand the future needs. Initiatives of ongoing intervention to reduce stigma exist globally. Emerging issues in research priorities have been highlighted to counter consequences of pandemic from social perspective of human dignity and rights.