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Broadly neutralizing antibodies (bnAbs) have been considered to be potent therapeutic tools and potential vaccine candidates to enable protection against various clades of human immunodeficiency virus (HIV). The generation of bnAbs has been associated with enhanced exposure to antigen, high viral load and low CD4+ T cell counts, among other factors. However, only limited data are available on the generation of bnAbs in viraemic non-progressors that demonstrate moderate to high viraemia. Further, since HIV-1 subtype C viruses account for more than 50 % of global HIV infections, the identification of bnAbs with novel specificities is crucial to enable the development of potent tools to aid in HIV therapy and prevention. In the present study, we analysed and compared the neutralization potential of responses in 70 plasma samples isolated from ART-naive HIV-1 subtype C-infected individuals with various disease progression profiles against a panel of 30 pseudoviruses. Among the seven samples that exhibited a neutralization breadth of ≥70 %, four were identified as ‘elite neutralizers’, and three of these were from viraemic non-progressors while the fourth was from a typical progressor. Analysis of the neutralization specificities revealed that none of the four elite neutralizers were reactive to epitopes in the membrane proximal external region (MPER), CD4-binding site and V1V2 or V3 glycan. However, two of the four elite neutralizers exhibited enhanced sensitivity towards viruses lacking N332 glycan, indicating high neutralization potency. Overall, our findings indicate that the identification of potent neutralization responses with distinct epitope specificities is possible from the as yet unexplored Indian population, which has a high prevalence of HIV-1 subtype C infection.

Poor psychosocial health contributes to HIV risk behavior and reduced engagement in treatment and care. This study investigates depression and its correlates among 11,992 MSM recruited via respondent driven sampling in 12 cities across India using the Patient Health Questionnaire-9 and supplemented by analysis of qualitative research from 15 sites with 363 MSM. Overall prevalence of depression was 11 %, with substantial variation across sites and subgroups of MSM, and high prevalence of suicidal thoughts among depressed MSM. In multivariable analyses identification as a kothi (feminine sexual identity) [adjusted odds ratio (aOR) = 1.91], disclosure of being MSM to non-family (aOR = 1.7) and family (aOR = 2.4), disclosure of HIV-status (aOR = 5.6), and substance use were associated with significantly higher odds of depression. Qualitative results emphasized dire social consequences of disclosing MSM- and HIV- status, especially to family, including suicidality. Combination prevention interventions should include mental health services that address disclosure, suicidality, and substance use.

OBJECTIVE: To characterize prevalence incidence and associated correlates of HIV infection among MSM in 12 cities across India. DESIGN: Cross-sectional sample using respondent-driven sampling from September 2012 to June 2013. METHODS: A total 12022 MSM (~1000/city) were recruited. Participants had to be at least 18 years self-identify as male and report oral/anal intercourse with a man in the prior year. HIV infection was diagnosed using three rapid tests. Cross-sectional HIV incidence was estimated using a multiassay algorithm. All estimates incorporate respondent-driven sampling-II weights. RESULTS: Median age was 25 years 45% self-identified as panthi (predominantly penetrative anal intercourse) and 30.6% reported being married to a woman. Weighted HIV prevalence was 7.0% (range: 1.7-13.1%). In multivariate analysis significantly higher odds of HIV infection was observed among those who were older had lower educational attainment were practicing purely receptive anal sex or both receptive and penetrative sex and those who were herpes simplex virus-2 positive. Of 1147 MSM who tested HIV positive 53 were identified as recent HIV infections (annualized incidence = 0.87%; range = 0-2.2%). In multivariate analysis injecting drugs in the prior 6 months syphilis and higher number of male partners and fewer female partners were significantly associated with recent HIV infection. CONCLUSION: We observed a high burden of HIV among MSM in India with tremendous diversity in prevalence incidence and risk behaviors. In particular we observed high incidence in areas with relatively low prevalence suggesting emerging epidemics in areas not previously recognized to have high HIV burden.

BACKGROUND: Little is known regarding barriers to hepatitis C virus (HCV) treatment among people who inject drugs (PWID) in low-resource settings, particularly in the era of direct-acting antiviral therapies. METHODS: Between March, 2015–August, 2016, a cross-sectional survey was administered to community-based PWID in Chennai, India to examine the HCV care continuum and associated barriers. Adjusted prevalence ratios (APR) were estimated by multivariable Poisson regression with robust variance. RESULTS: All participants were male (n=541); 152 participants had HCV mono-infection and 61 participants had HIV/HCV co-infection. Only one HCV mono-infected and one HIV/HCV co-infected participant was linked to HCV care. Overall, there was moderate knowledge of HCV disease but poor knowledge of HCV treatment. Higher total knowledge scores were negatively associated with HIV/HCV co-infection (vs. HCV mono-infection), though this was not statistically significant in adjusted analysis (APR=0.71[95%CI=0.47–1.06]). Participants ≥45 years (APR=0.73[95%CI=0.58–0.92]) and participants with HIV/HCV co-infection (APR=0.64[95%CI=0.47–0.87]) were less willing to take weekly interferon injections for 12 weeks. Willingness to undergo HCV treatment improved with decreasing duration of therapy, higher perceived efficacy, and use of pills vs. interferon, though willingness to use interferon improved with decreasing duration of therapy. Most participants preferred daily visits to a clinic for HCV treatment versus receiving a month’s supply. Participants ≥45 years (vs.

In countries such as India, men who have same-sex partnerships may marry women due to cultural pressures regardless of their sexual desires and preferences. The wives of such men may be at risk for HIV but limited existing research addresses this issue. This qualitative study used in-depth interviews to investigate HIV-related risk among married men who have sex with men (n = 34) and women who were aware of their husband's same-sex behaviour (n = 13) from six research sites in five states and a Union Territory in India: Delhi (Delhi), Visakhapatnam (Andhra Pradesh), Hyderabad (Telangana), Bengaluru (Karnataka), Chennai and Madurai (Tamil Nadu). Thematic analysis revealed that wives of men who have sex with men were at risk for HIV from their husbands' sexual practices, which are often hidden to avoid the potential consequences of stigmatisation, as well as from gender-based inequities that make husbands the primary decision-makers about sex and condom use, even when wives are aware of their husband's same-sex behaviour. Innovative interventions are needed to address HIV-related risk in couples where wives remain unaware of their husband's same-sex behaviour, and for wives who are aware but remain within these marriages.

Background A major barrier to achieving ambitious targets for global control of HIV and hepatitis C virus (HCV) is low levels of awareness of infection among key populations such as men who have sex with men (MSM) and people who inject drugs (PWID). We explored the potential of a strategy routinely used for surveillance in these groups, respondent-driven sampling (RDS), to be used as an intervention to identify HIV- and HCV-infected PWID and MSM who are unaware of their status and those who are viremic across 26 Indian cities at various epidemic stages. Methods and findings Data were collected as part of the baseline assessment of an ongoing cluster-randomized trial. RDS was used to accrue participants at 27 sites (15 PWID sites and 12 MSM sites) selected to reflect varying stages of the HIV epidemic among MSM and PWID in India. A total of 56 seeds recruited a sample of 26,447 persons (approximately 1,000 participants per site) between October 1, 2012, and December 19, 2013. Across MSM sites (n = 11,997), the median age was 25 years and the median number of lifetime male partners was 8. Across PWID sites (n = 14,450), 92.4% were male, the median age was 30 years, and 87.5% reported injection in the prior 6 months. RDS identified 4,051 HIV-infected persons, of whom 2,325 (57.4%) were unaware of their HIV infection and 2,816 (69.5%) were HIV viremic. It also identified 5,777 HCV-infected persons, of whom 5,337 (92.4%) were unaware that they were infected with HCV and 4,728 (81.8%) were viremic. In the overall sample (both MSM and PWID), the prevalence of HIV-infected persons who were unaware of their status increased with sampling depth, from 7.9% in participants recruited in waves 1 through 5 to 12.8% among those recruited in waves 26 and above (p-value for trend < 0.001). The overall detection rate of people unaware of their HIV infection was 0.5 persons per day, and the detection rate of HIV-infected persons with viremia (regardless of their awareness status) was 0.7 per day. The detection rate of HIV viremic individuals was positively associated with underlying HIV prevalence and the prevalence of HIV viremia (linear regression coefficient per 1-percentage-point increase in prevalence: 0.05 and 0.07, respectively). The median detection rate of PWID who were unaware of their HCV infection was 2.5 per day. The cost of identifying 1 unaware HIV-infected individual ranged from US$51 to US$2,072 across PWID sites and from US$189 to US$5,367 across MSM sites. The mean additional cost of identifying 1 unaware HCV-infected PWID was US$13 (site range: US$7–US$140). Limitations of the study include the exclusivity of study sites to India, lack of prior HIV/HCV diagnosis confirmation with clinic records, and lack of cost data from other case-finding approaches commonly used in India. Conclusions In this study, RDS was able to rapidly identify at nominal cost a substantial number of unaware and viremic HIV-infected and HCV-infected individuals who were currently not being reached by existing programs and who were at high risk for transmission. Combining RDS (or other network-driven recruitment approaches) with strategies focused on linkage to care, particularly in high-burden settings, may be a viable option for achieving the 90-90-90 targets in key populations in resource-limited settings., In a large cross-sectional study done in India, Sunil Solomon and colleagues report on respondent-driven sampling for identification of HIV and HCV infections., Author summary Why was this study done? Men who have sex with men (MSM) and people who inject drugs (PWID) bear a high burden of HIV and HCV, and fall behind other at-risk groups in achieving Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets. The behaviors of PWID and MSM (injection drug use and engagement in same-sex relationships) are highly stigmatized in many low- and middle-income countries, resulting in large segments of these populations being hidden. Finding PWID and MSM who are HIV-infected but unaware of their status and not in treatment is critical to curbing the HIV epidemic. What did the researchers do and find? We used data collected as part of an ongoing cluster-randomized trial to explore the potential of respondent-driven sampling (RDS), a chain-referral recruitment strategy, to be used as an intervention to identify unaware and viremic HIV-infected MSM and PWID across 26 Indian cities. We further evaluated the potential of incorporating hepatitis C virus (HCV) testing for PWID. RDS was effective in identifying unaware and viremic HIV-infected MSM and PWID, as well as unaware and viremic HCV-infected PWID. The longer RDS ran (more waves), the more likely it was to identify unaware and viremic HIV-infected MSM and PWID. RDS was most effective in settings with high HIV and HCV burden and low service availability. Incorporating HCV testing into HIV programs for PWID is a cost-effective way of identifying PWID unaware of their HCV infection. What do these findings mean? As the HIV community embraces the UNAIDS 90-90-90 targets, respondent-driven recruitment could be a critical tool in achieving the first 90 target among MSM and PWID in low-and-middle-income countries. Programs targeting drug-using populations should consider combining HIV and HCV screening for maximal benefit to the population.

Syndemic theory describes the clustering and synergistic interaction of disease driven by contextual and social factors, which worsen health outcomes for a population, and has been applied to men who have sex with men (MSM) and their risk for HIV and other sexually transmitted infections. Recent reviews, however, have critiqued prevailing approaches in syndemic studies that assess only additive associations without evaluation of synergy. Following these suggestions, we compared the traditional additive approach with a test for synergistic association of 5 syndemic conditions (alcohol dependence, illicit drug use, depression, intimate partner violence (IPV), and childhood sexual abuse (CSA)) with unprotected anal intercourse (UAI) and active syphilis infection among 11,771 MSM recruited through respondent driven sampling from 12 cities in India. UAI was assessed via self-report and active syphilis infection was diagnosed by RPR and THPA tests. An additive association was explored using a condition count (range 0–5), and synergy was tested using relative excess risk due to interactions (RERIs) calculated from all 2-way and common 3-way interactions between conditions in adjusted regression models. There was a significant dose response associated with the syndemic count and UAI, and a similar pattern for syphilis, though not statistically significant. RERIs showed synergy for only one pair of conditions for UAI and syphilis, respectively: IPV + depression and alcohol dependence + illicit drug use. In this study, we found an additive association between syndemic conditions and UAI with evidence of synergistic interaction between a pair of psychosocial conditions, and no significant additive association, but a synergistic interaction between another pair of psychosocial conditions for syphilis. Our results lend further support to a critical reassessment of syndemic analyses. Closer attention to the cumulative development, underlying causal pathways, and possible synergistic interaction of co-occurring epidemics through combined qualitative and quantitative methodologies may yield more effective interventions for vulnerable, marginalized populations.

Background People who inject drugs (PWID) who are highly connected within their injection drug networks may be important HIV transmission nodes if they frequently share syringes with other PWID and are not engaged in HIV care. In India, HIV transmission fueled by injection drug use is increasing; however, little is known about the associations between injection network size and syringe sharing and viral suppression. Methods We recruited 14,481 PWID between October 2012 and December 2013 by respondent-driven sampling across 15 sites in India. Interviewer-administered questionnaires assessed network characteristics, substance use, HIV testing experience, and access to health services. We used multilevel logistic regression modeling to evaluate the relationship between injection drug network size and (1) syringe sharing at last injection and (2) viral suppression among HIV-positive participants ( Findings The median injection network size was 3 (interquartile range: 1-5), and 7% of participants injected with >10 members in the past 30 days. PWID who had >10 members in their network were 1.65 times (95% confidence interval: 1.12 to 2.42, P = 0.0111) more likely to have shared a syringe at last injection compared with those in the 0-1 members in their drug networks. In addition, individuals with the largest injection drug networks were 31% (95% confidence interval: 0.53 to 0.90, P = 0.006) less likely to be virally suppressed compared with those in the smallest injection drug networks. Discussion Individuals with larger networks may be important in HIV transmission within injection drug networks because they were the most likely to engage in recent syringe sharing and least likely to be virally suppressed.

Long-term follow-up of persons infected with HIV infection is essential to optimize clinical outcomes. However, limited data exist on the rates of dropout (DO) from HIV care and factors associated with DO especially from resource-limited settings. We conducted a retrospective analysis of the data available at YRGCARE, a private HIV care provider in south India that has registered over 15,000 HIV-infected persons since its inception in 1993. We included 7995 patients who registered for care between 1 January 2004 and 31 December 2009. A dropout was defined as a person who registered for care during this period and had not been seen in the clinic for >1 year. Logistic regression was used to examine factors associated with DO from clinical care. The median age of the patients registered for care was 34 years; 66% were male and 83% were married. The overall DO rate was 38.1 per 100 person-years - the majority of the DOs occurred within 6 months from registration. In multivariate analyses, patients who were enrolled in clinical studies/projects entitling them to free medications and retention staff (Odds Ratio [OR]: 0.65) or were on antiretroviral therapy (ART; OR: 0.37) or had a CD4 > 350 at the last visit (OR: 0.20) were significantly less likely to DO from clinical care. We observed a high rate of DO from clinical care at this tertiary HIV clinic in Chennai, India. Making ART available free of charge in the private sector and providing incentives/benefits for attending clinic visits as is routinely done in clinical trials might help improve retention.

BACKGROUND: Drug users (DUs) a population that accounts for some of the fastest-growing human immunodeficiency virus (HIV) epidemics globally lag behind other populations with regard to HIV-related outcomes. We evaluated the role of voucher incentives on linkage and retention in care among DUs in India. METHODS: In this randomized clinical trial 120 DUs who were aged >/=18 years HIV-infected antiretroviral therapy (ART) naive and ART eligible and who reported drug use in the prior month were randomized to incentive (INC) or control (CTL) conditions for 12 months. Participants randomized to the INC arm received incentives (redeemable for food/household goods) ranging in value from USD4 to USD8 for achieving prespecified targets (eg ART initiation visits to ART center). Subjects in the CTL group could win vouchers in prize-bowl drawings but HIV care behaviors were not incentivized. The primary endpoint was time to ART initiation. RESULTS: Sixty participants each were randomized to the INC and CTL arms between December 2009 and September 2010. Participants in the INC arm were more likely to visit the government ART center (49 vs 33; P = .002); 27 participants in the INC and 16 participants in the CTL arm initiated ART (P = .04; hazard ratio for ART = 2.33 [95% confidence interval 1.15-4.73]). Participants in the INC arm also had significantly more visits to the ART center (median number of visits 8 vs 3.5; P = .005). However no difference in viral suppression was observed. CONCLUSIONS: Modest voucher incentives improved linkage to and retention in HIV care but did not significantly impact viral suppression among DUs in India a disenfranchised and difficult-to-treat population. CLINICAL TRIALS REGISTRATION: NCT01031745. (c) The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions please e-mail: journals.permissions@oup.com.

Introduction There are limited data on young people who inject drugs (PWID) from low‐ and middle‐income countries where injection drug use remains a key driver of new HIV infections. India has a diverse injection drug use epidemic and estimates suggest that at least half of PWID are ≤30 years of age. We compared injection and sexual risk behaviours and HIV incidence between younger and older PWID and characterized uptake of HIV testing and harm reduction services to inform targeted HIV prevention efforts. Methods We analysed cross‐sectional data from 14,381 PWID recruited from cities in the Northeast and North/Central regions of India in 2013 using respondent driven sampling (RDS). We compared “emerging‐adult” (18 to 24 years, 26% of sample) and “young‐adult” PWID (25 to 30 years, 30% of sample) to older PWID (>30 years, 44% of sample) using logistic regression to evaluate factors associated with three recent risk behaviours: needle‐sharing, multiple sexual partners and unprotected sex. We estimated age‐stratified cross‐sectional HIV incidence using a validated multi‐assay algorithm. Results Compared to older adults, emerging‐adults in the Northeastern states were significantly more likely to share needles (males adjusted odds ratio [aOR] 1.82; females aOR 2.29, p

Despite extensive research on HIV and hepatitis C (HCV) among people who inject drugs (PWID), there remains a gap in knowledge on the burden among women who inject drugs and their unique contexts and risk factors. This analysis compares HIV and HCV prevalence in female and male PWID and estimates injection and sexual risk correlates of prevalent HIV and HCV infection among women in Northeast India.Cross-sectional sample accrued using respondent-driven sampling.Seven cities in Northeast India, 2013.A total of 6457 adult PWID.Participants completed an interviewer-administered survey. HIV infection was diagnosed on-site and HCV antibody testing was performed on stored specimens. HIV and HCV prevalence estimates were stratified by gender. Among women, the association of risk correlates with HIV and HCV were estimated using multi-level logistic regression models.A total of 796 (15.9%) of the PWID were women, of whom 52.9% [95% confidence interval (CI) = 49.3-56.5%] were HIV-infected and 22.3% (CI = 19.9-24.7%) were HCV-infected. HIV and HCV prevalence among men was 17.4% (CI = 16.9-24.7%) and 30.4% (CI = 31.2-32.0%), respectively. Among women, correlates of HIV were widowhood [adjusted odds ratio (aOR) versus currently married = 4.03, CI = 2.13-7.60] and a higher number of life-time sexual partners (aOR ≥8 versus none = 3.08, CI = 1.07-8.86). Correlates of HCV were longer injection duration (aOR per 10 years = 1.70, CI = 1.25-2.27), injecting only heroin and a combination of drugs (aOR versus pharmaceuticals only = 5.63, CI = 1.68-18.9 and aOR = 2.58, CI = 1.60-4.16, respectively), sharing needles/syringes (aOR = 2.46, CI = 1.29-4.56) and a larger PWID network (aOR ≥ 51 versus 1-5 = 4.17, CI = 2.43-7.17).Women who inject drugs in Northeast India have a high HIV prevalence, which was more than double their hepatitis C (HCV) prevalence, an opposite pattern than is observed typically among male PWID. HIV infection is associated with sexual risk factors while injection-related behaviors appear to drive HCV infection.

The glycan supersite centered on N332 in the V3 base of the HIV-1 envelope (Env) is a target for broadly neutralizing antibodies (bnAbs) such as PGT121 and PGT128. In this study, we examined the basis of resistance of HIV-1 clade C Envs obtained from broadly cross neutralizing (BCN) plasma of an Indian donor with N332 specificity. Pseudotyped viruses expressing autologous envs were found to be resistant to autologous BCN plasma as well as to PGT121 and PGT128 mAbs despite the majority of Envs containing an intact N332 residue. While resistance of one of the Envs to neutralization by autologous plasma antibodies with shorter V1 loop length was found to be correlated with a N332S mutation, resistance to neutralization of rest of the Envs was found to be associated with longer V1 loop length and acquisition of protective N-glycans. In summary, we show evidence of escape of circulating HIV-1 clade C in an individual from autologous BCN antibodies by three distinct mechanisms.

People who inject drugs (PWID) in India are at high risk for HIV, with women being at elevated risk. Using a socio-ecological framework, this study assessed whether factors associated with HIV transmission risk behaviors differed across men and women PWID. Data for this cross-sectional study were collected from 6449 PWID in 7 cities in Northeast India. Men (n = 5653) and women (n = 796) PWID were recruited using respondent-driven sampling (RDS). We assessed sex differences in two recent HIV transmission risk behaviors: multiple sex partners and needle/syringe sharing. We used multi-level logistic regression models, which incorporated sampling weights and random intercepts for city, to assess factors associated with these HIV risks, separately among men and women. The prevalence of HIV was significantly higher among women than men (53% vs 18.4%, p

Men who have sex with men (MSM) remain at high risk for HIV infection. Culturally specific sexual identities, encompassing sexual roles, behavior, and appearance, may shape MSM’s experiences of stigmatization and discrimination, and affect their vulnerability to HIV. This multi-site qualitative study (n = 363) encompassing 31 focus group discussions (FGDs) and 121 in-depth interviews (IDIs) across 15 sites in India investigated sexual identity formation, identity practices, and transitions and their implications for HIV prevention. IDIs and FGDs were transcribed, translated, and underwent thematic analysis. Our findings document heterogeneous sexual identity formation, with MSM who have more gender nonconforming behaviors or appearance reporting greater family- and community-level disapproval, harassment, violence, and exclusion. Concealing feminine aspects of sexual identities was important in daily life, especially for married MSM. Some participants negotiated their identity practices in accordance with socioeconomic and cultural pressures, including taking on identity characteristics to suit consumer demand in sex work and on extended periods of joining communities of hijras (sometimes called TG or transgender women). Participants also reported that some MSM transition toward more feminine and hijra or transgender women identities, motivated by intersecting desires for feminine gender expression and by social exclusion and economic marginalization. Future studies should collect information on gender nonconformity stigma, and any changes in sexual identity practices or plans for transitions to other identities over time, in relation to HIV risk behaviors and outcomes.

Background. Access to hepatitis C virus (HCV) treatment is limited in low- and middle-income countries (LMICs). Noninvasive biomarkers, such as fibrosis 4 (FIB-4) and aminotransferase to platelet ratio index (APRI), are low-cost alternatives to staging liver disease and identifying treatment need in people with chronic HCV infection, but their accuracy has not been evaluated in LMICs. Methods. We tested the accuracy of FIB-4 and APRI at validated cutoffs (FIB-4 3.25; APRI 1.5) in predicting severe liver stiffness by elastography among 281 persons chronically infected with HCV. Multivariable logistic and Cox regression were used to identify markers of improved prediction and mortality, respectively. Results. Sensitivity and specificity of FIB-4 and APRI for predicting severe stiffness were 62% and 87% and 61% and 83%, respectively. Fibrosis 4 and APRI were less accurate in excluding significant stiffness; however, performance of models significantly improved with γ-glutamyl transpeptidase (GGT) and body mass index (BMI) (area under receiver operating characteristic curve, 0.81; 95% confidence interval, .76–.87). Severe liver stiffness predicted via FIB-4 >3.25, APRI >1.5, and a modified FIB-4 that included GGT and BMI were significantly associated with increased mortality. Conclusions. Fibrosis 4 and APRI may be useful in identifying individuals with severe stiffness who need treatment and continued monitoring in LMICs. Exclusion of significant stiffness may be improved by including GGT and BMI to FIB-4 models.

HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India (ClinicalTrials.gov number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.Between Oct 1, 2012, and Dec 19, 2013, we recruited 26,503 participants, 12,022 men who have sex with men and 14,481 people who inject drugs. Median incidence of HIV was 0·87% (IQR 0·40-1·17) in men who have sex with men and 1·43% (0·60-4·00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0·81, 95% CI 0·62-0·91; p0·0001) than all other measures, although correlation was significant with aware viral load (0·59, 0·27-0·79; p=0·001), population viral load (0·51, 0·16-0·74; p=0·007), and population ART coverage (-0·54, -0·76 to -0·20; p=0·004). In-care viral load was not correlated with HIV incidence (0·29, -0·10 to 0·60; p=0·14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4·34%, and ART use in HIV-positive individuals would need to increase by 19·5%.Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.US National Institutes of Health, Elton John AIDS Foundation.

Respondent-driven sampling was used to recruit female sex workers (FSWs) for a community survey conducted in southern India. After survey completion, participants were given a brochure describing a clinical trial that entailed daily use of a placebo vaginal gel for four months. This study assessed predictors of screening among survey respondents, predictors of enrollment among those eligible for the trial, and predictors of visit attendance and retention among those enrolled. FSWs who reported having symptoms of sexually transmitted infections (STI), engaging in sex work in the past month, and living in a subdistrict easily accessible by public transportation with a high concentration of FSWs, were more likely to screen. FSWs who had never been tested for HIV were more likely to enroll. This analysis suggests that the primary reason FSWs participated in the trial was a desire for health care-not other factors hypothesized to be important, e.g., HIV risk perception and poverty status.

Nagpur is an industrial hub in Maharashtra, a state in Central India that has the second highest HIV prevalence in the country. Approximately 3000 brothel-based female sex workers (FSWs) are estimated to be working in Nagpur’s Ganga-Jamuna red light district. The extent to which brothel madams, known as gharwalis, support HIV/STI prevention for FSWs has not been examined. The present study sought to identify personal, social, and behavioral characteristics of gharwalis in Nagpur as well as enhance our understanding of the gharwali’s role in shaping the sexual practices of brothel-based FSWs. Thirty gharwalis participated in a survey that covered personal, social, behavioral, and environmental characteristics. Respondents ranged in age from 29 to 50 years (M = 38.9) and had worked as a gharwali for an average of 5.3 years; 80% had no formal education, 43% had never married and 30% were divorced or separated, and 93% earned money from their own sex work. Gharwalis managed an average of 4.2 FSWs (range 2 to 10). Overall, gharwalis reported positive attitudes toward condoms, promoted use of condoms by their FSWs with clients, taught FSWs how to use condoms, knew where to obtain condoms for free, and required HIV testing for their FSWs; however, levels of HIV prevention knowledge were low. Gharwalis also reported providing a range of support services to FSWs who lived in their brothels, including shelter, protection from drunk and aggressive clients and police, emotional support, caring and love, and health care. These data suggest the feasibility of involving gharwalis in brothel-based HIV prevention programs.

Aims To characterize factors associated with injection cessation, relapse and initiation. Design The Madras Injection Drug User and AIDS Cohort Study (MIDACS) is a prospective cohort of injection drug users (IDUs) recruited in 2005–06 with semi-annual follow-up to 2009. Discrete-time survival models were used to characterize predictors of time to first injection cessation and relapse. Setting Chennai, India. Participants A total of 855 IDUs who reported injecting in the 6 months prior to baseline and had >1 follow-up visit. Measurements Cessation was defined as the first visit where no injection drug use was reported (prior 6 months) and relapse as the first visit where drug injection (prior 6 months) was reported after first cessation. Findings All participants were male; median age was 35 years. Over 3 years, 92.7% reported cessation [incidence rate (IR): 117 per 100 person-years]. Factors associated positively with cessation included daily injection and incarceration and factors associated negatively with cessation included marriage, alcohol and homelessness. Of those who reported cessation, 23.6% relapsed (IR: 19.7 per 100 person-years). Factors associated positively with relapse included any education, injection in the month prior to baseline, sex with a casual partner, non-injection drug use, incarceration and homelessness. Alcohol was associated negatively with relapse. The primary reasons for cessation were medical conditions (37%) and family pressure (22%). The majority initiated with non-injection drugs, transitioning to injection after a median 4 years. Conclusions Injection drug users in southern India demonstrate a high rate of injection cessation over 3 years, but relapse is not uncommon. Compensatory increases in alcohol use indicate that cessation of injection does not mean cessation of all substance use. Family pressure, concerns about general health, fear of human immunodeficiency virus infection and a history of non-injection drug use are important correlates of cessation.

The purpose of this study was to examine whether social network factors predict HIV and Hepatitis C (HCV) serostatus after controlling for individual-level factors at baseline among a cohort of male injection drug users in Chennai, India.The sample, which was recruited through street outreach, consists of 1078 males who reported having injected drugs in the last 6 months.The participants reported 3936 social support and risk network members. HIV and HCV positive serostatus were negatively associated with network member providing emotional support, and positively associated with network member providing material support. In addition, HCV positivity was associated with network member being an active drug user known for more than 10 years and network member being male kin networks, even after adjusting for individual demographic factors and risk behaviors.These findings suggest that social network factors are significantly linked to HIV and HCV status among IDUs in Southern India and highlight the mixed effects of social capital on health. Future HIV/HCV prevention efforts should incorporate IDU peers to alter drug network injection risk norms. For drug users who have minimal network support, support groups and other informal and formal support mechanisms may be need to help them with health care and psychological support needs for dealing with HIV/HCV.

Although sex work is highly stigmatized throughout the world, a limited body of research has examined stigma among female sex workers (FSWs). We developed a Sex Worker Stigma (SWS) Index to measure perceived stigma among 150 FSWs in Chennai, India. These women were at a median age of 35 years and reported, on average, having engaged in sex work for nine out of the previous 12 months. The two-factor structure of the index was verified in both exploratory and confirmatory factor analyses with acceptable goodness of fit. The final 10-item index comprises of two domains of perceived stigma from the community and perceived stigma from one's family. Cronbach's α coefficients were 0.87 and 0.88 for each domain, respectively. In regression analysis, we found that income from jobs other than sex work was correlated with decreased levels of perceived stigma from both the community (β = - 0.16; 95% CI: -0.30 and -0.02) and the family (β = - 0.24; 95% CI: -0.40 and -0.07); prior experience of accessing health care system increased perceived stigma from the community while heavier financial responsibility for the family was associated with lower perceived stigma from women's family. With the proposed SWS Index, we have a valid and reliable metric to document and track levels of perceived stigma among FSWs to assess the impact of stigma reduction interventions.

Background There is a paucity of data on factors associated with viral suppression in representative populations of HIV-positive MSM in low-middle income country (LMIC) settings. We characterized factors associated with viral suppression among a community-recruited sample of MSM across India with a particular focus on depression, alcohol use and recreational drug use. Methods Of 10,024 MSM recruited using respondent-driven sampling (RDS) from 10 Indian cities between August 2016 and April /2017, 1,460 were HIV-positive and eligible for ART. Alcohol dependence was defined as AUDIT score ≥15; severe depression as PHQ-9 score ≥15; recreational drug use included both injection and non-injection use of drugs common in India, excluding marijuana. Prevalence ratios (aPrR) were obtained using multivariable Poisson regression incorporating RDS2 weights and accounting for clustering by site. Results Median age was 37 years, 34.1% had at least high school education and 66.0% reported monthly income >$115. Prevalence of viral suppression among HIV+ ART eligible MSM was 66.2% overall, ranging from 35.2% in Bhopal to 76.1% in Madurai with no regional trends. Prevalence of severe depression was 4.0%, alcohol dependence 66.3% and recreational drug use 9.5%. Viral suppression was significantly more common among those who were older and had higher treatment literacy. In analyses that adjusted for these factors and sexual identity, those who reported drug use and had evidence of severe depression had a significantly lower likelihood of being virally suppressed (aPrR 0.38; [95% CI: 0.16–0.89]) than those with neither (P-value for interaction = 0.05). Similarly, compared with those who used neither alcohol nor drugs, those using both had a lower prevalence of viral suppression (aPrR: 0.61; [95% CI: 0.40–0.94]) although the interaction did not achieve statistical significance (P = 0.07). Conclusion In this population of MSM in an LMIC, recreational drug use appeared to be a key barrier to achieving viral suppression. Moreover, the impact of drug use was greater in the context of co-occurring severe depression or co-occurring alcohol dependence. It is critical that HIV programming in India and other resource-limited settings incorporate interventions to address these conditions in differentiated care models to maximize viral suppression. Disclosures All authors: No reported disclosures.

With an estimated 2.5 million people living with HIV/AIDS, India has the third highest number of HIV-infected people in the world. Despite reductions in prevalence among the general population, the percentage of all infections occurring among Indian women is continuing to rise. Women's risk of HIV infection from their partner and observed associations between sexual violence and HIV infection in India underscore the importance of understanding determinants of forced sex. A probability survey was conducted from June 2003 to August 2007 in Chennai, India, among alcohol venue ("wine shops") patrons to estimate the prevalence of sexual violence and to identify risk factors associated with perpetrating forced sex. Among 1499 men, 28.5% reported forced sex with at least one partner in the past 3 months. In multivariate analysis, earning income for less than 12 months a year, visiting the wine shop with friends, STD symptoms, perpetration of physical violence, and number of sexual partners were statistically significantly associated with perpetrating forced sex. Men who reported having 3 or more close friends were less likely to perpetrate violence. HIV interventions that facilitate formal groups that foster positive social support and address a range of HIV risk behaviors including sexually and physically abusive behaviors are recommended to reduce sexual violence.

The purpose of this study was to examine the relationship between perceived drug use stigma, acquiescence response bias, and HIV injection risk behaviors among current injection drug users in Chennai, India.The sample consists of 851 males in Chennai, India who reported having injected drugs in the last month and were recruited through street outreach.Results indicate a strong and consistent positive association between drug use stigma and HIV injection drug use risk behaviors. This association held across the injection behaviors of frequency of sharing needles, cookers, cotton filters, rinse water, pre-filled syringes and common drug solutions, even after controlling for acquiescence response bias, frequency of injection, and HIV/HCV serostatus.These findings suggest that future HIV prevention and harm reduction programs for injection drug users and service providers should address drug use stigma.

Female sex workers have been central in India's HIV epidemic since it was first diagnosed among them in 1989. Female sex workers' risk of HIV is primarily economically motivated. The Pi pilot study examined the feasibility and association of a microenterprise intervention, the tailoring of canvas bags, on sexual risk behaviors among female sex workers (N = 100) in Chennai. Women were randomized to an intervention or control arm. Between-group comparisons at baseline and at six-month follow-up were performed. Multivariate linear regression with bootstrapping was conducted to estimate the intervention effect. At baseline, women were a median of 35 years old, 61% were married and they had an average of two children. Intervention participants reported a significantly lower number of sex partners and significant increases in income at the 6-month follow-up compared to control participants. In a multivariate model, intervention participants had a significantly lower number of paying clients per month at follow-up compared to control participants. By graduation, 75% of intervention arm participants had made at least one sellable canvas bag and 6 months after the study's end, 60% have continued involvement in bag production. The pilot study demonstrated that microenterprise interventions are successful in both providing FSWs with licit income opportunities and was associated with reductions in HIV risk behaviors.

Injection drug users (IDUs) have estimated mortality rates over 10 times higher than the general population; much of this excess mortality is HIV-associated. Few mortality estimates among IDUs from developing countries, including India, exist.IDUs (1158) were recruited in Chennai from April 2005 to May 2006; 293 were HIV positive. Information on deaths and causes was obtained through outreach workers and family/network members. Mortality rates and standardized mortality ratios were calculated; multivariate Poisson regression was used to identify predictors of mortality.We observed 85 deaths over 1998 person-years (p-y) of follow-up [mortality rate (MR) 4.25 per 100 p-y; 95% confidence interval (CI) = 3.41-5.23]. The overall standardized mortality ratio was 11.1; for HIV-positive IDUs, the standardized mortality ratio was 23.9. Mortality risk among HIV-positive IDUs (MR: 8.88 per 100 p-y) was nearly three times that of negative IDUs (MR: 3.03 per 100 p-y) and increased with declining immune status (CD4 cells350: 5.44 per 100 p-y vs. CD4 cellsor = 200: 34.5 per 100 p-y). This association persisted after adjustment for confounders. The leading causes of mortality in both HIV negative and positive IDUs were overdose (n = 22), AIDS (n = 14), tuberculosis (n = 8) and accident/trauma (n = 9).Substantial mortality was observed in this cohort with the highest rates among HIV-positive IDUs with CD4 counts of less than 350 cells/microl. Although, in these 2 years, non-AIDS deaths outnumbered 0002030-related deaths, the relative contribution of 0002030-associated mortality is likely to increase with advancing HIV disease progression. These data reinforce the need for interventions to reduce the harms associated with drug use and increase HAART access among IDUs in Chennai.

This article examined the prevalence of physical and sexual violence among 1,974 married women from 40 low-income communities in Chennai, India. The authors found a 99% and 75% lifetime prevalence of physical abuse and forced sex, respectively, whereas 65% of women experienced more than five episodes of physical abuse in the 3 months preceding the survey. Factors associated with violence after multivariate adjustment included elementary/middle school education and variables suggesting economic insecurity. These domestic violence rates exceed those in prior Indian reports, suggesting women in slums may be at increased risk for HIV and other sexually transmitted infections.

To estimate the prevalence of HIV and hepatitis C virus (HCV) and hepatitis B virus (HBV) coinfections and current risk behaviors among HIV-positive and -negative injection drug users (IDUs) in Chennai, India.Cross-sectional analysis of a convenience sample of 912 IDUs recruited between March 2004 and April 2005. Specimens were tested for HIV, HBV, and HCV. Adjusted prevalence ratios (PRs) were estimated using Poisson regression with robust variance estimates.The prevalence of HIV, hepatitis B surface antigen, and anti-HCV were 29.8%, 11.1%, and 62.1%, respectively. Among HIV-infected IDUs, prevalence of coinfection with anti-HCV and hepatitis B surface antigen/anti-HCV were 86% and 9.2%, respectively. In multivariate analysis, injecting at a dealer's place (PR: 1.57) and duration of injection drug useor=11 years (PR: 3.02) were positively associated with prevalent HIV infection. Contrastingly, alcohol consumptionor=1 per week (PR: 0.55) was negatively associated with HIV. HIV-positive IDUs were as or more likely compared with HIV-negative IDUs to report recent high-risk injection-related behaviors.There is a high burden of HIV, HCV, and HBV among IDUs that needs to be addressed by improving access to therapies for these infections; furthermore, preventive measures are urgently needed to prevent further spread of HIV, HBV, and HCV in this vulnerable population.

Sexually transmitted infections (STIs) have been identified as cofactors of HIV transmission. Greater understanding of local STI burdens can assist in the development of more effective STI and HIV prevention strategies. The aim of this study is to determine the prevalence and incidence of STIs among South Indian men and women identified to be at increased risk for HIV infection. Individuals at increased risk for HIV infection were enrolled in a prospective longitudinal study in Chennai, India (n = 480) between August 2002 and December 2003. Participants were enrolled from patients seeking services at an sexually transmitted disease (STD) clinic and a confidential HIV testing and counseling program. The most common prevalent STIs were herpes simplex virus (HSV)-2 (50% of women, 29% of men), syphilis (11% of women, 8% of men), and Trichomonas vaginalis (6% of women). At enrollment, women, participants with no schooling, participants with greater than four sex partners, and single participants were found to be at increased risk for HSV-2 infection (p < 0.05). The two most common incident STIs at 12 months were HSV-2 with 12% of men and 8% of women testing positive and hepatitis B with 2% of men and 5% of women testing hepatitis B surface antigen (HBsAg) positive. In this cohort of South Indian men and women with a high background prevalence of HSV-2, suppressive therapy against herpes replication may have a substantial impact in reducing both HSV-2 transmission and HIV acquisition. With the high incidence of STIs, targeted prevention and clinical management strategies among individuals practicing high risk behaviors may help to slow the continued spread of HIV in India.

There are no studies that examine street-based female sex workers' vulnerability to HIV from both clients and intimate partners. This study documents street-based female sex workers' experiences of client and intimate partners, examines the intersections of violence, alcohol use in condom use, and highlights survival strategies used to avert harm.Ethnographic data were collected from 49 female sex workers through focus group discussions and in-depth interviews.Female sex workers experienced multifarious forms of severe client and intimate partner violence. Sexual coercion and forced group sex in the context of alcohol use posed formidable barriers for condom use negotiation. Further, traditional gender norms dictated women's inabilities to negotiate condom-use with intimate partners. However, there was evidence of adoption of successful survival strategies in the face of danger and women's positive evaluations of the benefits of sex work and their contributions to family well-being.Harm reduction efforts with female sex workers need to account for their vulnerability to HIV from intimate partners in addition to clients. HIV prevention programmes need to include male clients in order to reduce harm among street-based female sex workers. There is an urgent need to build on sex workers' strengths and involve them in designing individual level, community, and structural interventions that could help in reducing women's vulnerability to intimate partner violence and HIV in India.

SUMMARY This article uses the Theory of Gender and Power to examine women's vulnerability to HIV/AIDS in order to: understand the vulnerability of female sex workers/poor women due to poverty and lack of educational resources; explore women's vulnerability in the context of client/partner violence, alcohol use, male partner's high-risk behaviors, and women's lack of control in their intimate relationships; and explore the role of traditional heterosexual gender norms in the outcomes of sexual negotiation. Ethnographic data were collected from 32 women and 38 men in India as part of an ongoing National Institute of Mental Health study. Results highlighted women's vulnerability to HIV/AIDS stemming from partner violence, alcohol use, poverty, dangers of sex work environments, and tacit acceptance of cultural/gender norms.

HIV/AIDS stigma is a frequently cited barrier to HIV prevention, including voluntary counseling and testing. A reliable and valid measurement instrument is critical to empirically assess the extent and effects of HIV/AIDS stigma. The paper reports the development and psychometric testing of an HIV/AIDS stigma scale among 200 men in India. The resulting 24-item scale and the four subscales had good internal consistency (Cronbach's alpha overall was 0.81; subscales were 0.86, 0.73, 0.72 and 0.76, respectively). The scale and distinct subscales suggest a valid and reliable measure for HIV/AIDS stigma in a setting with highly prevalent HIV risk behaviors.

Background Dengue and chikungunya are rapidly expanding viruses transmitted by mosquitoes of the genus Aedes. Few epidemiological studies have examined the extent of transmission of these infections in South India despite an increase in the number of reported cases, and a high suitability for transmission. Methods and findings We conducted a household-based seroprevalence survey among 1010 individuals aged 5-40 years living in fifty randomly selected spatial locations in Chennai, Tamil Nadu. Participants were asked to provide a venous blood sample and to complete a brief questionnaire with basic demographic and daily activity information. Previous exposure to dengue and chikungunya was determined using IgG indirect ELISA (Panbio) and IgG ELISA (Novatec), respectively. We used this data to estimate key transmission parameters (force of infection and basic reproductive number) and to explore factors associated with seropositivity. While only 1% of participants reported history of dengue and 20% of chikungunya, we found that 93% (95%CI 89-95%) of participants were seropositive to dengue virus, and 44% (95%CI 37-50%) to chikungunya. Age-specific seroprevalence was consistent with long-tem, endemic circulation of dengue and suggestive of epidemic chikungunya transmission. Seropositivity to dengue and chikungunya were significantly correlated, even after adjusting for individual and household factors. We estimate that 23% of the susceptible population gets infected by dengue each year, corresponding to approximately 228,000 infections. This transmission intensity is significantly higher than that estimated in known hyperendemic settings in Southeast Asia and the Americas. Conclusions These results provide unprecedented insight into the very high transmission potential of dengue and chikungunya in Chennai and underscore the need for enhanced surveillance and control methods., Author Summary Despite a recent increase in the number of cases, little data exist on the extent of dengue and chikungunya transmission in Indian cities. We conducted a household-based serosurvey conducted in randomly selected spatial locations across the metropolis of Chennai. We tested samples for evidence of previous infection by dengue and chikungunya viruses and used this data to estimate key transmission parameters (force of infection and basic reproductive number) and to explore factors associated with seropositivity. We found that 93% of participants had been exposed to dengue virus, and 44% to chikungunya. We estimate that 23% of the susceptible population gets infected by dengue virus each year, corresponding to approximately 228,000 infections per year. This transmission intensity is almost three times larger than that in traditionally hyperendemic district in Thailand, and suggests an extremely large proportion of asymptomatic/sub-clinical disease, a lack of recognition of the disease and/or under-reporting.

BACKGROUND: Injecting drug use has historically been the principal driver of the HIV epidemic in the northeast states of India. However recent data indicate growing numbers of people who inject drugs (PWIDs) in north and central Indian cities. METHODS: We conducted face-to-face surveys among PWIDs in seven northeast and eight north/central Indian cities using respondent-driven sampling. We used a rapid HIV-testing protocol to identify seropositive individuals and multiassay algorithm to identify those with recent infection. We used multilevel regression models that incorporated sampling weights and had random intercepts for site to assess risk factors for prevalent and incident (recent) HIV infection. RESULTS: We surveyed 14 481 PWIDs from 15 Indian cities between January and December 2013. Participants reported high rates of needle/syringe sharing. The median (site range) estimated HIV prevalence and incidence were 18.1% (5.9 44.9) and 2.9 per 100 person-years (0 12.4) respectively. HIV prevalence was higher in northeast sites whereas HIV incidence was higher in north/central sites. The odds of prevalent HIV were over three-fold higher in women than in men. Other factors associated with HIV prevalence or incidence included duration since first injection injection of pharmaceutical drugs and needle/syringe sharing. CONCLUSIONS: The burden of HIV infection is high among PWIDs in India and may be increasing in cities where injecting drug use is emerging. Women who inject drugs were at substantially higher risk for HIV than men - a situation that may be mediated by dual injection-related and sexual risks.

In-depth interviews were conducted with 50 HIV-positive adults (23 women, 27 men) with access to care at a non-governmental organization in Chennai, India to gain a broad understanding of how they managed their HIV infection. Using a Social Cognitive Model of Health, we identified factors within the model's three domains--Personal, Environmental, and Behavioral--that are applicable to this socio-cultural context. The Personal domain's factors were a positive self-concept, family-focused goals, and treatment optimism; the Environmental domain comprised family-based support, treatment availability, access and quality, and HIV stigma and discrimination; and the Behavior domain's factors were medication adherence and health habits, sexual behavior, and social relationships and emotional well-being. Significant differences for many of the factors within the three domains were observed across married men and women, widowed women, unmarried men, and female sex workers. Implications for an enhanced intervention for HIV-infected individuals in similar treatment settings are discussed.

Objective: To estimate the incidence of HIV and study the impact of risk-reduction counseling (RRC) in a cohort of people with high-risk behavior for HIV transmission in Chennai, India. Design: Prospective cohort follow-up of 500 HIV-negative people (250 men and 250 women) at increased risk for HIV acquisition in Chennai, India for a maximum of 1 year was conducted. They received RRC at 0, 6, and 12 months. Generalized estimating equation methodology was used to determine the statistical significance of differences reported in behavior between baseline, 6 months, and 12 months. Results: The overall HIV incidence in this cohort was 0.44 per 100 person-years (95% confidence interval: 0.05-1.60). In the course of the study, both male and female participants reported statistically significant decreases in the number of different sexual partners, the number of new partners, and the proportion of sexual encounters with nonprimary partners. Participants who had more than 3 different partners at baseline and/or exchanged money for sex in the 6 months before enrollment demonstrated the greatest reductions in the number of different sexual partners. Conclusions: Individualized sexual RRC seems to be a useful intervention to reduce risk-taking behavior among at-risk heterosexuals in India.

Objectives: To examine gender differences in sexual behaviour, the prevalence of laboratory-detected sexually transmitted infections (STIs) and self-reported genital symptoms in urban Chennai, Tamil Nadu, India. Study design: The data were based on a cross-sectional survey (n = 1649) of residents from low-income communities in Chennai. Data were collected during community-wide health camps comprising physical examinations, interviews and laboratory testing between March and June 2001. Results: The population was young, sexually active, with a low prevalence of STI. The most commonly detected STI was Herpes simplex virus type 2 (HSV2; 13.2%). Women had a higher prevalence of HSV2, but were more likely than men to be asymptomatic. Most of the self-reported genital symptoms could not be linked to a laboratory-detected STI. >10% of the cohort had a history of an ulcerative STI and >5% had an inflammatory STI. Conclusions: Given a high prevalence of HSV2 in the study population, interventions targeting HSV2 transmission may be particularly relevant for this population.

The objective of this study was to examine the pathways by which gender norms may influence marital violence in low‐income communities of Chennai, India. As part of a multisite international behavioural HIV intervention trial, 48 in‐depth interviews and 14 focus groups with men and women were conducted in two randomly selected low‐income communities within the city. Interviews were taped, transcribed, translated, coded and analysed to identify recurrent themes. A multi‐layered conceptual framework was used to examine individual, relational, community and societal level determinants of marital violence in this setting. Participants noted that husbands hold decision‐making power in economic, social and sexual spheres. Clear patterns of violence were present; respondents reported that husbands regularly beat wives in most marriages. Marital conflicts were intensified by the presence of community level stressors such as poverty and unemployment. Participants perceived violence to be a necessary tool that serv...

This paper examines how marital violence affects women's ability to protect themselves from HIV/AIDS. In-depth interviews (n = 48) and focus groups (n = 84, 3–7 per group) were conducted among men and women in two randomly selected slums of Chennai, India. The study showed that community gender norms tacitly sanction domestic violence that interferes with adopting HIV-preventive behaviors. Given the choice between the immediate threat of violence and the relatively hypothetical specter of HIV, women often resign themselves to sexual demands and indiscretions that may increase their risk of HIV acquisition. In conclusion, AIDS-prevention interventions must incorporate gender-related social contexts in settings where husbands strictly enforce their locus of control. HIV-prevention messages targeting men may effectively reduce women's exposure to HIV/AIDS.

Traditional recruitment methods for microbicide efficacy trials are labor intensive and may fail to reach high-risk hard-to-reach populations. We report duration of recruitment and lessons learned from a two-stage process to recruit female sex workers (FSWs) into a placebo microbicide trial, and examined characteristics associated with successful recruitment of peers who screened for and enrolled in the trial. FSWs were first recruited via respondent-driven sampling (RDS) to complete a survey and subsequently invited to screen for enrollment into a placebo microbicide trial taking place at a local clinic. It took 6 months to enroll 267 participants into the trial. Successful recruiters of peers who enrolled were more likely to have enrolled themselves (AOR 2.0, CI 1.3–2.9) and less likely to visit Nellore city (AOR 0.5, CI 0.3–0.9). Recruitment of FSWs via a two-stage recruitment strategy with RDS can be a good option for future clinical trials.

The aim of this study was to examine female sex workers' solicitation of clients using mobile phones and the association between this and condom use with clients. Cross-sectional data were utilised to address the study's aim, drawing on data collected from female sex workers in Calicut, Kerala, and Chirala, Andhra Pradesh. Use of mobile phone solicitation was reported by 46.3% (n = 255) of Kerala participants and 78.7% (n = 464) of those in Andhra Pradesh. Kerala participants reporting exclusive solicitation using mobile phones demonstrated 1.67 times higher odds (95% CI: 1.01-2.79) of inconsistent condom use than those reporting non-use of mobile phones for solicitation. However, those reporting exclusive solicitation through mobile phones in Andhra Pradesh reported lower odds of inconsistent condom use (OR: 0.03; 95% CI: 0.01-0.26) than those not using mobile phones for solicitation. Findings indicate that solicitation of clients using mobile phones facilitates or hampers consistency in condom use with clients depending on the context, and how mobile phones are incorporated into solicitation practices. Variations in sex work environments, including economic dependence on sex work or lack thereof may partially account for the different effects found.

Success of HIV vaccine trials is dependent on infrastructural preparedness of the site, technical expertise of the trial team and strong Socio-political support of the local community. The processes followed and experiences gained while implementing various community based initiatives for recruitment of healthy volunteers during the three HIV vaccine trials in India are described. Major initiatives in community engagement implemented for the first time in India included establishment and involvement of Community Advisory Board and capacity building and engagement of lay community based volunteers called “peers” using “lay health promotion” model. Community education program designed for trial participants’ education, identification and enrollment was a three-tiered approach, moving from large community awareness meetings (first step) to facility-based small group meeting to provide trial specific information (second step); ending with one-to-one vaccine center based meeting with the volunteers to clear doubts, myths, and misconceptions about HIV/ AIDS, the experimental vaccine and HIV vaccine trials as well as to explain trial specific procedures (third step). It is important to focus on gender issues, locally relevant socio-cultural factors, informed consent, and post-trial care related matters during the conduct of sensitive clinical trials in socio-culturally diverse and resource limited setting like India.

Little is known regarding the epidemiology of drug injection and risk behaviors among injection drug users (IDUs) across India. In particular, there is limited data on the prevalence of stimulant injection.We sampled 801 HIV positive IDUs from 14 locations throughout India to represent the geography of India as well as the diversity in IDU epidemic stage (established epidemics, emerging epidemics and large cities). All participants underwent a behavioral survey and blood draw. Given prior associations with stimulant injection and HIV risk, we compared stimulant injectors (cocaine and/or methamphetamine) to those who injected opiates and/or pharmaceuticals only.The median age was 33; 86% were male. The primary drugs injected were heroin, buprenorphine and other pharmaceuticals. In all but four sites,50% of those actively injecting reported needle sharing. Stimulant injection was most common in emerging epidemics. Compared to exclusive opiate injectors, stimulant injectors were significantly younger, more likely to be educated and employed, more likely to report non-injection use of heroin, crack/cocaine and amphetamines, heavy alcohol use, recent needle sharing (71% vs. 57%), sex with a casual partner (57% vs. 31%) and men having sex with other men (33% vs. 9%; p0.01 for all).Emerging IDU epidemics have a drug/sexual risk profile not previously been observed in India. Given the high prevalence of stimulant injection in these populations, HIV prevention/treatment programs may need to be redesigned to maximize effectiveness. The high levels of injection sharing overall reinforce the need to ensure access to harm-reduction services for all.

Female sex workers (FSWs) were recruited for a 4-month placebo vaginal gel trial in Nellore, India. Two experiments explored if prior knowledge of biomarkers for unprotected sex and insertion of gel applicators would yield more accurate self-reports. A third experiment compared self-reports of gel use and adherence levels between FSWs randomly assigned to interactive voice response survey (IVRS) and those assigned to paper diaries. Prior knowledge of biomarkers did not improve accuracy of self-reported condom or gel use, nor did it affect actual adherence. Of those who tested positive for the presence of semenogelin in the vagina, 76 % reported no unprotected sex in the previous 48 h. Overall, women reported using gel on 90 % of days whereas the biomarker indicated gel use on fewer than 50 % of days. Compliance to IVRS was low, despite familiarity with mobile phone technology. Additional explorations with other populations are needed.

Short Summary: Four-month placebo vaginal gel trial conducted to determine the feasibility of recruiting FSWs for future Phase 2/3 microbicide trials. RH morbidity and HIV and STI prevalence are reported. Women constitute 38% of India’s 2.4 million HIV-infected persons. Microbicides are potential HIV-prevention products currently undergoing clinical trials for efficacy. A four-month placebo vaginal gel trial was conducted in Nellore, India to determine the feasibility of recruiting a suitable cohort of female sex workers (FSWs) for a future vaginal microbicide efficacy trial. We report on the HIV and STI prevalence and reproductive health (RH) morbidity of FSWs screened for the trial. Results: 529 FSWs completed screening procedures; of those 33.6% were found ineligible. The mean age was 30.9 years; 68.6% women were married and 57.5% were home-based FSWs. Self-reported symptoms included abnormal vaginal discharge (31.6%), genital itching (3.4%), uterine mass/prolapse (3%) and painful intercourse (2.6%). Gynecological surgery was reported by 73.2% of participants; of those 10.5% had undergone a hysterectomy. Female sterilization was the most commonly reported contraceptive method. Pelvic examination showed vaginal discharge (50.7%), cervical discharge (5.3%), uterine/vaginal wall prolapse (2.6%), and cervical mass/nodule/vesicles/genital warts (4.2%). Common epithelial findings included erythema (79.1%) and vesicles/bullae (6%); 46% of participants had Papanicolaou tests graded as inflammatory and 1.1% as malignant. HSV-2 was the mostly commonly detected STI (60.7%) followed by trichomoniasis (15.5%), HIV (5.3%), syphilis (2.8%), chlamydia (2.2%) and gonorrhoea (0.7%). RTIs were more common: bacterial vaginosis (27.8%) and candidiasis (18.9%). Conclusions: The low HIV prevalence and high RH morbidity in the population makes this site unsuitable for a future phase 2 or 3 microbicide efficacy trial. HIV prevention programs targeting this population should include access to RH services.

Background and Objective We characterize the burden of liver disease in a cohort of PWID in Chennai, India, with a high prevalence of HCV. Materials and Methods 1,042 PWID were sampled through community outreach in Chennai. Participants underwent fasting blood draw, questionnaire and an examination that included liver stiffness assessment using transient elastography (Fibroscan) and assessment of steatosis via ultrasound. Results The median age was 39 years, all were male, 14.8% were HIV infected and 35.6% were HCV antibody positive, of whom 78.9% were chronically infected (HCV RNA positive). Median liver stiffness was 6.2 kPA; 72.9% had no evidence of or mild stiffness, 14.5% had moderate stiffness, and 12.6% had evidence of severe stiffness/cirrhosis. Prevalence of severe stiffness/cirrhosis was significantly higher among persons who were older, had a longer duration of injecting drugs, higher body mass index, higher prevalence of insulin resistance, higher prevalence of steatosis, higher HCV RNA levels and evidence of alcohol dependence. An estimated 42.1% of severe stiffness/cirrhosis in this sample was attributable to HCV. 529 (53.0%) had some evidence of steatosis. Prevalence of steatosis was higher among those who had larger waist circumference, insulin resistance, higher HDL cholesterol and a history of antiretroviral therapy. Conclusions We observed a high burden of liver disease in this relatively young cohort that was primarily driven by chronic HCV infection, metabolic factors (insulin resistance and steatosis) and heavy alcohol use. Interventions to improve access to HCV treatment and reduce alcohol use are needed to prevent further progression of liver disease.

HIV/AIDS stigma can severely compromise the quality of life of people living with HIV/AIDS (PLHA) by reducing access and quality of care, adherence to therapy, and disclosure of HIV status, thereby potentially increasing transmission. The objective of this study was to develop and psychometrically test three parallel scales measuring self, experienced, and perceived stigma among PLHA (n=188) in Chennai, India. Exploratory factor analysis (EFA), which was used to facilitate item reduction and assess construct validity, confirmed the presence of three underlying theoretical domains. The final number of items and Cronbach's Alpha for each scale were: 8 items, Alpha of 0.84, for self stigma; 7 items, Alpha of 0.86, for experienced stigma; and 7 items, Alpha of 0.83, for perceived stigma. External validity was ascertained by confirming a significant positive association between the measure of each type of stigma and depression (measured using CES-D), using structural equation modeling (SEM). Therefore, scales were parsimonious, reliable, and were found to be valid measures of HIV/AIDS stigma. Using these validated scales, researchers can accurately collect data to inform the design of stigma reduction programs and interventions and enable subsequent evaluation of their effectiveness.

The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January to April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when first tested for HIV. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.

Background & Objectives: We characterized HCV antibody prevalence, viral persistence, genotype and liver disease prevalence among IDUs in Chennai, India as the study of the association of HIV with each of these states is important and there are no data available. Methods: Between 2005-2006, 1158 IDUs were recruited and followed semi-annually. All were tested for HCV antibodies at baseline; a random sample of 400 antibody positives (200 HIV-positive and 200 HIV-negative) were tested for HCV RNA; 13 of these were sequenced. Assessment of asparate amino transferase (AST)-to-platelet ratio index (APRI) was done on 557 IDUs. Prevalence ratios of each outcome were examined. Results: Median age was 35 yr; 99 per cent were male. HCV antibody prevalence was 55 per cent and was associated with older age, being unmarried, longer injection history, tattoo and injecting at a dealer’s place. Of the 400 HCV antibody positive IDUs, 281 (70.3%) had persistent infection which was less common among hepatitis B-infected persons but not associated with HIV. Of the 13 samples sequenced, 11 (85%) were HCV genotype 3a. Fibrosis prevalence according to APRI was: HIV/HCV-uninfected, 4 per cent; HIV mono-infected, 3 per cent; HCV mono-infected, 11 per cent; HIV/HCV co-infected, 12 per cent (P