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Self-Compacting Concrete (SCC) is a standout amongst “the most progressive advancements” in developing the industry. This solid can stream and fill the most confined spots of the structural work without vibration. The Self-Consolidating Concrete is a superior solid which is progressively predict the strength. To improve the quality of SCC, polypropylene is included. Polypropylene Fiber is moderately another developing material, which is utilized in SCC to expand the flexural and elasticity of cement. For proper work capacity, Super Plasticizer (SP) and Viscosity Modifying Agent (VMA) are added to lessen isolation of the total. Self-Compacting Concrete has indistinguishable quality, with the utilization of VMA and Super Plasticizer. The expense of SCC is a lot higher than the Conventional Concrete [1] . The expense of materials for SCC is most prominent around 10–15%, when contrasted with materials for conventional Concrete. Be that as it may, it is affordable like, reserve funds in the rate of work, rate of flow and rate to fix work and so forth. In this examination 0.3%, 0.6%, 0.9% and 1.2% of polypropylene fiber by the heaviness of bond are included cement to upgrade the assets of SCC. Polypropylene fiber with a fiber length of 6–12 mm breadth of 14 µm and an angle proportion of 0.3, 0.6, 0.9, and 1.2 is utilized. In this test work, M20 evaluation of cement is taken to decide the Flexural quality, split rigidity of SCC with the ideal level of Super plasticizer, polypropylene fiber and VMA.

IntroductionIndia’s National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent to which exposure to ASHAs’ home visits has reduced perinatal health inequalities as intended. This study aimed to examine whether ASHAs’ third trimester home visits may have contributed to equitable improvements in institutional delivery and reductions in perinatal mortality rates (PMRs) between women with varying education levels in Uttar Pradesh (UP) state, India.MethodsCross-sectional survey data were collected from a representative sample of 52 615 women who gave birth in the preceding 2 months in rural areas of 25 districts of UP in 2014–2015. We analysed the data using generalised linear modelling to examine the associations between exposure to home visits and education-based inequalities in institutional delivery and PMRs.ResultsThird trimester home visits were associated with higher institutional delivery rates, in particular public facility delivery rates (adjusted risk ratio (aRR) 1.32, 95% CI 1.30 to 1.34), and to a lesser extent private facility delivery rates (aRR 1.09, 95% CI 1.04 to 1.13), after adjusting for confounders. Associations were stronger among women with lower education levels. Having no compared with any third trimester home visits was associated with higher perinatal mortality (aRR 1.18, 95% CI 1.09 to 1.28). Having any versus no visits was more highly associated with lower perinatal mortality among women with lower education levels than those with the most education, and most notably among public facility births.ConclusionsThe results suggest that ASHAs’ home visits in the third trimester contributed to equitable improvements in institutional deliveries and lower PMRs, particularly within the public sector. Broader strategies must reinforce the role of ASHAs’ home visits in reaching the sustainable development goals of improving maternal and newborn health and leaving no one behind.

Background Achievement of successful health outcomes depends on evidence-based programming and implementation of effective health interventions. Routine Health Management Information System is one of the most valuable data sets to support evidence-based programming, however, evidence on systemic use of routine monitoring data for problem-solving and improving health outcomes remain negligible. We attempt to understand the effects of systematic evidence-based review mechanism on improving health outcomes in Uttar Pradesh, India. Methods Data comes from decision-tracking system and routine health management information system for period Nov-2017 to Mar-2019 covering 6963 health facilities across 25 high-priority districts of the state. Decision-tracking data captured pattern of decisions taken, actions planned and completed, while the latter one provided information on service coverage outcomes over time. Three service coverage indicators, namely, pregnant women receiving 4 or more times ANC and haemoglobin testing during pregnancy, delivered at the health facility, and receive post-partum care within 48 h of delivery were used as outcomes. Univariate and bivariate analyses were conducted. Results Total 412 decisions were taken during the study reference period and a majority were related to ante-natal care services (31%) followed by delivery (16%) and post-natal services (16%). About 21% decisions-taken were focused on improving data quality. By 1 year, 67% of actions planned based on these decisions were completed, 26% were in progress, and the remaining 7% were not completed. We found that, over a year, districts witnessing > 20 percentage-point increase in outcomes were also the districts with significantly higher action completion rates (> 80%) compared to the districts with Conclusions Findings revealed a significantly higher improvement in coverage outcomes among the districts which used routine health management data to conduct monthly review meetings and had high actions completion rates. A data-based review-mechanisms could specifically identify programmatic gaps in service delivery leading to strategic decision making by district authorities to bridge the programmatic gaps. Going forward, establishing systematic evidence-based review platforms can be an important strategy to improve health outcomes and promote the use of routine health monitoring system data in any setting.

Background It is argued that Indian gender minorities displayed differential mental health problems and suicide attempts. Hence, the study was intended to understand the prevalence of anxiety, depression and suicidality among this group, specifically those living in a metropolitan city in South India. Methods The data was generated from a cross-sectional study that employed a structured questionnaire to collect information about experiences of anxiety, depression and suicidal behavior among gender-diverse individuals in Bangalore, the capital city of Karnataka state. The study used stratified simple random sampling of eligible individuals who were 18 years of age and older and who were enrolled in an HIV prevention program implemented for gender-diverse individuals run by the Karnataka Health Promotion Trust and the University of Manitoba at the time of the study (2012). Bivariate and multivariate analyses were used to assess the relative contribution of various factors that affect suicide ideation or actual attempts among the gender diverse participants. Results Results showed that 62% whose main source of income was Basti (socially sanctioned practice of begging), 52% of Hijras, 56% who lived with their Gurus, 58% who were not happy with their physical appearance, 55% who consumed alcohol daily, and 63% who experienced high depression had ever thought of or attempted suicide in the month prior to the survey. However, multivariate analysis showed that respondents who were not happy with their physical appearance and thought of changing it had significantly higher odds (AOR = 2.861; CI 1.468,5.576; p = 0.002) of either having thoughts that it was better being dead or wished they died. Similarly, those who experienced high depression, their odds of either having had thoughts of or having attempted suicide increased by three times (AOR = 3.997; CI 1.976, 8.071; p Conclusions It is observed that a high percentage of gender minorities had attempted suicide or thought of suicide during the month preceding the data collection. The findings bring new insights on the proximate determinant of physical appearance on the suicidality of gender minorities assigned male at birth and appropriate to account for this while addressing the mental health issues.

During the assembly of the parts, drilling is usually the final procedure in these implementations. Any fault that contributes to the dismissal of the components constitutes a costly loss. In various research fields, including automotive, aeronautical, etc., PMC materials are finding increased implementations, and, consequently, the need for precision machining for the composites has significantly grown. To its characteristics, polymeric composites are considered excellent choices for structural members. Fortunately, while creating holes for attachment, they demonstrate several kinds of problems. The removal rate is considered the most important damage, as it reduces the part’s useful life. Our research is four different polymer matrix composite plates of the process of three various size holes (3, 6 & 12mm diameter) with different spindle speeds (25, 50 & 75RPM) to predict the material removal rate.

Aluminium metal matrix composite (AMMC) has a wide range of applications in engineering materials, such as high-quality materials with visible properties such as lightweight, low-temperature expansion temperature, strong durability, high strength, low density. It is a challenge to make aluminum alloy steel barriers that are reinforced by traditional methods. The key to the long-term survival of AMMC is the unusual structure which makes its surface layer stiff and smooth with more fatigue strength. WEDM is the most appropriate and possible advanced method of making aluminum metal matrix composites. This paper shows the experimental work on AMMC composite Al6060-reinforced (SiC) broadcast with broadcast technology to investigate the current WEDM processing results, timing & closing time and percentage stabilization at Metal Removal Rate (MRR) & Surface sharpness. The rate of metal removal has been found to decrease as the % of reinforcement increases, and the local pressure rises as the percentage of reinforcement increases.

The method of assembling the solid-state of the combustion welding is often used within the different combinations and similarities of aluminum, copper and titanium alloys. In the study, the collision welding of Al 6082 aluminum alloys was performed with various feed, axial strength and rotational speed of the tool. In this study, performance evaluation of the specification of welding friction is necessary to monitor the weld distortion & consequently increase the productivity of the process. Therefore, it is important to observe the limits of welding input to ensure the best quality welding and control weld distortion. In this research project, tests were performed on Al 6082 of 4mm size used to collide the welding process (Square pin) as a tool with regular parameters such as RPM, Feed & Axial Load. The materials were transferred from the surface during the Friction Stir Welding (FSW) process to the retracting side behindhand the pin anywhere the weld was made. During the investigation, the 2nd sample strength of the strongest force was found to be 53.11 N/mm2, and the lowest hardness value found on the third test plate is 48HRB.

The manufacturing industry has become one of the largest polymer matrix composite (PMC) customers, which comes from cost savings and lightweight. In the design of cars, PMCs' structures are very important in fulfilling some of their most pressing needs, which include weight loss for vehicles. The compounds are suitable for hazardous environments, such as chemical plants and paper converting, oil and gas refineries and water treatment plants. Typical applications include fans, tanks, pipes, hoods, pumps and cabinets. A polymer composite is a multi-stage component in which reinforcement is filled with a polymer matrix, resulting in synergistic mechanical structures that cannot be achieved individually. So, our research is based on the weight reduced to the product of the helmet. First, plate making in six different combinations with the help of natural fiber (jute) and synthetic fiber (carbon) material is used and resin (epoxy & vinyl-ester). The study evaluates the tensile, compression, flexural and impact strength and selects the better combination of plate material. Further, to create the helmet design and analysis established on the structural oriented with Ansys software's help.

Background Family planning is a key means to achieving many of the Sustainable Development Goals. Around the world, governments and partners have prioritized investments to increase access to and uptake of family planning methods. In Uttar Pradesh, India, the government and its partners have made significant efforts to increase awareness, supply, and access to modern contraceptives. Despite progress, uptake remains stubbornly low. This calls for systematic research into understanding the ‘why’—why people are or aren’t using modern methods, what drives their decisions, and who influences them. Methods We use a mixed-methods approach, analyzing three existing quantitative data sets to identify trends and geographic variation, gaps and contextual factors associated with family planning uptake and collecting new qualitative data through in-depth immersion interviews, journey mapping, and decision games to understand systemic and individual-level barriers to family planning use, household decision making patterns and community level barriers. Results We find that reasons for adoption of family planning are complex–while access and awareness are critical, they are not sufficient for increasing uptake of modern methods. Although awareness is necessary for uptake, we found a steep drop-off (59%) between high awareness of modern contraceptive methods and its intention to use, and an additional but smaller drop-off from intention to actual use (9%). While perceived access, age, education and other demographic variables partially predict modern contraceptive intention to use, the qualitative data shows that other behavioral drivers including household decision making dynamics, shame to obtain modern contraceptives, and high-risk perception around side-effects also contribute to low intention to use modern contraceptives. The data also reveals that strong norms and financial considerations by couples are the driving force behind the decision to use and when to use family planning methods. Conclusion The finding stresses the need to shift focus towards building intention, in addition to ensuring access of trained staff, and commodities drugs and equipment, and building capacities of health care providers.

Background Timely initiation of breastfeeding, also known as early initiation of breastfeeding, is a well-recognized life-saving intervention to reduce neonatal mortality. However, only one quarter of newborns in Uttar Pradesh, India were breastfed in the first hour of life. This paper aims to understand the association of community-based prenatal counselling and postnatal support at place of delivery with early initiation of breastfeeding in Uttar Pradesh, India. Methods Data from a cross-sectional survey of 9124 eligible women (who had a live birth in 59 days preceding the survey) conducted in 25 districts of Uttar Pradesh, India, in 2018, were used. Simple random sampling was used to randomly select 40 Community Development Blocks (sub district administrative units) in 25 districts. The Primary Sampling Units (PSUs), health service delivery unit for frontline workers, were selected randomly from a linelisting of PSUs in each selected Community Development Block. Bivariate and multivariate logistic regression analyses were performed to assess the association of prenatal counselling and postnatal support on early initiation of breastfeeding in public, private and home deliveries. Results Overall 48.1% of mothers initiated breastfeeding within an hour, with major variation by place of delivery (61.2% public, 23.6% private and 32.6% home). The adjusted odds ratio (aOR) of early initiation of breastfeeding was highest among mothers who received both counselling and support (aOR 2.67; 95% CI 2.30, 3.11), followed by those who received only support (aOR 1.99; 95% CI 1.73, 2.28), and only counselling (aOR 1.40; 95% CI 1.18, 1.67) compared to mothers who received none. The odds of early initiation of breastfeeding was highest among mothers who received both prenatal counselling and postnatal support irrespective of delivery at public health facilities (aOR 2.49; 95% CI 2.07, 3.01), private health facilities (aOR 3.50; 95% CI 2.25, 5.44), or home (aOR 2.84; 95% CI 2.02, 3.98). Conclusions A significant association of prenatal counselling and postnatal support immediately after birth on improving early initiation of breastfeeding, irrespective of place of delivery, indicates the importance of enhancing coverage of both the interventions through community and facility-based programs in Uttar Pradesh.

IntroductionImproving the quality of care during childbirth is essential for reducing neonatal and maternal mortality. One barrier to improving quality of care is understanding the appropriate level to target interventions. We examine quality of care data during labour and delivery from multiple countries to assess whether quality varies primarily from nurse to nurse within the same facility, or primarily between facilities.MethodsTo assess the relative contributions of nurses and facilities to variance in quality of care, we performed a variance decomposition analysis using a linear mixed effect model on two data sources: (1) the number of vital signs assessed for women in labour from a study of nurse practices in Uttar Pradesh, India; 2) broad-scale indices of respectful and competent care generated from Service Provision Assessments in Kenya and Malawi. We used unsupervised clustering, a data mining technique that groups objects together based on similar characteristics, to identify groups of facilities that displayed distinct patterns of vital signs assessment behaviour.ResultsWe found 3–10 times more variance in quality of care was explained by the facility where a patient received care than by the nurse who provided it. The unsupervised clustering analysis revealed groups of facilities with highly distinct patterns of vital signs assessment, even when overall rates of vital signs assessments were similar (eg, some facilities consistently test fetal heart rate, but not other vitals, others only blood pressure).ConclusionFacilities within a region can vary substantially in the quality of care they provide to women in labour, but within a facility, nurses tend to provide similar care. This holds true both for care that can be influenced by equipment availability and technical training (eg, vital signs assessment), as well as cultural aspects (eg, respectful care).

Background In 2001, India prioritized eight most socioeconomically disadvantaged states known as Empowered Action Group (EAG) states and in 2013, it prioritized 190 of the 718 as high priority districts (HPDs) to accelerate the decline in maternal and newborn mortality. This paper assesses whether the HPDs achieved a greater coverage of maternal and newborn health interventions than the non-HPDs and HPDs in EAG states achieved greater coverage than those in non-EAG states. Methods We used data from the Sample Registration System to assess rural neonatal mortality trends in EAG states and all India. We computed a co-coverage index based on seven maternal and newborn health interventions from the 2015/16 National Family Health Survey. Difference in differences (DID) analyses were used to examine the contribution of district prioritization, considering the HPDs and the illiterate as treatment groups and 2013 as the time cut-off for the pre- and post-treatment. Results Neonatal mortality declined in rural India from 36 to 27 per 1000 live births during 2010-2016 at 4.5% per year. Four EAG states experienced faster rates of decline than the national rate. From 2013, the co-coverage index increased significantly more in the HPDs compared to non-HPDs (DID = 0.11, P ≤ 0.005). The district prioritization effect on co-coverage was statistically significant in only EAG states (DID = 0.13, P ≤ 0.05). The coverage gains for illiterate mothers were greater than for literate mothers, especially in the HPDs. Conclusions The district prioritization in India is associated with greater improvements in the coverage of maternal and newborn health services in EAG states and the HPDs, including reductions in inequalities within those states and districts. There are however still large gaps between states and districts and within districts by the mother's literacy status that need further prioritization to make progress towards the SDG targets by 2030.

We identified how the quantity and quality of actions taken by community health workers can be refined to move from a one-size-fits-all model to a precision approach that stands to benefit the health of the mothers and newborns they support., Key Findings Community health worker (CHW) presence, number and timing of visits, behavior change messaging strategies, and focus on specific household members for different behaviors associates with maternal and newborn care practices.Local sociocultural factors such as the decision dynamics of households and common false beliefs about neonatal care should inform how the CHW communicates. Key Implications Program managers can use these insights to adapt the CHW training, incentives, and tools to achieve greater impact.Other CHW programs can use this approach to identify opportunities to improve the effectiveness of their workers in terms of communication, knowledge, and number and timing of visits., Introduction: Community health workers (CHWs) play a key role in the health of mothers and newborns in low- and middle-income countries. However, it remains unclear by what actions and messages CHWs enable good outcomes and respectful care. Methods: We collected a uniquely linked set of questions on behaviors, beliefs, and care pathways from recently delivered women (n=5,469), their husbands (n=3,064), mothers-in-law (n=3,626), and CHWs (accredited social health activists; n=1,052) in Uttar Pradesh, India. We used logistic regression to study associations between CHW actions and household behaviors during antenatal, delivery, and postnatal periods. Results: Pregnant women who were visited earlier in pregnancy and who received multiple visits were more likely to perform recommended health behaviors including attending multiple checkups, consuming iron and folic acid tablets, and delivering in a health facility (ID), compared to women visited later or receiving fewer visits, respectively. Counseling the woman was associated with higher likelihood of attending 3+ checkups and consuming 100+ iron and folic acid tablets, whereas counseling the husband and mother-in-law was associated with higher rates of ID. Certain behavior change messages, such as the danger of complications, were associated with more checkups and ID, but were only used by 50%–80% of CHWs. During delivery, 57% of women had the CHW present, and their presence was associated with respectful care, early initiation of breastfeeding, and exclusive breastfeeding, but not with delayed bathing or clean cord care. The newborn was less likely to receive delayed bathing if the CHW incorrectly believed that newborns could be bathed soon after birth (which is believed by 30% of CHWs). CHW presence was associated with health behaviors more strongly for home than facility deliveries. Home visits after delivery were associated with higher rates of clean cord care and exclusive breastfeeding. Counseling the mother-in-law (but not the husband or woman) was associated with exclusive breastfeeding. Conclusion: We identified potential ways in which CHW impact could be improved, specifically by emphasizing the importance of home visits, which household members are targeted during these visits, and what messages are shared. Achieving this change will require training CHWs in counseling and behavior change and providing supervision and modern tools such as apps that can help the CHW keep track of her beneficiaries, suggest behavior change strategies, and direct attention to households that stand to gain the most from support.

Background Integration of program monitoring data with focused research studies can be a powerful approach to program evaluation and outcome assessment. This paper draws on examples from a large HIV prevention program in Karnataka, India implemented by the University of Manitoba, and funded by the Bill & Melinda Gates Foundation. Methods Data sources included (1) routine program data to monitor coverage (2) semi-annual assessment of behavioural outcomes using rapid, unlinked anonymous methods called Polling Booth Surveys (PBS) (3) Integrated Behavioural and Biological Surveys (IBBS) and (4) mathematical modeling of HIV transmission dynamics. Results The program monitoring data indicated that the monthly coverage of the estimated female sex workers (FSWs) increased from 68% to 76% and the monthly clinical attendance increased from 19% to 27% over a one year period. PBS demonstrated that the condom use among FSWs in last sex with any client increased from 64% to 73% over four years. IBBS indicated that HIV prevalence among the FSWs declined from 25% at baseline to 13% at end line. The mathematical modeling which used parameters from these data sources suggested that a total of over 80,000 infections were averted by the Karnataka program. The monitoring and evaluation teams were embedded within the program, independently carrying out the design, data collection, analysis and feedback. Discussion The embeddedness of program monitoring and evaluation enabled regular feedback to program implementation in terms of which geographies to focus, which sub-groups to prioritize etc. Special intervention packages were implemented for the young and high-volume FSWs. Conclusion The examples presented here used interactive processes of data use throughout the program cycle through regular feedback to program implementation pon geographies/sub-populations that are lagging behind in terms of both coverage and quality. Disclosure No significant relationships. S01.4 Evaluating complex public health issue violence: understanding and measuring violence and evaluating violence interventions – lessons from STRIVE Sinead Delany-Moretlwe Wits Reproductive Health and HIV Institute, South Africa

Background Uttar Pradesh (UP) is the most populous state in India with historically high levels of fertility rates than the national average. Though fertility levels in UP declined considerably in recent decades, the current level is well above the government’s target of 2.1. Data and methods Fertility and family planning data obtained from the different rounds of Sample Registration System (SRS) and the National Family Health Survey (NFHS). We analyzed fertility and family planning trends in India and UP, including differences in methods mix, using SRS (1971–2016) and NFHS (1992–2016). Bivariate and multivariate regression analyses were used. Results From 2000, while the total fertility rate (TFR) declined in UP, it is still well above the national level in 2015–16 (2.7 vs 2.18, respectively). The demand for family planning satisfied increased from 52 to 72% during 1998–99 to 2015–16 in UP, compared to an increase from 75 to 81% in India. Traditional methods play a much greater role in UP than in India (22 and 9% of the demand satisfied respectively), while use of sterilization was relatively low in UP when compared to the national averages (18.0 and 36.3% of current married women 15–49 years in UP and India, respectively in 2015–16). Within UP, district fertility ranged from 1.6 to 4.4, with higher fertility concentrated in districts with low female schooling, predominantly located in north-central UP. Fertility declines were largest in districts with high fertility in the late nineties (B = 7.33, p

Evidence shows that low condom use is the norm in relationships between female sex workers (FSWs) and their regular partners. We investigated the timing of sexual initiation in a relationship with a regular partner as a critical factor in determining condom use. Three rounds of Integrated Behavioral and Biological Assessment (IBBA) surveys were used to derive whether regular partner relationships began before or after sex work initiation. Of the 7,015 FSWs surveyed, 33% started an intimate partner relationship before sex work initiation, 27% after beginning sex work, and the remaining 40% did not have a regular partner. Condom use was significantly higher in a FSW’s relationship after sex work initiation (p

Purpose: Men and transgender women who have sex with men (MTWSM) continue to be an at-risk population for human immunodeficiency virus (HIV) infection in India. Identification of risk factors and determinants of HIV infection is urgently needed to inform prevention and intervention programming. Methods: Data were collected from cross-sectional biological and behavioral surveys from four districts in Karnataka, India. Multivariable logistic regression models were constructed to examine factors related to HIV infection. Sociodemographic, sexual history, sex work history, condom practices, and substance use covariates were included in regression models. Results: A total of 456 participants were included; HIV prevalence was 12.4%, with the highest prevalence (26%) among MTWSM from Bellary District. In bivariate analyses, district (P = 0.002), lack of a current regular female partner (P = 0.022), and reported consumption of an alcoholic drink in the last month (P = 0.004) were associated with HIV infection. In multivariable models, only alcohol use remained statistically significant (adjusted odds ratios: 2.6, 95% confidence intervals: 1.2–5.8; P = 0.02). Conclusion: The prevalence of HIV continues to be high among MTWSM, with the highest prevalence found in Bellary district.

Introduction:Multiple sexual partnering is a known predictor for risk of STI and HIV transmission. This study explored the multiple sexual partnering and its predictors among people who visited public social venues (bars, restaurants, hotels, lodges, cafes, karaokes and discos) in Bhutan’s two largest townships of Thimphu and Phuntsholing. Methods:We interviewed 755 sexually active venue patrons from 102 randomly selected venues (56 in Thimphu, 46 in Phuntsholing) from a list of all venues identified as having sex workers or patrons seeking sexual partners. Both bivariate and multivariate analyses were carried out to characterize the predictors of multiple sexual partnering among 755 respondents who had previously had sex. Results:Of the 755 patrons, 46.09% had one sexual partner while the remaining 54.91% had multiple sex partners (≥2 sexual partners) in the 12 months preceding the study. Overall, 6.23% of respondents had received payment from someone at least once for sex; 34.61% of male respondents had paid someone at least once for sex. Nearly all patrons (97.72%) had heard about HIV/ AIDS. About one quarter (24.20%) felt that they were at risk of being infected with HIV, while 37.28% had taken an HIV test in the 12 months preceding the study. In multivariate analysis, males had higher odds of multiple sexual partners compared to females (OR =3.19, 95% CI 1.90-5.20). The odds of having multiple sexual partners was 2.24 (95% CI 1.30-3.90) times higher in those never married compared to those who were married/divorced or separated; multiple partnering increased with increasing age (OR = 1.07 per year, 95% CI 1.02-1.13). Between the townships of Phuentsholing and Thimphu, the odds of multiple sexual partnering did not vary. Conclusions: Venue patrons had a high prevalence of multiple sexual partnering and have the potential for creating sexual networks that could propagate wider transmission of infection, including to their monogamous partner. Targeting HIV prevention program to these groups of people in urban locations presents an opportunity to make a great impact in maintaining Bhutan’s current low HIV epidemic level. Keywords: Bhutan; HIV Transmission; Sexual partnerin.

IntroductionMeeting ambitious global health goals with limited resources requires a precision public health (PxPH) approach. Here we describe how integrating data collection optimisation, traditional analytics and causal artificial intelligence/machine learning (ML) can be used in a use case for increasing hospital deliveries of newborns in Uttar Pradesh, India.MethodsUsing a systematic behavioural framework we designed a large-scale survey on perceptual, interpersonal and structural drivers of women’s behaviour around childbirth (n=5613). Multivariate logistic regression identified factors associated with institutional delivery (ID). Causal ML determined the cause-and-effect ordering of these factors. Variance decomposition was used to parse sources of variation in delivery location, and a supervised learning algorithm was used to distinguish population subgroups.ResultsAmong the factors found associated with ID, the causal model showed that having a delivery plan (OR=6.1, 95% CI 6.0 to 6.3), believing the hospital is safer than home (OR=5.4, 95% CI 5.1 to 5.6) and awareness of financial incentives were direct causes of ID (OR=3.4, 95% CI 3.3 to 3.5). Distance to the hospital, borrowing delivery money and the primary decision-maker were not causal. Individual-level factors contributed 69% of variance in delivery location. The segmentation analysis showed four distinct subgroups differentiated by ID risk perception, parity and planning.ConclusionThese findings generate a holistic picture of the drivers and barriers to ID in Uttar Pradesh and suggest distinct intervention points for different women. This demonstrates data optimised to identify key behavioural drivers, coupled with traditional and ML analytics, can help design a PxPH approach that maximise the impact of limited resources.

Inadequate quality of care in healthcare facilities is one of the primary causes of patient mortality in low- and middle-income countries, and understanding the behavior of healthcare providers is key to addressing it. Much of the existing research concentrates on improving resource-focused issues, such as staffing or training, but these interventions do not fully close the gaps in quality of care. By contrast, there is a lack of knowledge regarding the full contextual and internal drivers-such as social norms, beliefs, and emotions-that influence the clinical behaviors of healthcare providers. We aimed to provide two conceptual frameworks to identify such drivers, and investigate them in a facility setting where inadequate quality of care is pronounced. Using immersion interviews and a novel decision-making game incorporating concepts from behavioral science, we systematically and qualitatively identified an extensive set of contextual and internal behavioral drivers in staff nurses working in reproductive, maternal, newborn, and child health (RMNCH) in government public health facilities in Uttar Pradesh, India. We found that the nurses operate in an environment of stress, blame, and lack of control, which appears to influence their perception of their role as often significantly different from the RMNCH program's perspective. That context influences their perceptions of risk for themselves and for their patients, as well as self-efficacy beliefs, which could lead to avoidance of responsibility, or incorrect care. A limitation of the study is its use of only qualitative methods, which provide depth, rather than prevalence estimates of findings. This exploratory study identified previously under-researched contextual and internal drivers influencing the care-related behavior of staff nurses in public facilities in Uttar Pradesh. We recommend four types of interventions to close the gap between actual and target behaviors: structural improvements, systemic changes, community-level shifts, and interventions within healthcare facilities.

BACKGROUND : Diabetic Neuropathy is one of the most common troublesome complications of diabetes mellitus. It is frequently associated with other microvascular complications like retinopathy and nephropathy. Early detection of peripheral neuropathy will prevent further progression of other microvascular complications. METHODOLOGY : This cross sectional study was conducted in the Dept. of medicine at Dr. B. R. Ambedkar Medical College for a period of 1year. A total of 50 subjects were taken, 36 were males, and 14 were females. The present study used the Diabetic Neuropathy Examination Score (DNE ), which was designed by Meijer. Nerve conduction studies were done according to a standard protocol. All other routine investigations were done using standard procedures. RESULTS : In the study it was observed that out of the 29 subjects who were found to have neuropathy by NCS, 26 tested positive by the DNE score which gave a sensitivity of 89.7%.There is statistically significant association between clinical examination score (DNE) and nerve conduction study. It was found that there is statistically signi ficant correlation between diabetic neuropathy and retinopathy (P

This study was conducted to explore the decision-making processes regarding sites for delivery of infants among women, their husbands, and mothers-in-law in a rural area of northern Karnataka state, south India. Qualitative semi-structured, individual in-depth interviews were conducted in 2010 among 110 pregnant women, new mothers, husbands and mothers-in-law. Interviews were conducted by trained local researchers in participants' languages and then translated into English. Decisions were made relationally, as family members weighed their collective attitudes and experiences towards a home, private or public delivery. Patterns of both concordance and discordance between women and their families' preferences for delivery site were present. The voice of pregnant women and new mothers was not always subordinate to that of other family members. Still, the involvement of husbands and mothers-in-law was important in decision-making, indicating the need to consider the influence of household gender and power dynamics. All respondent types also expressed shifts in social context and cultural attitudes towards increasing preference for hospital delivery. An appreciation of the interdependence of family members' roles in delivery site decision-making, and how they are influenced by the socio-cultural context, must be considered in frameworks used to guide the development of relevant interventions to improve the utilization and quality of maternal, neonatal and child health services.

Background Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India. Methods Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses’ knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets. Results Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience. Conclusions This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India. Trial registration This study is registered at clinicaltrials.gov, Identifier No. NCT02004912, November 27, 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1933-1) contains supplementary material, which is available to authorized users.

Objectives. We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India. Methods. We conducted behavioral–biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM. Results. By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI = 2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM. Conclusions. CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.

Objective To assess the impact of the Avahan HIV prevention programme for female sex workers (FSWs) in south India on reducing syphilis prevalence among their clients, by comparing rates of syphilis over time as reported in two large-scale surveys of FSWs’ clients. Methods A random-effect multilevel logistic regression analysis was performed using syphilis as the dependent variable, with individual independent variables (from the two survey rounds) at level 1 and the district-level programme (from the Avahan computerised monitoring and information system) and contextual variables (from Indian government datasets) at level 2. Programme variables included their 2006 value and their difference in value between 2008 and 2006, as well as the interaction between the latter and the study round. The analysis also controlled for baseline syphilis prevalence and its interaction with the study round. Results Syphilis decreased significantly among FSWs’ clients, from 4.8% (round 1) to 2.6% (round 2), p

Evidence suggests that in India, the early stages of a woman's career as a sex worker may be an important period to target for HIV and sexually transmitted infection prevention. Before such an intervention is designed and implemented, it is necessary to first understand the life circumstances of women at the start of their sex work careers. We performed a review to bring together available literature pertaining to entry into sex work in India and to highlight knowledge gaps. We found that historical traditions of dedication into sex work, financial insecurity, family discord, violence and coercion, and desire for financial independence are commonly reported reasons for entering into sex work. We also found that families and the broader sex worker community play an important role in the early stages of a woman's sex work career. We suggest that HIV-prevention programmes in India would substantially benefit from a deeper understanding of the life circumstances of new and young women sex workers. Further research should be conducted focusing on family and community involvement in women's entry into sex work, and on the important period of time after a woman's first commercial sex encounter, but before self-identification as a sex worker.

Summary Background Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall effectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention. Methods We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the first 4 years (2004–07 or 2005–08 dependent on the district) and the full 10 years (2004–13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the effectiveness estimates. Using regression analysis, we extrapolated the prevention effect in the districts covered by IBBAs to all 69 Avahan districts. Findings In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32 700 HIV infections (95% credibility interval 17 900–61 600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62 800 (32 000–118 000) averted infections, and extrapolation suggested that 202 000 (98 300–407 000) infections were averted across all 69 Avahan districts in South India, increasing to 606 000 (290 000–1 193 000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted. Interpretation This is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives. Funding Bill & Melinda Gates Foundation.

OBJECTIVE: Estimate the potential impact of Avahan, the India AIDS Initiative, among female sex workers (FSWs) and their clients in five districts of Karnataka state, south India. DESIGN: Examination of time trends in sexually transmitted infection (STI)/HIV prevalence from serial cross-sectional surveys, combined with mathematical modelling. METHODS: Survey data from each district were used to monitor changes in FSW STI/HIV prevalence during Avahan. A deterministic model, parameterized with district-specific survey data, was used to simulate HIV/HSV-2/syphilis transmission among high-risk groups in each district. Latin hypercube sampling was used to obtain multiple parameter sets that reproduced district-specific HIV prevalence trends. A Bayesian framework tested whether self-reported increases in consistent condom use (CCU) during Avahan were more compatible with FSW HIV prevalence trends than assuming no or slow (preintervention rates) CCU increases, and were used to estimate HIV incidence and infections averted. RESULTS: Declines in FSW HIV prevalence occurred over 5 years in all districts, and were statistically significant in three. Self-reported increases in CCU were more consistent with observed declines in HIV prevalence in three districts. In all five districts, an estimated 25-64% (32-70%) HIV infections were averted among FSWs (clients) over 5 years. This corresponded to 142-2092 FSW infections averted depending on the district (two-fold to nine-fold more among clients). CONCLUSION: Empirical HIV prevalence trends combined with Bayesian modelling have provided plausible evidence that Avahan has reduced HIV transmission among FSWs and their clients. If current CCU levels are sustained, FSW HIV prevalence could decline to low levels by 2015, with many more infections averted.

Background: Clients of female sex workers (FSWs) are an important bridging population for HIV and other sexually transmitted infections. However, the extent of risk to female noncommercial partners (NCPs) of clients has not been explored. Methods: Data originated from a cross-sectional behavioral and biological survey of FSW clients from 5 districts in Karnataka state, southern India. Clients were classified into 3 groups: married, single with at least 1 NCP, and single without an NCP. Bivariate and multivariable logistic regression models were constructed to examine the association between group membership and condom use patterns with FSWs and, where applicable, NCPs. HIV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections were examined. Normalized weights were used to account for a complex sampling design. Results: Most respondents in our sample (n = 2328) were married (61%). Compared with single respondents without an NCP, married clients were more likely to never use condoms with both occasional (adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.3Y2.5; P G 0.0001) and regular (AOR, 1.7; 95% CI, 1.1Y2.6; P = 0.015) FSWs. Among clients with an NCP, married clients were at higher odds of never using a condom with their NCP (AOR, 5.5; 95% CI, 3.7Y8.1; P G 0.0001). Overall prevalence for HIV, HSV-2, syphilis, and chlamydia or gonorrhea infection was 5.7%, 28.3%, 3.6%, and 2.1%, respectively. The prevalence of HSV-2 was 37%, 16%, and 19% among those who were married, those single without an NCP, and those single with an NCP, respectively. Conclusions: Married respondents were least likely to use condoms with both commercial and noncommercial sexual partners, while also having the highest prevalence of HSV-2. These results illustrate the risk posed to both commercial partners and NCPs of married clients.

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 87035 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: 55160-150784). 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.

Background Maternal health care refers to health care for women during pregnancy, childbirth and post-partum periods. Such care not only affects the health outcomes of mothers and children but also drastically reduces maternal and neonatal deaths. Motherhood should be a positive and fulfilling experience to every woman, but for many mothers it is associated with sufferings, ill health and at times deaths. Many of the health schemes by the national and state governments are focused on the most vulnerable population and disadvantaged groups in the society, so as to provide equity in maternal healthcare services. Women belonging to scheduled castes (SC) and scheduled tribes (ST) constitute about 16.6% and 8.6% of India9s population respectively. This study aims to assess the differentials between SC/ST women and non-SC/ST women in accessing antenatal care, delivery services and postnatal care in rural areas of eight districts of north Karnataka. Methods Study used the data collected as part of the baseline household survey in the year 2012 and the end-line household survey in the year 2015 under the Project Sukshema. The study adopted systematic stratified sampling with two-staged selection of villages and selection of households and eligible women. The baseline covered 4,881 households and 5,240 ever-married women (2,628 from the SC/ST segment and 2,612 from the non-SC/ST segment) between age 15–34 years. The end-line survey covered 4,952 households and 5,154 ever-married women (2,565 from the SC/ST segment and 2,589 from the non-SC/ST segment). The study design and methods adopted were identical in both waves of the household survey. Findings Significant differences were observed between SC/ST women and non-SC/ST women in availing antenatal care services in terms of getting pregnancy confirmation test, first trimester registration of pregnancy, receiving at least three antenatal check-ups, getting at least one tetanus toxoid and at least 100 iron folic acid tablets (P Conclusion Though significant overall improvements have been observed in access to antenatal, delivery and postnatal services for women in North Karnataka districts, women from SC/ST category suffer from lesser access compared to women from non-SC/ST category. Grant funding (Bill & Melinda Gates Foundation) for research but no other competing interests.

OBJECTIVES: To assess the levels and trends in the prevalence of HIV and sexually transmitted infections in the general population in Bagalkot district using 2 cross-sectional surveys undertaken in 2003 and 2009. METHODS: In both surveys a target sample of 6600 adult males and females was selected systematically from a sample of 10 rural villages and 20 urban blocks in 3 of the 6 talukas (subdistrict units) in the district. Urine and blood samples were collected from all consenting participants for HIV and sexually transmitted infection testing. Changes in HIV prevalence in age subgroups were determined by logistic regression taking into account the survey design. RESULTS: HIV prevalence fell not significantly from 3.2% to 2.5% during the 6-year study period. It decreased significantly (P = 0.023) among persons aged 15 to 24 years from 2.4% in 2003 (95% confidence interval [95% CI]: 1.2-3.7) to 1.3% in 2009 (95% CI: 0.6 -2.0). However among males aged 35 and above HIV prevalence increased significantly (P = 0.008) from 3.0% (95% CI: 1.1-4.8) to 4.2% (95% CI: 1.8-6.6) a level similar to that found in the younger age-group in 2003. CONCLUSIONS: We observed a significant decline in HIV prevalence among people aged 15 to 24 years where HIV prevalence more closely reflects incidence. The increase in HIV prevalence among older males may have been because of the aging of a cohort of men among whom HIV prevalence was highest in the 2003 survey. It may also have in part reflected increased survival as a result of the scaling up of antiretroviral treatment programs throughout the district and state.

Quantifying sexual activity of sub-populations with high-risk sexual behaviour is important in understanding HIV epidemiology. This study examined inconsistency of seven outcomes measuring self-reported clients per month (CPM) of female sex workers (FSWs) in southern India and implications for individual/population-level analysis. Multivariate negative binomial regression was used to compare key social/environmental factors associated with each outcome. A transmission dynamics model was used to assess the impact of differences between outcomes on population-level FSW/client HIV prevalence. Outcomes based on 'clients per last working day' produced lower estimates than those based on 'clients per typical day'. Although the outcomes were strongly correlated, their averages differed by approximately two-fold (range 39.0-79.1 CPM). The CPM measure chosen did not greatly influence standard epidemiological 'risk factor' analysis. Differences across outcomes influenced HIV prevalence predictions. Due to this uncertainty, we recommend basing population-based estimates on the range of outcomes, particularly when assessing the impact of interventions.

BACKGROUND: Despite high HIV prevalence rates among most-at-risk groups, utilisation of HIV testing, treatment and care services was relatively low in Karnataka prior to 2008. The authors aimed to understand the barriers to and identify potential solutions for improving HIV service utilisation. METHODS: Focus group discussions were carried out among homogeneous groups of female sex workers, men who have sex with men and transgenders, and programme peer educators in six districts across Karnataka in March and April 2008. RESULTS: 26 focus group discussions were conducted, involving 302 participants. Participants had good knowledge about HIV and HIV voluntary counselling and testing (VCT) services, but awareness of other HIV services was low. The fear of the psychological impact of a positive HIV test result and the perceived repercussions of being seen accessing HIV services were key personal and interpersonal barriers to HIV service utilisation. Previous experiences of discrimination at government healthcare services, coupled with discriminatory attitudes and behaviours by VCT staff, were key structural barriers to VCT service uptake among those who had not been HIV tested. Among those who had used government-managed prevention of parent to child transmission and antiretroviral treatment services, poor physical facilities, long waiting times, lack of available treatment, the need to give bribes to receive care and discriminatory attitudes of healthcare staff presented additional structural barriers. CONCLUSIONS: Embedding some HIV care services within existing programmes for vulnerable populations, as well as improving service quality at government facilities, are suggested to help overcome the multiple barriers to service utilisation. Increasing the uptake of HIV testing, treatment and care services is key to improving the quality and longevity of the lives of HIV-infected individuals.

Objectives The purpose of the study was to obtain a better understanding of the relative importance of personal factors, male partner factors and situational factors, in determining condom breakage in a population of female sex workers (FSWs) in Bangalore. Methods The authors conducted a cross-sectional study that included a face-to-face interview and condom application test, with 291 randomly selected FSWs in Bangalore, India, in early 2011. Results Ninety-seven per cent of respondents noted condom use at last sex; 34% reported a condom breakage in the last month. Combining individual, situational and partner aspects of condom breakage into one logistic regression model and also controlling for client load, the authors found that partner and situational factors were dominant since the only significant predictors of condom breakage included being a paying client (adjusted odds ratio 4.61, 95% CI 1.20 to 17.58, p=0.025), the condom being too small for the penis (adjusted odds ratio 2.29, 95% CI 0.97 to 5.40, p=0.056) or too big for the penis (adjusted odds ratio 4.29, 95% CI 1.43 to 12.80, p=0.009) and rough sex (adjusted odds ratio 6.39 CI 3.55 to 11.52, p Conclusions Condom use among Bangalore FSWs is now very high. However, condom breakage is still a not uncommon event and puts women and their clients at unnecessary risk of infection. It may be difficult to eliminate the problem completely, but every effort should be made to discuss with sex workers the findings of this survey that point to possible personal markers of risk seen in the univariate analysis and to highlight the importance of avoiding rough sex and of ensuring the condom fits the client.

Bhutan's sustained low HIV prevalence can be attributed to its political commitment to maintain isolation from foreign cultural influence. Recently, rising HIV prevalence has coincided with the increase in human traffic along Bhutan's borders. The majority of infections, occurring primarily through sexual contact, have appeared in the urban environments that are situated along the main transport routes. This qualitative study explored the sexual networks that form at entertainment venues in the capital city of Thimphu. To more fully understand sexual network formation at theses venues, one must take into account an emerging modernity that reflects a convergence of cultural, economic and political influences emanating from Bhutan's unique 'middle-path' modernisation scheme. The growing appearance of transactional sex in Thimphu not only points to an emergent form of exploitation wrought by larger economic transformations and widening social inequalities; the power inequalities that surround its practice are also significantly exacerbated by the local cultural politics and moral ideologies that arise as Bhutan proceeds along the path towards global capitalism. Discourses of Bhutanese sexual morality articulate with broader political economic transformations to forcefully position village women engaging in transactional sex within a field of power relations that leaves them open to various forms of subjugation.

BACKGROUND: Syndromic case management remains the cornerstone for STI (sexually transmitted infection) treatment in many countries. We undertook this study to better understand the etiology of STIs in adults in south India and to inform STI management guidelines. METHODS: Adult males and females presenting with genital complaints were recruited from clinics in Karnataka state south India. A questionnaire was administered physical examination performed and blood collected for herpes simplex virus-type 2 (HSV-2) and syphilis serology. Men with urethral discharge (UD) and women with vaginal discharge were tested for Neisseria gonorrhoeae (NG) Chlamydia trachomatis (CT) and Trichomonas vaginalis (TV). Vaginal swabs were also tested for bacterial vaginosis and yeast infection. Participants with genital ulcers were tested for Treponema pallidum (TP) Haemophilus ducreyi (HD) and HSV-2. human immunodeficiency virus (HIV) testing was offered to all individuals. RESULTS: There were 401 male and 412 female participants and rates of HIV infection were high (men 17%; women 15%). HSV-2 was significantly associated with HIV in men and women. Among men with the complaint of UD NG was identified in 35% CT in 10.5% and TV in 8.5%. Very little NG or CT was detected among women with vaginal discharge. However bacterial vaginosis was identified in approximately 40% of women with significant amounts of TV and Candida also detected. HSV-2 was the most commonly identified pathogen among participants with genital ulcer disease and the clinical distinction of herpetic versus nonherpetic lesions was not helpful. CONCLUSIONS: Current STI management guidelines should be reevaluated in south India. Consideration should be given to treating all persons with GUD for both HSV-2 and syphilis and to adding initial treatment for TV for men with UD in areas of high background prevalence of HSV-2 and TV respectively. This population is at high risk for HIV and should be counseled and tested appropriately.

Background Avahan, the India AIDS Initiative, is a large-scale targeted intervention. Data on condom use prior to Avahan are unavailable. The authors used a novel method of analysing cross-sectional survey data to ‘reconstruct’ condom use rates in presurvey years, and to assess the relationship between Avahan and time trends in condom use among female sex workers (FSWs). Methods Among FSWs reporting consistent condom use (CCU) with clients in surveys from 21 districts in southern India (n=7358), data on length of time using condoms, and length of time selling sex, were converted into number of FSWs using condoms (numerator) and selling sex (denominator) by year, to give yearly rates of CCU from 2001 to year of survey. Linear regression with generalised estimating equations was used to assess time trends and to compare the rate of increase in condom use before and after Avahan initiation in 2003. Results In all 21 districts, the rate of increase in CCU from 2001 to time of the surveys was highly significant. Overall CCU increased from 27% (22%) with occasional (regular) clients in 2001, to 76% (68%) in 2006, respectively. The yearly rate of increase in CCU was significantly greater after (slope 2003–2006: 12.7% (12.0%) per year for occasional (regular) clients) than prior to Avahan (slope 2001–2003: 5.1% (5.3%) per year for occasional (regular) clients) implementation (p

Objectives A key indicator of success of HIV prevention programmes is the number of female sex worker (FSW) sex acts protected by condoms. This measure usually relies on FSW reports, which may be biased. We examined condom availability data in five Karnataka districts to estimate the proportion of FSW sex acts potentially protected by condoms. Methods Financial, programme, population, condom and contraceptive data were obtained from governmental and non-governmental sources, surveys and HIV prevention programmes. Sexual behaviour data were obtained from general population and FSW surveys. We examined four scenarios in a sensitivity analysis, each one assuming different proportions of available condoms that might have been used by sex workers. Results Possible condom use rates for all FSW sex acts ranged from 3%–36% in 2004 to 56%–96% in 2008. The two most realistic scenarios that discounted the number of private sector condoms that might have been bought for sex acts other than with FSWs showed that 16–24% of FSW sex acts could have been protected by condoms in 2004 rising to 77–85% in 2008. Conclusions These data suggest that condom availability in these Karnataka districts in 2004 was low in relation to the number of FSW sex acts, but rose substantially over the ensuing 4 years. Condom availability data can be useful for triangulation with other available data, such as self-reported condom use, to provide a range of possibilities regarding the number of FSW sex acts protected by condoms.

Objectives This study assesses whether the observed declines in HIV prevalence since the beginning of the ‘Avahan’ India HIV/AIDS prevention initiative are consistent with self-reported increases in condom use by female sex workers (FSWs) in two districts of southern India, and provides estimates of the fraction of new infections averted among FSWs and clients due to increases in condom use in commercial sex after 2004. Methods A deterministic compartmental model of HIV/sexually transmitted infection (STI) transmission incorporating heterogeneous sexual behaviour was developed, parameterised and fitted using data from two districts in Karnataka, India. Three hypotheses of condom use among FSWs were tested: (H 0 ), that condom use increased in line with reported FSW survey data prior to the Avahan initiative but remained constant afterwards; (H 1 ) that condom use increased following the Avahan initiative, in accordance with survey data; (H 2 ) that condom use increased according to estimates derived from condom distribution data. The proportion of fits to HIV/STI prevalence data was examined to determine which hypothesis was most consistent. Results For Mysore 0/36/82.7 fits were identified per million parameter sets explored under hypothesis H 0 /H 1 /H 2 , respectively, while for Belgaum 9.7/8.3/0 fits were identified. The HIV epidemics in Belgaum and Mysore are both declining. In Mysore, increases in condom use during commercial sex between 2004 and 2009 may have averted 31.2% to 47.4% of new HIV infections in FSWs, while in Belgaum it may have averted 24.8% to 43.2%, if there was an increase in condom use. Discussion Increased condom use following the Avahan intervention is likely to have played a role in curbing the HIV epidemic in Mysore. In Belgaum, given the limitations in available data, this method cannot be used alone to decide if there has been an increase in condom use.

Objective This paper evaluates Avahan programme9s coverage of female sex workers (FSWs), focus on high-risk FSWs and intermediate outcomes. Methods First round of cross-sectional survey data, Integrated Behavioral and Biological Assessments (IBBA), conducted in 22 districts, were aggregated into district categories: Solo, where Avahan was the sole service provider covering all FSWs and Major or Minor where Avahan was not the sole provider, but intended coverage was >50% or ≤ 50% of FSWs respectively. Multivariate logistic regression was applied to compare exposure by district categories, vulnerability factors and intermediate outcomes associated with exposure. Results Reported exposure, evaluated on basis of having received any of three core services, was higher in Solo (75%) compared with Minor (66%) districts. Logistic regression showed that FSWs in solo districts were more likely to be exposed (adjusted odds ratio (AOR)=1.5; 95% CI 1.20 to 1.86) compared with FSWs in Minor districts. Multivariate analysis in Solo districts revealed that FSW with ≥15 clients in the past week had a higher chance of being exposed to core services (AOR=1.56; 95% CI 1.03 to 2.35). Exposure to the three services in Solo Avahan districts was significantly associated with correct knowledge on condom use (AOR=1.36; 95% CI 1.05 to 1.78), consistent condom use with occasional clients (AOR=3.17; 95% CI 2.17 to 4.63) and regular clients (AOR=2.47; 95% CI 1.86 to 3.28) and STI treatment-seeking behaviour (AOR=3.00; 95% CI 1.94 to 4.65). Conclusions Higher coverage of FSWs was achieved in districts where Avahan was the only intervention compared with districts having multiple and longstanding non-Avahan programmes. Exposure in Solo districts was associated with intermediate outcomes; this need to be further evaluated in comparison with non Avahan areas and substantiated through data from next IBBA.

In rural India, with hundreds of thousands of villages, a priority from a programmatic perspective is to efficiently determine which villages are at highest risk of HIV/AIDS transmission. The authors first report on the use of a rapid ethnographic approach in 10 rural villages of Karnataka, India, to develop a domains and indicators framework of village-level HIV/AIDS risk and a subsequent rapid assessment tool. They then analyze the rapid ethnographic approach and the rapid assessment tool to discuss differences and commonalities among rapid designs. They also discuss if these studies can be properly categorized as ethnographies, are mainly qualitative in nature, and are in essence participatory, and how appropriate they are to the public health field in general and the HIV/AIDS field in particular.

OBJECTIVE:: To develop a modelfor prioritizing economic sectors for HIV preventive intervention programs in the workplace. METHODS:: This study was undertaken in Karnataka state India. A 3-stage survey process was undertaken. In the first stage we reviewed secondary data available from various government departments identified industries in the private sector with large workforces and mapped their geographical distribution. In the second stage an initial rapid risk assessment of industrial sectors was undertaken using key-informant interviews conducted in relation to a number of enterprises and in consultation with stakeholders. In the third stage we used both quantitative (polling booth survey) and qualitative methods (key informant interviews in-depth interviews focus group discussions) to study high-risk sectors in-depth and assessed the need and feasibility of HIV workplace intervention programs. RESULTS:: The highest risk sectors were found to be mining garment/textile sugar construction/infrastructure and fishing industries. Workers in all sectors had at best partial knowledge about HIV/AIDS coupled with common misconceptions about HIV transmission. There were intersector and intrasector variations in risk and vulnerability across different geographical locations and across different categories of workers. This has implications for the design and implementation of workplace intervention programs. CONCLUSIONS:: There is tremendous scope for HIV preventive interventions in workplaces in India. Given the variation in HIV risk across economic sectors and limited available resources there will be increased pressure to prioritize intervention efforts towards high-risk sectors. This study offers a model for rapidly assessing the risk level of economic sectors for HIV intervention programs.

OBJECTIVE: In four states in southern India we explored the determinants of HIV prevalence among female sex workers (FSW) as well as factors associated with district-level variations in HIV prevalence among FSW. METHODS: Data from cross-sectional surveys in 23 districts were analysed with HIV prevalence as the outcome variable and sociodemographic and sex work characteristics as predictor variables. Multilevel logistic regression was applied to identify factors that could explain variations in HIV prevalence among districts. RESULTS: HIV prevalence among the 10 096 FSW surveyed was 14.5% (95% confidence interval 14.0-15.4) with a large interdistrict variation ranging from 2% to 38%. Current marital status and the usual place of solicitation emerged as important factors that determine individual probability of being HIV positive as well as the HIV prevalence within districts. In multivariate analysis compared with home-based FSW the odds of being HIV positive was greater for brothel-based FSW [adjusted odds ratio (AOR) 2.17 P