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Background Understanding care patterns of persons living with HIV prior to diagnosis can inform prevention opportunities, earlier diagnosis, and engagement strategies. We examined healthcare utilization among HIV-positive individuals and compared them to HIV-negative controls. Methods Data were from a retrospective cohort from Manitoba, Canada. Participants included individuals living with HIV presenting to care between 2007 and 2011, and HIV-negative controls, matched (1:5) by age, sex, and region. Data from population-based administrative databases included physician visits, hospitalizations, drug dispensation, and chlamydia and gonorrhea testing. Diagnoses associated with physician visits were classified according to International Classification of Diseases chapters. Conditional logistic regression models were used to compare cases/controls, with adjusted odds ratios (AORs) and their 95% confidence intervals (95% CI) reported. Results A total of 193 cases and 965 controls were included. Physician visits and hospitalizations were higher for cases, compared to controls. In the 2 years prior to case date, cases were more likely to be diagnosed with “blood disorders” (AOR: 4.2, 95% CI: 2.0–9.0), be treated for mood disorders (AOR: 2.4, 95% CI: 1.6–3.4), and to have 1+ visits to a hospital (AOR: 2.2, 95% CI: 1.4–3.6). Conclusion Opportunities exist for prevention, screening, and earlier diagnosis. There is a need for better integration of healthcare services with public health.

BACKGROUND Previous studies have shown substantial differences in geographic clustering of sexually transmitted infections (STI), such as chlamydia (CT) and gonorrhea (NG), conditional on epidemic phase. Chlamydia and NG have recently shown resurgent epidemiology in the northern hemisphere. This study describes the recent epidemiology of CT and NG in Winnipeg, Canada, combining traditional surveillance tools with place-based analyses, and comparing the ecological niches of CT and NG, in the context of their evolving epidemiology. METHODS Data were collected as part of routine public health surveillance between 2007 and 2016. Secular trends for CT and NG, and CT/NG coinfection were examined. Gini coefficients and population attributable fractions explored the distribution, and concentration of infections over time and space. RESULTS Rates of CT increased from 394.9/100,000 population to 476.2/100,000 population from 2007 to 2016. Gonorrhea rates increased from 78.0/100,000 population to 143.5/100,000 population during the same period. Each pathogen had its own ecological niche: CT was widespread geographically and socio-demographically, while NG was clustered in Winnipeg's inner-core. CT/NG co-infections had the narrowest space and age distribution. NG was shown to be undergoing a growth phase, with clear signs of geographic dispersion. The expansion of NG resembled the geographic distribution of CT. CONCLUSIONS We demonstrated that NG was experiencing a growth phase, confirming theoretical predictions of geographic dispersion during a growth phase. During this phase, NG occupied similar geographic spaces as CT. Knowledge of different ecological niches could lead to better targeting of resources for subpopulations vulnerable to STIs.

Background The COVID-19 pandemic has challenged health services and governments in Canada and around the world. Our research aims to evaluate the effect of domestic and international air travel patterns on the COVID-19 pandemic in Canadian provinces and territories. Methods Air travel data were obtained through licensed access to the ‘BlueDot Intelligence Platform’, BlueDot Inc. Daily provincial and territorial COVID-19 cases for Canada and global figures, including mortality, cases recovered and population data were downloaded from public datasets. The effects of domestic and international air travel and passenger volume on the number of local and non-local infected people in each Canadian province and territory were evaluated with a semi-Markov model. Provinces and territories are grouped into large (>100 000 confirmed COVID-19 cases and >1 000 000 inhabitants) and small jurisdictions (≤100 000 confirmed COVID-19 cases and ≤1 000 000 inhabitants). Results Our results show a clear decline in passenger volumes from March 2020 due to public health policies, interventions and other measures taken to limit or control the spread of COVID-19. As the measures were eased, some provinces and territories saw small increases in passenger volumes, although travel remained below pre-pandemic levels. During the early phase of disease introduction, the burden of illness is determined by the connectivity of jurisdictions. In provinces with a larger population and greater connectivity, the burden of illness is driven by case importation, although local transmission rapidly replaces imported cases as the most important driver of increasing new infections. In smaller jurisdictions, a steep increase in cases is seen after importation, leading to outbreaks within the community. Conclusions Historical travel volumes, combined with data on an emerging infection, are useful to understand the behaviour of an infectious agent in regions of Canada with different connectivity and population size. Historical travel information is important for public health planning and pandemic resource allocation.

OBJECTIVES Empirical time trends in HIV prevalence in female sex workers (FSWs) are helpful to understand the evolving HIV epidemic, and to monitor the scale-up, coverage, and impact of ongoing HIV prevention and treatment programmes. DESIGN Serial HIV prevalence study. METHODS We analyzed time trends in HIV prevalence in FSWs accessing services at seven Sex Worker Outreach Programme (SWOP) clinics in Nairobi from 2008 to 2017 (N = 33 560). The Mantel--Haenszel test for trend and independent samples Kruskal--Wallis test were used to analyze categorical and continuous variables, respectively. Multivariable binomial regression was used to estimate prevalence ratios/year, adjusting for several covariates. RESULTS HIV prevalence decreased over time in all age groups. This was particularly evident among FSWs less than 25 years of age; HIV was 17.5% in 2008-2009, decreasing to 12.2% in 2010-2011, 8.3% in 2012-2013, 7.3% in 2014-2015, and 4.8% in 2016-2017 (P

The COVID-19 pandemic has challenged health services and governments in Canada and around the world. Our research aims to evaluate the effect of domestic and international air travel patterns on the COVID-19 pandemic in Canadian provinces and territories.Air travel data were obtained through licensed access to the 'BlueDot Intelligence Platform', BlueDot Inc. Daily provincial and territorial COVID-19 cases for Canada and global figures, including mortality, cases recovered, and population data were downloaded from public datasets. The effects of domestic and international air travel and passenger volume on the number of local and non-local infected people in each Canadian province and territory were evaluated with a semi-Markov model. Provinces and territories are grouped into large (100 000 confirmed COVID-19 cases and 1 000 000 inhabitants) and small jurisdictions (≤100 000 confirmed COVID-19 cases and ≤ 1 000 000 inhabitants).Our results show a clear decline in passenger volumes from March 2020 due to public health policies, interventions, and other measures taken to limit or control the spread of COVID-19. As the measures were eased, some provinces and territories saw small increases in passenger volumes, although travel remained below pre-pandemic levels. During the early phase of disease introduction, the burden of illness is determined by the connectivity of jurisdictions. In provinces with a larger population and greater connectivity, the burden of illness is driven by case importation, although local transmission rapidly replaces imported cases as the most important driver of increasing new infections. In smaller jurisdictions, a steep increase in cases is seen after importation, leading to outbreaks within the community.Historical travel volumes, combined with data on an emerging infection, are useful to understand the behaviour of an infectious agent in regions of Canada with different connectivity and population size. Historical travel information is important for public health planning and pandemic resource allocation.

In 2013, the Living with HIV (LHIV) Innovation team established clinical cohorts of people living with HIV in Manitoba and Newfoundland and Labrador, and they linked the data to provincial health administrative databases. Access to these data enabled researchers to conduct studies across provincial borders; contribute to a national dialogue on HIV health system performance; and give recommendations for evidence-based healthcare, health policy and public health. However, research funding is episodic; maintaining cohorts requires stable funding. We support the establishment of a cross-jurisdictional approach to facilitate streamlined data collection and linkage without interruption and to allow for meaningful analysis in order to inform national policies.

The COVID-19 pandemic, and its attendant responses, has led to massive health, social, and economic challenges on a global scale. While, so far, having a relatively low burden of COVID-19 infection, it is the response in lower- and middle- income countries that has had particularly dire consequences for impoverished populations such as sex workers, many of whom rely on regular income in the informal economic sector to survive. This commentary captures the challenges in Kenya posed by daily curfews and lost economic income, coupled with further changes to sex work that increase potential exposure to infection, stigmatisation, violence, and various health concerns. It also highlights the ways in which communities and programmes have demonstrated resourcefulness in responding to this unprecedented disruption in order to emerge healthy when COVID-19, and the measures to contain it, subside.

Background In the development of administrative data case-definitions for HIV, it is important to understand the contribution of each data source to prevalence estimates, especially as it pertains to generalizability of methods. Methods HIV case-definitions were constructed from four population-based databases available in Manitoba: physician claims, hospital discharge, pharmaceutical dispensations, and provincial laboratory tests. Performance was assessed using sensitivity, specificity, positive/negative predictive value (PPV & NPV), and Youden’s index (YI). Cases identified by HIV case-definitions, and those reported to public health surveillance were compared using annualized incidence. The distribution of those flagged as HIV-positive was compared by database. Results The best performing case-definition (YI 0.71) was two or more HIV diagnoses in two years in physician claims, or in hospital discharge abstracts; or 14 or more HAART dispensations in two years; or one positive HIV laboratory. Sensitivity, specificity, PPV and NPV was 82.3% (95%CI: 79.1%-85.5%), 86.8% (95%CI: 84.9%-88.7%), 74.1% (95%CI: 70.6%-77.6%), 91.4% (95%CI: 89.8%-93.1%), respectively. Annualized incidence (2009–2015) calculated from this case-definition was 7.4/100,000 persons (95%CI: 6.8–8.1)]; annualized incidence calculated from surveillance data was 7.7/100,000 persons (95%CI: 7.1–8.3). Approximately 76% of cases would have been flagged through a positive laboratory; 43% through pharmaceutical claims; 34% through physician claims; and 11% through hospital abstracts. 95% of cases would have been flagged through the combination of laboratory and pharmaceutical databases. Only 4% of cases were flagged in all four data sources. Conclusion Although the combination of four databases produced the most complete prevalence snapshot, laboratory data was the most important contributor. The combination of laboratory and pharmaceutical databases would have identified the predominant majority of cases in our sample. Findings can be used to inform the construction of administrative data cohorts where the availability of population-based data sources may be more limited. Disclosure No significant relationships.

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.

The aim of this study was to examine trends in infectious syphilis epidemiology among women in Winnipeg, Canada. A descriptive study of syphilis among Winnipeg residents between 2003 and 30 June 2015 was undertaken. Adjusted rate ratios (ARR) and 95% confidence intervals (95%CI) from Poisson regression analyses are reported. Characteristics of men and women were compared using logistic regression, with adjusted odds ratios (AOR) reported. Between 2014 and 2015, the rate of syphilis was 1.7/100,000, representing a five-fold increase since 2006–2013. All cases have been heterosexual, 90% 20–39 years of age, and 59% living in Winnipeg’s inner core. Approximately 24% were pregnant at diagnosis; no cases of congenital syphilis have been reported. Compared to men, women were more likely to report alcohol use (AOR: 3.8, 95% CI: 1.2–11.9) and co-infection with chlamydia (AOR: 5.0, 95% CI: 1.1–22.9). In conclusion, the rates of infectious syphilis are increasing among women. Prenatal screening and education for inner-core women and the health care providers serving them should be prioritized.

This study aimed to: (1) examine the relationship between interpersonal as well as social-demographic, cultural and structural factors, and condom non-use by sex workers' main intimate or other non-paying male sex partners (NPPs), as reported by a sample of sex workers (SWs); and (2) understand HIV/sexually transmitted infections (STIs) risk (e.g., numbers of sexual partners; condom use with different partners) among couples comprised of a sub-set of SWs and their NPPs. Bivariate and multivariable logistic regression was used to identify factors associated with condom non-use at last sex by the main NPP, as reported by SWs. Adjusted odds ratios and 95% confidence intervals are reported (AOR[95%CIs]). Data were drawn from cross-sectional surveys in Bagalkot District, Karnataka State, South India. Responses by SWs whose main NPPs agreed to enrol in the study and the main NPP enroled were linked; these responses by couples (pairs of SWs and NPPs) were examined to assess sexual risk for HIV/STIs. Overall, this study included 257 SWs and 76 NPPs. The data from 67 couples (88.2%) could be linked. In over a quarter of partnerships, at least one (SW or NPP) partner reported having another type of partner besides each other (and clients of SWs). In multivariable analysis, significantly increased odds of condom non-use at last sex with the main NPP were found for the following key factors: planning to have a child with their main NPP (AOR = 3.71[1.44-9.58]); and having decisions about condom use made by their main NPP (AOR = 9.87[4.03-24.16]) or both equally (AOR = 3.18[1.39-7.80]) (versus by the SWs herself). Our study highlights the potential risk for HIV/STI acquisition and transmission between NPPs and SWs, and between NPPs and their non-SWs wives and other sex partners. Study results underscore the need for HIV/STI prevention approaches that incorporate informed decision-making about childbearing and parenting, and empowerment strategies for SWs in the context of their relationships with NPPs.

The high prevalence of substance use among HIV-infected individuals creates numerous challenges to patient care. This study was undertaken in order to understand the impact of substance use on care outcomes for HIV-infected individuals in Manitoba. Clinical records of 564 HIV-infected individuals in care at Health Sciences Centre in Winnipeg, Manitoba were reviewed. Clinical data were extracted from patient charts for substance users (illicit substance users, alcohol abusers and chronic users of opioids or benzodiazepines) and non-users. Substance users and non-users were analysed using chi-square analysis and logistic regression models to compare basic socio-demographic and clinic variables. Chi-square and analysis of variance were used to compare a subset of substance users based on similar socio-demographic and clinical characteristics. Among HIV-infected individuals in Manitoba, 38% were substance users with over-representation by Aboriginals, females, young adults and residents of Winnipeg's core areas. Opioids and benzodiazepines were the most commonly used substances with the majority of substance users having used multiple classes of substances in their lifetime. Substance users were more likely than non-users to have missed clinic appointments. Among substance users, missed appointments were more common among those who self-identified as Aboriginal, female, young adults, residents of Winnipeg's core areas, heterosexuals and those who had abused alcohol or cocaine/crack. Aboriginal substance users were also less likely to achieve viral load suppression compared to non-Aboriginal substance users. With the high prevalence of substance use among HIV-infected individuals in Manitoba, it is important to identify at-risk individuals in order to implement appropriate care strategies and improve treatment adherence and health outcomes.

Background: Early c hildhood vaccinations have been hypothesized to contribute to the emergence of paediatric inflammatory bowel disease [IBD] in developed countries. Using linked populationbased administrative databases, we aimed to explore the association between vaccination with measles-containing vaccines and the risk for IBD. Methods: This w as a case-control study using the University of Manitoba IBD Epidemiology Database [UMIBDED]. The UMIBDED was linked to the Manitoba Immunization Monitoring System [MIMS], a population-based database of immunizations administered in Manitoba. All paediatric IBD cases in Manitoba, born after 1989 and diagnosed before March 31, 2008, were included. Controls were matched to cases on the basis of age, sex, and region of residence at time of diagnosis. Measles-containing vaccinations received in the first 2 years of life were documented, with vaccinations categorized as ‘None’ or ‘Complete’, with completeness defined according to Manitoba’s vaccination schedule. Conditional logistic regression models were fitted to the data, with models adjusted for physician visits in the first 2 years of life and area-level socioeconomic status at case date. Results: A total of 951 indi viduals [117 cases and 834 controls] met eligibility criteria, with average age of diagnosis among cases at 11 years. The proportion of IBD cases with completed vaccinations was 97%, compared with 94% of controls. In models adjusted for physician visits and area-level socioeconomic status, no statistically significant association was detected between completed measles vaccinations and the risk of IBD (adjusted odds ratio [AOR]: 1.5; 95% confidence interval [CI]: 0.5–4.4; p = 0.419]. Conclusions: No significant association between completed measles-containing vaccination in the fir st 2 years of life and paediatric IBD could be demonstrated in this population-based study.

INTRODUCTION Recent studies have identified Mx2 as a novel HIV-1 innate restriction factor that inhibits proviral integration. A pilot proteomic study of immune cells from highly exposed HIV-seronegative (HESN) individuals enrolled in the Pumwani sex worker cohort identified Mx1 as potential correlate of HIV protection. A detailed population level analysis of Mx1 and Mx2 expression and their role in reduced susceptibility to HIV infection in HESN women was conducted. METHODS Peripheral blood mononuclear cells (PBMC) were isolated from 102 HESN women and 100 high-risk negative controls enrolled in a Nairobi-based sex worker cohort. Whole-cell lysates were prepared and analyzed for Mx1 and Mx2 expression by commercial ELISA. Bivariate and multiple linear regression analyses were conducted to account for confounding epidemiological factors. RESULTS Mx2, but not Mx1, was found to be significantly overexpressed in HESN women compared with high-risk negative controls (P = 0.027). After multiple linear regression analysis, accounting for age, menopause, pregnancy, Depo-Provera use, recent infections and medication usage, Mx2 expression remained significantly overexpressed in the PBMC of HESN women (P = 0.05). Additionally, an interaction model analysis indicated that HESN women who use Depo-Provera have 2.6-fold higher levels of Mx2 than any other group (P

ObjectivesThe aim of this study is to determine the transmission impact of using prior syphilis infection to guide a focused syphilis screening intervention among men who have sex with men (MSM).MethodsWe parameterised a deterministic model of syphilis transmission in MSM to reflect the 2011–2015 syphilis outbreak in Winnipeg, Canada. Enhanced screening of 75% of men with prior syphilis every 3 months (A) was compared with distributing equivalent number tests to all MSM (B) or those with the highest partner number (C). We compared early syphilis incidence, diagnoses and prevalence after 10 years, relative to a base case of 30% of MSM screened annually.ResultsStrategy A was expected to avert 52% of incident infections, 44% of diagnosed cases and reduce early syphilis prevalence by 89%. Strategy B had the least impact. Strategy C was most effective, averting 59% of incident cases. When screening frequency was semiannual or annual, strategy A was the most effective.ConclusionsEnhanced screening of MSM with prior syphilis may efficiently reduce transmission, especially when identification of high-risk men via self-reported partner numbers or high-frequency screening is difficult to achieve.

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.

Background & Aims As for many complex diseases, the incidence of inflammatory bowel disease (IBD) is higher among individuals born during certain seasons. This difference could arise from seasonal variations in many factors, including exposure to sunlight, antibiotics, or infectious agents. We investigated the relationship between season of birth, early childhood exposure to antibiotics, and incidence of IBD. Methods We performed a nested case-control analysis using data from the University of Manitoba inflammatory bowel disease epidemiology database. We compared seasons of birth among 11,145 individuals with IBD (cases) and 108,633 controls using conditional logistic regression models. We collected data on use of antibiotics in the first year of life for cases and controls from the Manitoba Drug Program Information Network—a comprehensive database of all prescriptions given to residents of Manitoba since 1995. Results Approximately 27.0% of cases were born from April through June, compared with 25.6% of controls (odds ratio, 1.07; 95% confidence interval, 1.02–1.12; P = .002). Comparisons made by sex (male vs female) and type of IBD (ulcerative colitis vs Crohn's disease) showed statistical significance only for men with Crohn's disease (odds ratio, 1.13; 95% confidence interval, 1.03–1.25; P = .009). At ages 6 months and older, cases and controls born from April through June received a significantly greater number of prescriptions for antibiotics than cases and controls born in other months. Conclusions Men with Crohn's disease are more likely to have been born in the months of April through June.

Objectives Men who have sex with men (MSM) are at high risk of HIV-1 acquisition and transmission, yet there remains limited data in the African context, and for men who sell sex to men (MSM SW) in particular. Methods We enrolled 507 male sex workers in a Nairobi-based prospective cohort study during 2009–2012. All participants were offered HIV/STI screening, counselling and completed a baseline questionnaire. Results Baseline HIV prevalence was 40.0% (95% CI 35.8% to 44.3%). Prevalent HIV infection was associated with age, less postsecondary education, marijuana use, fewer female partners and lower rates of prior HIV testing. Most participants (73%) reported at least two of insertive anal, receptive anal and insertive vaginal sex in the past 3 months. Vaginal sex was reported by 37% of participants, and exclusive MSM status was associated with higher HIV rates. Condom use was infrequent, with approximately one-third reporting 100% condom use during anal sex. HIV incidence was 10.9 per 100 person-years (95% CI 7.4 to 15.6). Predictors of HIV risk included history of urethral discharge (aHR 0.29, 95% CI 0.08 to 0.98, p=0.046), condom use during receptive anal sex (aHR 0.05, 95% CI 0.01 to 0.41, p=0.006) and frequency of sex with male partners (aHR 1.33/sex act, 95% CI 1.01 to 1.75, p=0.04). Conclusions HIV prevalence and incidence were extremely high in Nairobi MSM SW; a combination of interventions including increasing condom use, pre-exposure prophylaxis and access to effective treatment is urgently needed to decrease HIV transmission in this key population.

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 determine whether a diagnosis of otitis media in the first 5 years of childhood is associated with the development of pediatric inflammatory bowel disease (IBD). Study design This was a nested case-control analysis of a population-based IBD database in Manitoba, Canada. A total of 294 children with IBD diagnosed between 1989 and 2008 were matched to 2377 controls, based on age, sex, and geographic region. The diagnosis of ottis media was based on physician claims. IBD status was determined based on a validated administrative database definition. Multivariate conditional logistic regression models were used to model the association between otitis media and IBD, adjusted for annual physician visits. Results Approximately 5% of the IBD cases and 12% of the controls did not have an otitis media diagnosis before that IBD case date. By age 5 years, 89% of the IBD cases had at least one diagnosis of otitis media, compared with 82% of the controls. In multivariate analyses, compared with cases and controls without an otitis media diagnosis, individuals with an otitis media diagnosis by age 5 years were 2.8-fold more likely to be an IBD case (95% CI, 1.5-5.2; P = .001). This association was detected in stratified models examining Crohn's disease and ulcerative colitis separately. Conclusion Compared with controls, subjects diagnosed with IBD were more likely to have had at least one early childhood episode of otitis media before their diagnosis. We suspect that otitis media serves as a proxy measure of antibiotic use.

Objectives We describe the characteristics of injecting drug users (IDU) in Pakistan in 2006 and 2011, and assess the heterogeneity of IDU characteristics across different cities and years as well as factors associated with HIV infection. Methods Cross-sectional, integrated behavioural-biological surveys of IDU were conducted in 10 cities across Pakistan in 2006 and 2011. Univariate and multivariable analyses were used to describe the differences in HIV prevalence and risk behaviours between cities and over time. Results Large increases in HIV prevalence among injection drug users in Pakistan were observed, with overall HIV prevalence increasing from 16.2% in 2006 to 31.0% in 2011; an increase in HIV prevalence was also seen in all geographic areas except one. There was an increase in risk behaviours between 2006 and 2011, anecdotally related to a reduction in the availability of services for IDU. In 2011, larger proportions of IDU reported injecting several times a day and using professional injectors, and fewer reported always using clean syringes. An increase in the proportion living on the street was also observed and this was associated with HIV infection. Cities differ in terms of HIV prevalence, risk profiles, and healthcare seeking behaviours. Conclusions There is a high prevalence of HIV among injection drug users in Pakistan and considerable potential for further transmission through risk behaviours. HIV prevention programs may be improved through geographic targeting of services within a city and for involving groups that interact with IDU (such as pharmacy staff and professional injectors) in harm reduction initiatives.

OBJECTIVE: To determine whether a simple monitoring and tracking tool, Mwanzo Mwema Monitoring and Tracking Tool (MMATT), would enable community health volunteers (CHVs) in Kenya to 1) plan their workloads and activities, 2) identify the women, newborns and children most in need of accessing critical maternal, newborn and child health (MNCH) interventions and 3) improve key MNCH indicators. METHODS: A mixed methods approach was used. Household surveys at baseline ( n = 912) and endline ( n = 1143) collected data on key MNCH indicators in the four subcounties of Taita Taveta County, Kenya. Eight focus group discussions were held with 40 CHVs to ascertain their perspectives on using the tool. RESULTS: Qualitative findings revealed that the CHVs found the MMATT to be useful in planning their activities and prioritizing beneficiaries requiring more support to access MNCH services. They also identified potential barriers to care at both the community and health system levels. At endline, previously pregnant women were more likely to have received four or more antenatal care visits, facility delivery, postnatal care within two weeks of delivery and a complete package of care than baseline respondents. Among women with children under 24 months, those at endline were more likely to report early breastfeeding and exclusive breastfeeding for the first six months. These results remained after adjustment for age, subcounty, gravida, mother’s education and asset index. CONCLUSION: Our results demonstrate that simple tools enable CHVs to identify disparities in service delivery and health outcomes, and to identify barriers to MNCH care. Tools that enhance CHVs’ ability to plan and prioritize the women and children most in need increase CHVs’ potential impact.

Background In Manitoba, Canada, school-based clinics providing sexual and reproductive health services for adolescents have been implemented to address high rates of sexually transmitted infections (STIs) and pregnancies. Methods The objectives of this population-based study were to compare pregnancy and STI rates between adolescents enrolled in schools with school-based clinics, those in schools without clinics, and those not enrolled in school. Data were from the PATHS Data Resource held in the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. Adolescents aged 14 to 19 between 2003 and 2009 were included in the study. Annualized rates of pregnancies and positive STI tests were estimated and Poisson regression models were used to test for differences in rates amongst the three groups. Results As a proportion, pregnancies among non-enrolled female adolescents accounted for 55 % of all pregnancies in this age group during the study period. Pregnancy rates were 2–3 times as high among non-enrolled female adolescents. Compared to adolescents enrolled in schools without school-based clinics, age-adjusted STI rates were 3.5 times (p

The objective of this study was to determine if the use of antibiotics 2-5 years before diagnosis was associated with the development of inflammatory bowel disease (IBD).This was a nested case-control analysis of the population-based University of Manitoba Inflammatory Bowel Disease Epidemiologic Database. A total of 2,234 subjects diagnosed with IBD between 2001 and 2008 were matched to 22,346 controls, based on age, sex, and geographic region. Antibiotic data were drawn from the Manitoba Drug Program Information Network, a comprehensive database of all prescription drugs for all Manitobans dating back to 1995.The mean age at diagnosis was 43.4 years. In all, 12% of cases had ≥3 prescriptions 2 years before the case date, compared with 7% of controls. The odds ratio for those receiving ≥3 dispensations 2 years before their study inclusion was 1.5 (95% confidence interval: 1.3,1.8; P0.0001) of being an IBD case. This difference in ≥3 dispensations between cases and controls was fairly consistent at 3, 4, and 5 years before IBD case date. Antibiotic dispensations were associated with both Crohn's disease (CD) and ulcerative colitis (UC), with the association nominally stronger in CD cases for ≥1 and ≥2 dispensations, while the association was stronger in UC cases for ≥3 dispensations. A dose-dependent relationship between the number of antibiotic dispensations, and the risk of IBD was observed across all years investigated.Subjects diagnosed with IBD were more likely to have been prescribed antibiotics 2-5 years before their diagnosis. This possibly implicates antibiotic use as a predisposing factor in IBD etiology.

The development of commensal flora in infants has been shown to be sensitive to antibiotic use. Altered intestinal flora is thought to contribute to the etiology of inflammatory bowel disease (IBD), an idiopathic chronic condition. We aimed to determine if early use of antibiotics was associated with the development of IBD in childhood.Nested case-control analysis of the population-based University of Manitoba Inflammatory Bowel Disease Epidemiologic Database was carried out. IBD status was determined from a validated administrative database definition. A total of 36 subjects diagnosed between 1996 and 2008 were matched to 360 controls, on the basis of age, sex, and geographic region. Antibiotic data were drawn from the Manitoba Drug Program Information Network, a comprehensive population-based database of all prescription drugs for all Manitobans dating back to 1995. Antibiotic use in the first year of life was compared between IBD cases and controls.The mean age at IBD diagnosis was 8.4 years. Twenty-one cases (58%) had one or more antibiotic dispensations in their first year of life compared with 39% of controls. Crohn's disease was diagnosed in 75% of IBD cases. Those receiving one or more dispensations of antibiotics were at 2.9 times the odds (95% confidence interval: 1.2, 7.0) of being an IBD case.Subjects diagnosed with IBD in childhood are more likely to have used antibiotics in their first year of life.

Objectives There is a dearth of published information on the characteristics of sex workers in Pakistan. This study sought to characterise and compare hijra and non-hijra sex workers from eight large cities in Pakistan. Design c 2 and KruskaleWallis tests, and multivariable logistic regression were used where appropriate. Methods Study respondents were described on demographic, sex-work, and risk behaviour variables using a cross-sectional integrated biological and behavioural quantitative survey. Results A total of 3350 respondents were surveyed, of which 2694 were included in the study. The average age of respondents was 24.1 years (SD 6.3), and the average duration of sex work was 7.5 years (SD 5.9). Respondents averaged 30.9 (SD 2.7) paid receptive anal sex acts in the month prior to their interview, while 21.5% reported using a condom during their last occurrence of paid anal sex. Of those surveyed, HIV prevalence was 5.4 per 1000; notably, no HIV-positive respondents reported any injection drug use. Finally, intercity heterogeneity was observed on demographic, sex work and risk behaviour characteristics, with almost all characteristics differing at the p

Diez Roux has used the concept of complex systems to describe approaches for the incorporation of social factors into health research. These systems consist of heterogeneous interdependent units that also exhibit emergent properties. The latter embodies the concept that the interdependent units interact with and affect each other such that the resulting properties are not simple aggregates of the individual-level properties. This paper reviews research from Manitoba with a view towards conceptualising and phrasing the observed patterns within a complex system framework. A review of the temporal and spatial patterns seen within two large sexual network databases from Manitoba was undertaken and framed against the overlying patterns of sexually transmitted infection (STI) transmission within Manitoba. The review includes a summation of STI epidemiological patterns in Manitoba over a 5-year time frame, a comparison of temporal sexual network patterns, and an analysis of network patterns in relation to disparity in STI rates. Hypotheses are generated that focus on how individual-level behaviours and interactions create the observed complex system (network) patterns.

Objectives The aim was to construct and validate algorithms for osteoporosis case ascertainment from administrative databases and to estimate the population prevalence of osteoporosis for these algorithms. Study Design and Setting Artificial neural networks, classification trees, and logistic regression were applied to hospital, physician, and pharmacy data from Manitoba, Canada. Discriminative performance and calibration (i.e., error) were compared for algorithms defined from different sets of diagnosis, prescription drug, comorbidity, and demographic variables. Algorithms were validated against a regional bone mineral density testing program. Results Discriminative performance and calibration were poorer and sensitivity was generally lower for algorithms based on diagnosis codes alone than for algorithms based on an expanded set of data features that included osteoporosis prescriptions and age. Validation measures were similar for neural networks and classification trees, but prevalence estimates were lower for the former model. Conclusion Multiple features of administrative data generally resulted in improved sensitivity of osteoporosis case-detection algorithm without loss of specificity. However, prevalence estimates using an expanded set of features were still slightly lower than estimates from a population-based study with primary data collection. The classification methods developed in this study can be extended to other chronic diseases for which there may be multiple markers in administrative data.

Dans cette étude, on a estimé la concordance entre les données des populations administratives et les données des populations d'enquête lorsqu'il s'agit de déterminer les cas d'arthrite, d'asthme, de diabète, de cardiopathie, d'hypertension et d'accident vasculaire cérébral. Des définitions de cas de maladies chroniques, qui variaient de par la source des données, le nombre d'années de données et les codes de diagnostic et de médicaments prescrits employés, ont été élaborées à partir des données administratives du Manitoba. Un recoupement a ensuite été fait entre ces données et celles tirées de l'Enquête sur la santé dans les collectivités canadiennes. La concordance entre ces deux sources de données, estimée par le coefficient κ, a été calculée pour chaque définition de cas, et les différences ont été testées. Les variables socio-démographiques et les variables liées à la comorbidité en lien avec la concordance ont été testées au moyen d'une régression logistique pondérée. C'est pour le diabète et l'hypertension que l'on a observé la concordance la plus élevée, et pour l'arthrite que l'on a observé la concordance la plus faible. Les éléments de la définition de cas qui contribuaient à la concordance la plus élevée entre les deux sources de données des populations variaient selon les maladies chroniques. Il est probable que les données administratives et les données d'enquête concordent peu dans le cas des affections qui sont difficiles à diagnostiquer, mais cette concordance est aussi influencée par les caractéristiques socio-démographiques et l'état de santé des individus. Toute définition de cas de maladie chronique fondée sur des données administratives devrait être accompagnée d'une justification du choix de chacun de ses éléments.

This study estimated agreement between population-based administrative and survey data for ascertaining cases of arthritis, asthma, diabetes, heart disease, hypertension and stroke. Chronic disease case definitions that varied by data source, number of years and number of diagnosis or prescription drug codes were constructed from Manitoba's administrative data. These data were linked to the Canadian Community Health Survey. Agreement between the two data sources, estimated by the κ coefficient, was calculated for each case definition, and differences were tested. Socio-demographic and comorbidity variables associated with agreement were tested using weighted logistic regression. Agreement was strongest for diabetes and hypertension and lowest for arthritis. The case definition elements that contributed to the highest agreement between the two population-based data sources varied across the chronic diseases. Low agreement between administrative and survey data is likely to occur for conditions that are difficult to diagnose, but will be mediated by individual socio-demographic and health status characteristics. Construction of a chronic disease case definition from administrative data should be accompanied by a justification for the choice of each of its elements.

Aims Despite the establishment of syringe exchange programmes, syringe-sharing behaviour remains common among some injection drug users (IDU). Previous studies have identified several individual- and social network-level variables associated with syringe sharing. We examine the extent to which each of these variables is related independently to this behaviour within a diverse study population. Design, setting and participants A cross-sectional survey of 435 IDU conducted between December 2003 and September 2004 in Winnipeg, Canada. Measurements Individual and social-network variables were obtained from a survey instrument administered through a personal interview. Syringe sharing was defined as receptive syringe sharing in the last 6 months. Logistic regression analysis with generalized estimating equations was used to determine simultaneously the role of individual-level and risk network member-level variables on the odds of syringe sharing. Findings Individuals' relationship to a risk network member (sex partner, OR: 15.3 95% CI: 7.6–30.8; family member, OR: 3.4 95% CI: 1.3–9.0) and difficulty of access to syringes (OR: 3.6 95% CI: 1.3–9.9) were predictive of syringe sharing. Dyads who ‘often’ pooled resources to obtain drugs were at 4.9 times (95% CI: 2.1–11.6) the odds of syringe sharing, while those who ‘sometimes’ pooled resources were at 2.8 times (95% CI: 1.1–6.7) the odds, compared to those who ‘never’ pooled resources together. Conclusions Syringe sharing in this population depended on both the availability of clean syringes and social network relationships. Adopting interventions that take into account relationships and behaviours that shape social norms present in networks/dyads would be a necessary prevention strategy alongside the provision of clean syringes.

The variable infectivity and transmissibility of HIV/SHIV has been recently associated with the menstrual cycle, with particular susceptibility observed during the luteal phase in nonhuman primate models and ex vivo human explant cultures, but the mechanism is poorly understood. Here, we performed an unbiased, mass spectrometry-based proteomic analysis to better understand the mucosal immunological processes underpinning this observed susceptibility to HIV infection. Cervicovaginal lavage samples ( n = 19) were collected, characterized as follicular or luteal phase using days since last menstrual period, and analyzed by tandem mass spectrometry. Biological insights from these data were gained using a spectrum of computational methods, including hierarchical clustering, pathway analysis, gene set enrichment analysis, and partial least-squares discriminant analysis with LASSO feature selection. Of the 384 proteins identified, 43 were differentially abundant between phases ( P < 0.05, ≥2-fold change). Cell-cell adhesion proteins and antiproteases were reduced, and leukocyte recruitment (interleukin-8 pathway, P = 1.41E–5) and extravasation proteins ( P = 5.62E–4) were elevated during the luteal phase. LASSO/PLSDA identified a minimal profile of 18 proteins that best distinguished the luteal phase. This profile included cytoskeletal elements and proteases known to be involved in cellular movement. Gene set enrichment analysis associated CD4 + T cell and neutrophil gene set signatures with the luteal phase ( P < 0.05). Taken together, our findings indicate a strong association between proteins involved in tissue remodeling and leukocyte infiltration with the luteal phase, which may represent potential hormone-associated mechanisms of increased susceptibility to HIV. IMPORTANCE Recent studies have discovered an enhanced susceptibility to HIV infection during the progesterone-dominant luteal phase of the menstrual cycle. However, the mechanism responsible for this enhanced susceptibility has not yet been determined. Understanding the source of this vulnerability will be important for designing efficacious HIV prevention technologies for women. Furthermore, these findings may also be extrapolated to better understand the impact of exogenous hormone application, such as the use of hormonal contraceptives, on HIV acquisition risk. Hormonal contraceptives are the most widely used contraceptive method in sub-Saharan Africa, the most HIV-burdened area of the world. For this reason, research conducted to better understand how hormones impact host immunity and susceptibility factors important for HIV infection is a global health priority.

Reactivation of latent Mycobacterium tuberculosis infection is an important health concern for patients on hemodialysis because of their immunosuppressed state and in kidney transplant patients receiving immunosuppressive therapy to prevent organ rejection. There are several tests available to determine the presence of latent tuberculosis infection: the tuberculin skin test (TST), QuantiFERON-TB Gold (QFT-G), and T-SPOT.TB. The objective of this study is to evaluate the diagnostic accuracy of these tests in determining latent tuberculosis infection in the hemodialysis population.The study design was a systematic review. We selected studies with adequate information to ascertain test sensitivity or specificity of the TST, QFT-G, and TSPOT.TB with regards to determining latent tuberculosis infection in the hemodialysis population.One hundred two articles were selected for full review, and 17 were included in the meta-analysis. The TST had a pooled sensitivity of 31% (26%-36%, 95% confidence interval) and specificity of 63% (60%-65%) across eight studies. The QFT-G test had a pooled sensitivity of 53% (46%-59%) and specificity of 69% (65%-72%) across nine studies. The T-SPOT.TB test had a pooled sensitivity of 50% (42%-59%) and specificity of 67% (61%-73%) across three studies.The QFT-G and the T-SPOT.TB tests were more sensitive than the TST for diagnosis of latent tuberculosis infection in patients on hemodialysis while offering a comparable level of specificity. This systematic review calls into question the practice of using the TST to screen in this population, especially in patients considered for kidney transplantation.

Global literature on female sex workers suggests that being in an intimate relationship is associated with barriers to practising safe sex behaviours. Condom use within intimate relationships is often seen as a sign of infidelity and fosters mistrust which could affect longevity, trust and intimacy within partnerships. Using qualitative data from Devadasi sex workers and their intimate male partners in Bagalkot District, Karnataka, India, we examined both partners' perspectives to understand the quality and dynamics of these relationships and the factors that influence condom use in intimate relationships. Our thematic analysis of individual interviews conducted in May 2011 with 20 couples suggests that many Devadasi sex workers and their intimate partners define their relationships as 'like marriage' which reduced their motivation to use condoms. Evidence from this study suggests that active participation in sex workers' collectives (sanghas) can increase condom use, education and family planning services, among other things, and could be helpful for both Devadasis and their intimate partners to better understand and accept safer sexual practices. Our work has direct implications for designing couple-based health interventions for traditional Devadasi sex workers and their intimate partners in India.

Background The prevention of mother-to-child transmission of human immunodeficiency virus (HIV) is lauded as one of the more successful HIV prevention measures. However, despite some gains in the prevention of mother-to-child transmission of HIV (PMTCT) in sub-Saharan Africa, mother-to-child transmission rates are still high. In Kenya, mother-to-child transmission is considered one of the greatest health challenges and scaling up PMTCT services is crucial to its elimination by 2015. However, guideline implementation faces barriers that challenge scale-up of services. The objective of this paper is to identify barriers to PMTCT implementation in the context of a randomized control trial on the use of structured mobile phone messages in PMTCT. Methods The preliminary analysis presented here is based on survey data collected during enrolment in PMTCT services at one of two health facilities in Nairobi, Kenya, with overall number of antenatal care (ANC) visits determined from 48 hour follow up data. Results Data was collected for 503 women. Despite significant differences in the type of facility and sample characteristics between sites, all women presented to care at 20 weeks gestation or later and 88.8% attended less than four ANC visits. PMTCT counselling at first visit had high coverage (86%), however less than a third of women (31.34%) reported receiving contraception counselling. Although 60.8% of women had reportedly disclosed their status to their partners, only 40% were aware of their partner’s status. Very few women had been tested for TB (10%) or received single dose nevirapine during their first antenatal care appointment (20%). Conclusion Revised PMTCT guidelines aim to reduce the inequity between PMTCT services in high and low resource settings in efforts to eliminate mother-to-child transmission. However, guideline implementation in low resource settings continues to be confronted with challenges related to late presentation, less than four ANC visits, low screening rates for opportunistic infections, and limited contraception counselling. These challenges are further complicated by lack of disclosure to partners. Effective scale up and implementation of PMTCT services requires that such ongoing program challenges be identified and appropriately addressed within the local context.

The objective of this study was to perform a meta-analysis investigating antibiotic exposure as a risk factor for developing inflammatory bowel disease (IBD).A literature search using Medline, Embase, and Cochrane databases was performed to identify studies providing data on the association between antibiotic use and newly diagnosed IBD. Included studies reported Crohn's disease (CD), ulcerative colitis (UC), or a composite of both (IBD) as the primary outcome and evaluated antibiotic exposure before being diagnosed with IBD. A random-effects meta-analysis was conducted to determine overall pooled estimates and 95% confidence intervals (CIs).A total of 11 observational studies (8 case-control and 3 cohort) including 7,208 patients diagnosed with IBD were analyzed. The pooled odds ratio (OR) for IBD among patients exposed to any antibiotic was 1.57 (95% CI 1.27-1.94). Antibiotic exposure was significantly associated with CD (OR 1.74, 95% CI 1.35-2.23) but was not significant for UC (OR 1.08, 95% CI 0.91-1.27). Exposure to antibiotics most markedly increased the risk of CD in children (OR 2.75, 95% CI 1.72-4.38). All antibiotics were associated with IBD, with the exception of penicillin. Exposure to metronidazole (OR 5.01, 95% CI 1.65-15.25) or fluoroquinolones (OR 1.79, 95% CI 1.03-3.12) was most strongly associated with new-onset IBD.Exposure to antibiotics appears to increase the odds of being newly diagnosed with CD but not UC. This risk is most marked in children diagnosed with CD.

Objective We previously identified a high prevalence of Hepatitis C (HCV) amongst solvent-using injection drug users (S-IDU) relative to other injection drug users within the same locality. Here we incorporated social network variables to better characterize some of the behavioural characteristics that may be putting this specific subgroup of IDU at elevated disease risk. Methods A cross-sectional survey of at-risk populations was carried out in Winnipeg, Canada in 2009. Individuals reporting any history of injection drug and/or solvent use were included in the study. Associations between subgroup membership, infection with HCV and HIV and individual and social network variables were examined. Results In relation to other IDU, S-IDU were more likely to be infected with HCV, to report ever having shared a syringe, and to associate with other IDU. They were further differentiated in terms of their self-reported sexual orientation, ethnicity and in the injection drugs typically used. Conclusion Solvent use stands as a proxy measure of numerous other characteristics that put this group of IDU at higher risk of infection. Provision of adequate services to ostracized subpopulations may result in wider population-level benefits.

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing. Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID. The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19–5.74) and 1.99 (95% CI, 0.94–4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27–6.26), followed by those in Lahore, Quetta, and Faisalabad. Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely to monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local subepidemics.

OBJECTIVES: There is a lack of information on sexual violence (SV) among men who have sex with men and transgendered individuals (MSM-T) in southern India. As SV has been associated with HIV vulnerability, this study examined health related behaviours and practices associated with SV among MSM-T. DESIGN: Data were from cross-sectional surveys from four districts in Karnataka, India. METHODS: Multivariable logistic regression models were constructed to examine factors related to SV. Multivariable negative binomial regression models examined the association between physician visits and SV. RESULTS: A total of 543 MSM-T were included in the study. Prevalence of SV was 18% in the past year. HIV prevalence among those reporting SV was 20%, compared to 12% among those not reporting SV (p = .104). In multivariable models, and among sex workers, those reporting SV were more likely to report anal sex with 5+ casual sex partners in the past week (AOR: 4.1; 95%CI: 1.2-14.3, p = .029). Increased physician visits among those reporting SV was reported only for those involved in sex work (ARR: 1.7; 95%CI: 1.1-2.7, p = .012). CONCLUSIONS: These results demonstrate high levels of SV among MSM-T populations, highlighting the importance of integrating interventions to reduce violence as part of HIV prevention programs and health services. Language: en

Introduction Research on the HIV vulnerability of men who have sex with men (MSM) in India has tended to focus on aggregates of individual risk behaviours. However, such an approach often overlooks the complexities in the sexual networks that ultimately underpin patterns of spread. This paper analyses a set of sexual contact network (SCN) snapshots in relation to ethnographic findings to reorientate individual-level explanations of risk behaviour in terms of more complex systems. Methods Fifteen community researchers conducted a 2-month ethnographic study in three cities in Karnataka to generate descriptions of the risk environments inhabited by MSM. SCNs were reconstructed by two methods. First, initial participants, defined as nodes of various sexual networks, were purposively sampled. In each site, six nodes brought in three sexual partners separately as participants. In all sites, 72 participants completed 431 surveys for their 7-day sexual partners. Second, each site determined four groups representing various sexual networks, each group containing four individuals. In all sites, 48 participants completed 334 surveys for their regular sexual partner. Results Considerable differences were observed between sites for practically all included behavioural variables. On their own, these characteristics yielded contradictory interpretations with respect to understanding contrasts in HIV prevalence at each site. However, viewing these variables in relation to SCNs and ethnographic data produced non-linear interpretations of HIV vulnerability which suggested importance to local interventions. Conclusion SCN data may be used with existing data on risk behaviour and the structural determinants of vulnerability to re-tailor more tightly focused interventions.

BACKGROUND: This study investigated the structural-environmental and individual-level social factors associated with the numbers of commercial sex clients of female sex workers (FSWs) per month (CPM). METHODS: Data were analyzed from cross-sectional surveys of FSWs in 5 districts in Karnataka state India (2004-2005). Bivariate and multivariable negative binomial regression models with generalized estimating equations were constructed for each district. Normalized weights were used to account for complex sampling design. RESULTS: Median (average) CPM varied significantly (P < 0.001) across districts from 40.0 (56.9) CPM in the district with the highest immunodeficiency virus prevalence (33.9%) to 16.0 (26.1) in the district with the lowest prevalence (9.7%). In multivariable analysis there was a significant positive association between rates of CPM and sex work as sole income in 4 districts (adjusted incidence rate ratios AIRR: [95% confidence intervals]: AIRR: 1.3 [1.0-1.7] P < 0.005-1.7 [1.2-2.5] P < 0.01); age typology (place of solicitation) and marital status were significantly associated with CPM in 3 districts with an inverse association between age and CPM (P < 0.01). FSWs soliciting clients in brothels had higher rates of CPM than home-based FSWs in 2 districts (AIRR: 1.5 [1.1-2.0]-1.6 [1.0-2.7] P < 0.05) whereas public places-based FSWs had higher rates in 1 district (AIRR: 1.4 [1.1-1.8] P < 0.01); cohabiting FSWs had higher rates than married FSWs in 3 districts whereas single FSWs had higher rates in one district. CONCLUSIONS: These results provide support for the continued development of structural core group interventions that address common elements of sex work placing FSWs at higher risk for immunodeficiency virus as well as geographically focused programs that account for local differences in sexual structure.