Ajay Khera

Assessment of population-level effect of Avahan, an HIV-prevention initiative in India

BACKGROUND The aim of Avahan, the India AIDS Initiative, was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups. It was launched in 2003 in six states with a total population of 300 million and a high HIV burden. We assessed the population-level effect of the first phase of Avahan (2003-08). METHODS Population prevalence was estimated by use of adjustment factors from the national HIV sentinel surveillance data obtained annually from antenatal clinics. A mixed-effects multilevel regression model was developed to estimate the association between intervention intensity and population HIV prevalence trends, taking into account differences in the underlying epidemic trends in states and other potential confounders, and to estimate the number of HIV infections averted with Avahan. FINDINGS 80 (61%) of 131 districts in the six Avahan states received funding from Avahan for HIV prevention, as the only or shared source. Greater intensity of Avahan, measured as amount of grant per HIV population (medians US

HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes

24-432 in the six states), was significantly associated with lower HIV prevalence in Andhra Pradesh (p=0·004), Karnataka (p=0·004), and Maharashtra (p=0·008) states; this association was not significant in Tamil Nadu (p=0·06), Manipur (p=0·62), and Nagaland (p=0·67). Overall, we estimated that 100,178 HIV infections (95% CI 25,897-207,713) were averted at the population level from 2003 up to 2008 as a result of Avahan. INTERPRETATION The results of our analysis suggest that Avahan had a beneficial effect in reducing HIV prevalence at the population level over 5 years of programme implementation in some of the states. With stagnating funding for HIV prevention globally, our findings support investment in well planned and managed HIV prevention programmes in low-income and middle-income countries. FUNDING Bill & Melinda Gates Foundation.

Analysis of the Universal Immunization Programme and introduction of a rotavirus vaccine in India with IndiaSim.

Objective To determine the rates of death and infection from HIV in India. Design Nationally representative survey of deaths. Setting 1.1 million homes in India. Population 123 000 deaths at all ages from 2001 to 2003. Main outcome measures HIV mortality and infection. Results HIV accounted for 8.1% (99% confidence interval 5.0% to 11.2%) of all deaths among adults aged 25-34 years. In this age group, about 40% of deaths from HIV were due to AIDS, 26% were due to tuberculosis, and the rest were attributable to other causes. Nationally, HIV infection accounted for about 100 000 (59 000 to 140 000) deaths or 3.2% (1.9% to 4.6%) of all deaths among people aged 15-59 years. Deaths from HIV were concentrated in the states and districts with higher HIV prevalence and in men. The mortality results imply an HIV prevalence at age 15-49 years of 0.26% (0.13% to 0.39%) in 2004, comparable to results from a 2005/6 household survey that tested for HIV (0.28%). Collectively, these data suggest that India had about 1.4-1.6 million HIV infected adults aged 15-49 years in 2004-6, about 40% lower than the official estimate of 2.3 million for 2006. All cause mortality increased in men aged 25-34 years between 1997 and 2002 in the states with higher HIV prevalence but declined after that. HIV prevalence in young pregnant women, a proxy measure of incidence in the general population, fell between 2000 and 2007. Thus, HIV mortality and prevalence may have fallen further since our study. Conclusion HIV attributable death and infection in India is substantial, although it is lower than previously estimated.

Measles mortality in high and low burden districts of India: Estimates from a nationally representative study of over 12,000 child deaths

BACKGROUND AND OBJECTIVES India has the highest under-five death toll globally, approximately 20% of which is attributed to vaccine-preventable diseases. Indias Universal Immunization Programme (UIP) is working both to increase immunization coverage and to introduce new vaccines. Here, we analyze the disease and financial burden alleviated across Indias population (by wealth quintile, rural or urban area, and state) through increasing vaccination rates and introducing a rotavirus vaccine. METHODS We use IndiaSim, a simulated agent-based model (ABM) of the Indian population (including socio-economic characteristics and immunization status) and the health system to model three interventions. In the first intervention, a rotavirus vaccine is introduced at the current DPT3 immunization coverage level in India. In the second intervention, coverage of three doses of rotavirus and DPT and one dose of the measles vaccine are increased to 90% randomly across the population. In the third, we evaluate an increase in immunization coverage to 90% through targeted increases in rural and urban regions (across all states) that are below that level at baseline. For each intervention, we evaluate the disease and financial burden alleviated, costs incurred, and the cost per disability-adjusted life-year (DALY) averted. RESULTS Baseline immunization coverage is low and has a large variance across population segments and regions. Targeting specific regions can approximately equate the rural and urban immunization rates. Introducing a rotavirus vaccine at the current DPT3 level (intervention one) averts 34.7 (95% uncertainty range [UR], 31.7-37.7) deaths and

Linking HIV-Infected TB Patients to Cotrimoxazole Prophylaxis and Antiretroviral Treatment in India

215,569 (95% UR,

Male use of female sex work in India: a nationally representative behavioural survey.

207,846-

The World Health Organization Measles Programmatic Risk Assessment Tool—Pilot Testing in India, 2014

223,292) out-of-pocket (OOP) expenditure per 100,000 under-five children. Increasing all immunization rates to 90% (intervention two) averts an additional 22.1 (95% UR, 18.6-25.7) deaths and

Insights from global data for use of rotavirus vaccines in India

45,914 (95% UR,

Why is the oral cholera vaccine not considered an option for prevention of cholera in India? Analysis of possible reasons.

37,909-

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative

53,920) OOP expenditure. Scaling up immunization by targeting regions with low coverage (intervention three) averts a slightly higher number of deaths and OOP expenditure. The reduced burden of rotavirus diarrhea is the primary driver of the estimated health and economic benefits in all intervention scenarios. All three interventions are cost saving. CONCLUSION Improving immunization coverage and the introduction of a rotavirus vaccine significantly alleviates disease and financial burden in Indian households. Population subgroups or regions with low existing immunization coverage benefit the most from the intervention. Increasing coverage by targeting those subgroups alleviates the burden more than simply increasing coverage in the population at large.