Alok Agrawal

High HIV burden among people who inject drugs in 15 Indian cities.

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

Delivery models of opioid agonist maintenance treatment in South Asia: a good beginning

An estimated 6.5 to 13.2 million people with opioid dependence, representing more than half of the world’s estimated number, live in Asia.1 Although most people in Asia who are opioid dependent use heroin or opium, the use of pharmaceutical opioids, mainly through the injecting route, has raised concern in recent years.2 In South Asia – Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka – the estimated number of people who inject drugs illicitly ranges from 434 000 to 726 500. Of these people, from 34 500 to 135 500 are infected with the human immunodeficiency virus (HIV).3 Three countries in South Asia – Bangladesh, India and Nepal – have large numbers of people who inject drugs, many of whom are infected with HIV. In the Maldives, the population of people who inject drugs is also large.4 In response to the large burden of opioid injection, Bangladesh, India and Nepal have established needle and syringe programmes. In Bangladesh and India these programmes have been rapidly scaled up.2,5 However, this cannot be said for the use of opioid agonist maintenance treatment (alternatively known in South Asia as “opioid substitution therapy”), which is lagging far behind. This form of treatment for opioid dependence has been recognized as effective in preventing infection with HIV and in increasing adherence to antiretroviral treatment (ART); accordingly, it has been endorsed by different United Nations agencies, including the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO).6–9 The two opioid agonists most commonly used to treat opioid dependence, buprenorphine and methadone, are on WHO’s model list of essential medicines.10 A WHO collaborative multi-country study has established the effectiveness of opioid agonist maintenance treatment in developing countries.11 Different delivery models have been implemented across the world, and studies have several positive outcomes, including reductions in drug use, injecting behaviour, incidence of HIV infection, criminality and drug overdose.12,13 Opioid agonist maintenance treatment has not yet been integrated into routine health care in South Asia, a term used in this paper to refer to the six countries represented by the UNODC’s Regional Office for South Asia: Bangladesh, Bhutan, India, the Maldives, Nepal and Sri Lanka. A global review in 2010 showed that opioid agonist maintenance treatment is available in India, the Maldives and Nepal.5 Bangladesh also initiated opioid agonist maintenance treatment in 2010.2,14 In our experience while working closely with these six South Asian countries and as revealed by a review of the published literature, only four of them – Bangladesh, India, the Maldives and Nepal – have implemented opioid agonist maintenance treatment. Coverage, however, has been abysmally low; according to the global review, the percentage of people injecting opioids who receive opioid agonist maintenance treatment is only 1 to 3%.5 Ensuring optimal coverage is vital to these countries’ efforts to maximize HIV prevention among people who inject opioids. In countries of South Asia, opioid dependence has been traditionally considered a psychosocial rather than a biopsychosocial problem. The conventional approach to reducing the demand for opioids has centred on prevention and abstinence and on short-term withdrawal management followed by psychosocial intervention or rehabilitation. A report published in 2000 documented different types of interventions in South Asia, from preventive education to placement in therapeutic communities.15 Long-term pharmacotherapy, which is the mainstay of treatment for opioid dependence, was not mentioned among them except for an anecdotal mention of a methadone maintenance treatment clinic in Nepal.15 Most interventions based on short-term treatment or rehabilitation are run by nongovernmental organizations (NGOs) with some support from the government. The concept of drug dependence as a chronic, relapsing condition requiring medical treatment is poorly understood, as reflected in the limited availability of treatment services or qualitative policy research studies on the subject.16 Equally misunderstood is the concept behind opioid agonist maintenance treatment, which involves administering narcotics or psychotropics for the long term. This lack of understanding is also manifested in the low availability of narcotics or psychotropics for the treatment of other chronic medical symptoms and conditions, such as pain in cancer patients.17 Another problem is that existing models based on the delivery of opioid agonist maintenance treatment through exclusive clinics, licensed pharmacies or office-based prescription, which are typical of high-income countries, cannot be directly applied in South Asia. The infrastructure, availability of health-care professionals and regulatory mechanisms for pharmacies and health-care practitioners in countries of this region seldom allow it. Through one of its projects, the United Nations Office on Drugs and Crime in South Asia has assisted most countries in developing models for the delivery of opioid agonist maintenance treatment. Although the models adopted by these countries have certain similarities, they differ in terms of setting, human resources for treatment delivery, and location of medical, psychosocial and outreach services for clients. In the following section we briefly present an overview of models – as case examples – adopted for the delivery of opioid agonist maintenance treatment in those four countries of South Asia where this intervention is in place.

Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs.

INTRODUCTION AND AIMS Injecting pharmaceutical opioids for non-medical purposes is a major concern globally. Though pharmaceutical opioids injection is reported in India, the exact proportion of people who inject drugs (PWID) using pharmaceutical opioids is unknown. The objectives of this study were to describe the various types of drugs that are injected by people in India and to analyse the differences between the commonly injected drugs. DESIGN AND METHODS A cross-sectional, multicentric study covering 22 harm-reduction sites from different regions of the country was conducted. First 50 subjects, chosen randomly from a list of PWIDs accessing services from each site and fulfilling study criteria, were interviewed using a structured questionnaire. Data from 902 male subjects are presented here. RESULTS Pharmaceutical opioid injectors (POI) accounted for 65% of PWIDs (buprenorphine: 30.8%, pentazocine: 21.8% and dextropropoxyphene: 11.9%). Heroin, injected by 34.3%, was prevalent in most states surveyed. Buprenorphine and pentazocine were not injected in the north-east region, whereas dextropropoxyphene was injected in the north-east alone. Univariate and multivariate logistic regression showed that, compared with heroin injectors, the POI group was more likely to consume alcohol and pharmaceutical opioids orally, inject frequently, share needle/syringes and develop injection-site complications. Among individual POIs, buprenorphine injectors had significantly higher proportion of subjects injecting frequently, sharing needle/syringes and developing local complications. Irrespective of the opioid type, majority of subjects were opioid dependent. DISCUSSION AND CONCLUSIONS Pharmaceutical opioids are the most common drugs injected in India currently and have greater injection-related risks and complications. Significant differences exist between different pharmaceutical opioids, which would be important considerations for interventions.

Scale-up of opioid substitution therapy in India: Opportunities and challenges

The National AIDS Control Programme of India (NACO) has been elivering targeted interventions for high risk groups since 1996. urveillance data for 2008–2009 confirms declining HIV infections mongst female sex workers but there has been an increasing trend n many states amongst injecting drug users (IDUs); the current ational HIV prevalence amongst IDUs is 9.2% (NACO, 2010). The umber of IDU targeted interventions has increased from 90 by the nd of 2007 to 268 in July 2011 covering approximately 142 000 DUs (80% of the estimated 177 000 IDUs) with interventions such s needle syringe distribution, condom provision, HIV counselling nd testing and treatment of sexually transmitted infections. A ecent review of harm reduction interventions commissioned by ACO with support from the UK Department for International evelopment (DFID) identifies various challenges in IDU related nterventions; it highlights the significance of scale-up of opioid ubstitution therapy (OST) for IDUs in India (Kumar, Srikrishnan, oseph, & Dhanikachalam, 2011). India’s OST has a long history of small pilots and projects; uprenorphine treatment for opioid dependence as “long-term aintenance” was started in 1989 by the All India Institute of edical Sciences, and the first community based programme with ublingual buprenorphine was established in New Delhi in 1993 y SHARAN, a non-governmental organisation (NGO). This led to he initiation of a buprenorphine treatment project in New Delhi, mphal, Kolkata, Chennai and Mumbai in 1999 implemented by even NGOs. Though the project demonstrated declines in HIV elated risk behaviours amongst clients, it could not be sustained fter international funding ceased in 2002. After a gap, the DFID hallenge Fund supported a collaborative initiative to scale up HIV revention amongst IDUs across various states during 2006–2007. uring this project, trainings for health workers and clinical staff ere conducted; and treatment protocols for OST were established efore implementation of OST. Through drop-in-centres estabished by NGOs, OST was administered through directly observed reatment strategy and this ensured that there was no diversion f medication. The success of the OST project paved the way for eamless transition to governmental support for OST.

Early onset obsessive compulsive disorder with obsessive slowness: A case report and demonstration of management

Obsessive slowness is a rare entity and is conceptualized either as primary psychiatric illness or as part of obsessive compulsive disorder (OCD). Often its outcome is frustrating even with treatment. We report a case of early onset severe OCD with obsessive slowness which showed good response to combined pharmacotherapy and behavioral therapy.

Pattern of Drug Use and Associated Behaviors Among Female Injecting Drug Users From Northeast India: A Multi-Centric, Cross-Sectional, Comparative Study

Background: Studies from developed countries document the presence of injecting drug use among females and significantly higher vulnerabilities and risks as compared with male injecting drug users (IDUs). Studies comparing vulnerabilities and drug use patterns between female and male IDUs are not available for developing countries. Objectives: The aim of the study was to assess the drug use pattern and related HIV vulnerabilities among female IDUs and compare these findings with those from male IDUs from four states of Northeast India. Method: The study used data collected as part of a nationwide study of drug use pattern and related HIV vulnerabilities among IDUs. Ninety-eight female and 202 male IDUs accessing services from harm reduction sites across the four states of Northeast region of India were chosen through random sampling methodology. Drug use pattern, injecting practices, and knowledge of HIV were assessed using a structured questionnaire. Results: Significantly higher proportion of female IDUs was uneducated, unemployed, reported their occupation as sex workers, and switched to injecting drug use faster as compared with male IDUs. Female IDUs practicing sex work differed significantly from those who did not with respect to frequency of daily injections, choice of drugs injected, and concomitant use of non-injecting drugs. More than half of female IDUs initiated sharing within the first month of injecting. Conclusions: The study demonstrates that female IDUs differ from male IDUs in their drug use pattern, initiation into injection as well as injecting behavior, which would be an important consideration during designing of female-specific interventions.

Genetic algorithm based intelligent station-keeping for spherical underwater robot

In this paper, a spherical underwater robot is proposed that uses six degree of freedom thrust allocator to determine the magnitude and the direction of thrust required for each water-jetted bilge pump thruster to create force and moment equilibrium. However, in order to ensure safe operation of the underwater robot it is equipped with redundant thruster configuration and therefore is over-actuated. Therefore, the choice of a particular solution for thrust allocation is found using an optimization process. In this work, the thrust allocation problem is formulated as an optimization problem, with an objective to minimize the total power consumption of the spherical underwater robot. A set of all physically realizable surge, sway and heave force for the ith thruster is called as its Attainable Thrust Region (ATR). Since the thrust force produced by each thruster is restricted to its ATR, the power consumption of underwater robot is determined by establishing a relationship between the power consumption and the thrust of an individual bilge pump. The formulated optimal thrust allocation problem is solved using Mincon (Sequential Quadratic Programming) and GA (Genetic Algorithm) optimization algorithm. The percentage savings in total power consumption for thruster system using the GA as compared to Mincon method is 33.82 %.

Pelvic trauma in women of reproductive age

The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.The pelvic trauma can be a simple isolated one or can involve multiple skeletal structures or viscera also. Women of childbearing age who suffer from pelvic trauma have always a question in their mind regarding the future fertility and type of delivery they are going to have. The final functional outcome of pelvic injury depends on the severity of trauma and the type of surgical management. The aim of this article is to review the female pelvic anatomy, pelvic injuries, management options and future reproductive potential and other impacts of pelvic trauma in women of childbearing age.

Introduction to pelvic injury and its acute management

Human pelvis is a very stable structure. It achieves its stability from the surrounding musculature and ligaments. Hence, pelvic disruption requires high energy trauma specifically in young people. It is usually associated with multisystem injuries due to its close proximity to the vital structures. Mortality in pelvic injuries is mostly due to the uncontrolled hemorrhage and the late mortality due to associated multisystem injuries, multiorgan failure, and sepsis. Acute management focus on the complex pelvic trauma it includes the systemic control of hemorrhage, pelvic stabilization with external pelvic binder or external fixator, use of pelvic angiography, and embolization and preperitoneal packing. Every institute should develop its own protocol depending on facilities available.

Energy-efficient optimal thrust allocation for spherical underwater robot

In this paper, a spherical underwater robot uses optimal thrust allocator to determine the magnitude and the direction of thrust required for each water-jetted bilge pump thruster to create force and moment equilibrium. However, in order to ensure safe operation of the underwater robot it is equipped with redundant thruster configuration and therefore is over-actuated. Therefore, the choice of a particular solution for thrust allocation is found using an optimization process. In this work, the thrust allocation problem is formulated as an optimization problem, with an objective to minimize the total power consumption of the spherical underwater robot. The power consumption of underwater robot depends on the thrust generated by each bilge pump. The relationship between the power consumption and the thrust of the bilge pump is established using experimental data. The formulated optimal thrust allocation problem is solved using Mincon (Sequential Quadratic Programming) and SA (Simulated Annealing) optimization algorithm. The percentage savings in total power consumption for thruster system using the SA method as compared to Mincon method is 50.6 %.