M. Suresh Kumar

High Prevalence of Hiv, Hiv/hepatitis C Virus Coinfection, and Risk Behaviors Among Injection Drug Users in Chennai, India: A Cause for Concern

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

Risk factors for HIV infection in injection drug users and evidence for onward transmission of HIV to their sexual partners in Chennai India.

Objectives:Determining HIV prevalence in injection drug users (IDUs) and their regular sex partners in Chennai, India. Methods:A total of 226 IDUs and their regular sex partners were enrolled during April-July 2003. After informed consent was obtained, a semistructured questionnaire was administered and serum was tested for HIV antibody. Results:The HIV seroprevalence was 30% (68/226) in IDUs and 5% in their regular sex partners (11/226). While in 25% of couples only the male partner was HIV positive, 5% of the couples were concordant for HIV infection and 70% were HIV negative. Fifty-seven percent of the HIV-positive IDUs and 45% of the HIV-infected women thought that they had “no chance” or “very little chance” of getting HIV, reflecting low HIV risk perception. More than 20% IDUs reported borrowing or lending of injection equipment. In univariate analyses “sex” and “condom use” with sex workers had no bearing but “more than twice a day injecting frequency,” “history of incarceration,” “tattoos,” “recruitment from northern part of the city,” and ever-injecting drugs in drug-selling places had significant association with HIV infection in IDUs. In an adjusted model, the odds of HIV infection were 2 times higher among IDUs who had ever injected drugs in drug-selling places and 6 times higher in those who were recruited from the northern part of central Chennai. Conclusion:Reducing sharing of injection equipment and unsafe tattooing through targeted and environmental interventions, increasing HIV risk perception, and promoting safer sex practices among IDUs and their sex partners are urgent program needs.

Prevalence of Posttraumatic Stress Disorder in a Coastal Fishing Village in Tamil Nadu, India, After the December 2004 Tsunami

Two months after the December 2004 tsunami in Tamil Nadu, India, we surveyed adults aged 18 years or older in a severely affected coastal village using structured interviews and the Harvard Trauma Questionnaire. The prevalence of posttraumatic stress disorder was 12.7% (95% confidence interval [CI]=9.4%, 17.1%), and odds of posttraumatic stress disorder were higher among individuals with no household incomes, women, and those injured during the tsunami. In addition to promoting feelings of safety, interventions aimed toward populations affected by the December 2004 tsunami need to focus on income-generating activities. Also, there is a need to target initiatives toward women and those individuals injured during the tsunami, given that these groups are more likely to experience posttraumatic stress disorder.

The profile of injection drug users in Chennai, India: identification of risk behaviours and implications for interventions.

We characterize the demographics, injection practices and risk behaviours of 1,158 injection drug users (IDUs) in Chennai, the capital of Tamil Nadu in southern India, who were recruited during 2005–2006 by community outreach. The median age was 35 years; the majority of IDUs were male, of Tamil ethnicity and married, and earning less than US

The intersection between sex and drugs: a cross-sectional study among the spouses of injection drug users in Chennai, India

75 per month. Most (76%%) had injected in the prior month. The median age at first injection was 25 years; the most common drug injected was heroin (80%%) followed by buprenorphine. High risk behaviours were common and included needle-sharing, unsafe disposal, and inappropriate cleaning of needles as well as limited condom use. IDUs in India need to be educated on harm reduction and safe-injection practices; Pharmacies could serve as potential venues for HIV prevention interventions among IDUs in India, as most IDUs obtain their needles from pharmacies without prescription.

HIV Care Continuum Among Men Who Have Sex With Men and Persons Who Inject Drugs in India: Barriers to Successful Engagement

For persons living with HIV, hepatitis C is a major public health problem that must be controlled and could be eliminated. The challenge arises because the hepatitis C virus (HCV) is prevalent among HIV-infected persons in most parts of the world, because HIV worsens all HCV outcomes, and because HCV may add additional individual economic and psychosocial complications to HIV disease. Despite the major benefits of antiretroviral therapy on HIV outcomes, antiretroviral therapy is not sufficient to halt the complications of HCV. Nonetheless, HCV can be controlled at all stages, including prevention of infection and cure. Thus, HCV is an eradicable disease. There are significant inequalities worldwide in HCV control that could markedly constrain the impact of these measures.

Sexually transmitted infections and sexual practices in injection drug users and their regular sex partners in Chennai, India.

BackgroundIt is estimated that there are up to 1.1 million injection drug users (IDUs) in India; the majority are likely married. We characterize HIV, hepatitis B (HBV) and hepatitis C (HCV) prevalence and the risk environment of a sample of spouses of IDUs.MethodsA cohort of 1158 IDUs (99% male) was recruited in Chennai, India from 2005-06. A convenience sample of 400 spouses of the male IDUs in this cohort was recruited in 2009. A risk assessment questionnaire was administered and a blood sample collected. Logistic regression was used to identify factors associated with prevalent HIV.ResultsMedian age was 31 years; thirteen percent were widowed and 7% were not currently living with their spouse. Only 4 (1%) reported ever injecting drugs; Twenty-two percent and 25% reported ever using non-injection drugs and alcohol, respectively. The majority had one lifetime sexual partner and 37 (9%) reporting exchanging sex. Only 7% always used condoms with their regular partner. HIV, HBV and HCV prevalence were 2.5%, 3.8% and 0.5%, respectively; among spouses of HIV+ IDUs (n = 78), HIV prevalence was 10.3%. The strongest predictor of HIV was spousal HIV status (OR: 17.9; p < 0.001). Fifty-six percent of women had ever experienced intimate partner violence; Eight-six percent reported sexual violence.ConclusionsOur finding of a 10-fold higher HIV prevalence among spouses of IDUs compared with general population women indicates their vulnerability; prevalence is likely to increase given the context of low condom use and frequent sexual violence. Prevention efforts directed at IDUs should also include programs for spouses.

Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery.

BACKGROUND We characterize the human immunodeficiency virus (HIV) care continuum for men who have sex with men (MSM) and persons who inject drugs (PWID) across India. METHODS We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities, using respondent-driven sampling (September 2012 to December 2013). Participants were aged ≥18 years and either self-identified as male and reported sex with a man in the prior year (MSM) or reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV-positive status were characterized using multilevel logistic regression. RESULTS A total of 1146 MSM were HIV infected, of whom a median of 30% were aware of their HIV-positive status, 23% were linked to care, 22% were retained before antiretroviral therapy (ART), 16% had started ART, 16% were currently receiving ART, and 10% had suppressed viral loads. There was site variability (awareness range, 0%-90%; suppressed viral load range, 0%-58%). A total of 2906 PWID were HIV infected, of whom a median of 41% were aware, 36% were linked to care, 31% were retained before ART, 20% had started ART, 18% were currently receiving ART, and 15% had suppressed viral loads. Similar site variability was observed (awareness range: 2%-93%; suppressed viral load range: 0%-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), use of other services (PWID), more lifetime sexual partners (MSM), and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol use (MSM) were associated with lower awareness. CONCLUSIONS In this large sample, the major barrier to HIV care engagement was awareness of HIV-positive status. Efforts should focus on linking HIV testing to other essential services. CLINICAL TRIALS REGISTRATION NCT01686750.

Burden of Liver Disease among Community-Based People Who Inject Drugs (PWID) in Chennai, India

Objective: Measuring sexually transmitted infections (STIs) and sexual practices in injection drug users (IDUs) and their regular sex partners. Goal: Informing HIV intervention programs. Design: Cross-sectional. Results: One percent IDUs and 2% of their regular female sex partners were syphilis infected; 40% (84/211) and 38% respectively (81/211) were infected with HSV-2. 30% IDUs and 5% of their female regular sex partners were HIV positive. Serodiscordant results for syphilis and HSV-2 were noticed. Women having first sex at age ≤17 years and those who had HIV-positive IDUs as their male sexual partner had two times the odds of having any non-HIV-STI (OR 2.04; 95% CI 1.1–3.8; P = 0.02 and OR 2.38; 95% CI 1.1–5.1; P = 0.02 respectively) in a multivariate model. Women ≥38 years had seven times the odds of having any non-HIV-STI. Conclusion: Reaching out to IDUs and their female regular sex partners with modified STI management guideline and promoting women-controlled safer sex measures are needed harm-reduction measures.