Shrinivas Darak

Couple-oriented prenatal HIV counseling for HIV primary prevention: an acceptability study.

BackgroundA large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce. In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, we assessed the acceptability of couple-oriented post-test HIV counseling (COC) and mens involvement within prenatal care services, among pregnant women, male partners and health care workers in Cameroon, Dominican Republic, Georgia and India.MethodsQuantitative and qualitative research methods were used: direct observations of health services; in-depth interviews with women, men and health care workers; monitoring of the COC intervention and exit interviews with COC participants.ResultsIn-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care (ANC) services, mainly because these are traditionally and programmatically a womans domain. However mens involvement was reported to be acceptable and needed in order to improve ANC and HIV prevention services. COC was considered by the respondents to be a feasible and acceptable strategy to actively encourage men to participate in prenatal HIV counseling and testing and overall in reproductive health services.ConclusionsOne of the keys to mens involvement within prenatal HIV counseling and testing is the better understanding of couple relationships, attitudes and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counseling, which aims at integrated PMTCT and primary prevention of HIV.

Socio-demographic factors associated with loss to follow-up of HIV-infected women attending a private sector PMTCT program in Maharashtra, India

Abstract Currently, 40% of HIV-infected women enrolled in national prevention of mother-to-child transmission (PMTCT) program in India are loss to follow-up (LTF) before they can receive single dose Nevirapine. To date no study from India has examined the reasons for inadequate utilization of PMTCT services. This study sought to examine the socio-demographic factors associated with LTF of HIV-infected women enrolled during 2002–2008 in a large-scale private sector PMTCT program in Maharashtra, India. Data on HIV-infected women who were enrolled during pregnancy (N=734) and who reported live birth (N=770) were used to analyze factors associated with LTF before delivery and after delivery, respectively. Univariate and multivariate analyses were conducted to estimate the associations between being LTF and socio-demographic factors using generalized linear models. Eighty (10.9%) women were LTF before delivery and 151 (19.6%) women were LTF after delivery. Women with less than graduate level education (RR = 6.32), from a poor family (RR = 1.61), who were registered after 20 weeks of pregnancy (RR = 2.02) and whose partners were HIV non-infected or with unknown HIV status (RR = 2.69) were more likely to be LTF before delivery. Similarly, the significant factors for LTF after delivery were less than graduate level education (RR = 1.82), poor family (RR = 1.42), and registration after 20 weeks of pregnancy (RR = 1.75). This study highlights the need for innovative and effective counseling techniques for less educated women, economic empowerment of women, better strategies to increase uptake of partners HIV testing, and early registration of women in the program for preventing LTF in PMTCT programs. This need for innovative counseling techniques is even greater for PMTCT programs in the public health sector as the women accessing care in the public sector are likely to be less educated and economically more deprived.

Increasing HIV testing among male partners

Objective:Couple-oriented posttest HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. We conducted a randomized trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India). Methods:Pregnant women were randomized to receive standard posttest HIV counselling or COC and followed until 6 months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression. Results:Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group versus 14.3% in standard posttest HIV counselling group in Cameroon [odds ratio (OR) = 2.0 95% CI (1.2–3.1)], 23.1 versus 20.3% in Dominican Republic [OR = 1.2 (0.8–1.8)], 26.8 versus 1.2% in Georgia [OR = 29.6 (9.1–95.6)] and 35.4 versus 26.6% in India [OR = 1.5 (1.0–2.2)]. Women having received COC did not report more conjugal violence or union break-ups than in the standard posttest HIV counselling group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India. Conclusion:A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Systematic review of public health research on prevention of mother-to-child transmission of HIV in India with focus on provision and utilization of cascade of PMTCT services

BackgroundIn spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005. However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness.MethodsA systematic search using MEDLINE, US National Library of Medicine Gateway system (PubMed) and ISI Web of Knowledge resulted in 1,944 abstracts, of which 167 met our inclusion criteria.ResultsA huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector. Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women’s access to ANC care, HIV infected women’s immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care – is lacking.ConclusionsWhile the scale of the Indian PMTCT program is large, comprehensive understanding of the context-driven factors affecting its efficiency is lacking. Systematic and more focused public health research output is needed on the issues related to reduction of drop outs of women in the cascade, role of PMTCT programs in improving maternal and child health indicators and role of private sector in delivering PMTCT services.

Effect of highly active antiretroviral treatment (HAART) during pregnancy on pregnancy outcomes: experiences from a PMTCT program in western India.

Previous research regarding the effect of highly active antiretroviral treatment (HAART) on pregnancy outcomes shows conflicting results and is predominantly situated in developed countries. Recently, HAART is rapidly being scaled up in developing countries for prevention of mother-to-child transmission (PMTCT). This study compared adverse pregnancy outcomes among HIV infected women (N=516) who received either HAART (N=192)--mostly without protease inhibitor--or antepartum azidothymidine (AZT) with intrapartum nevirapine (N=324) from January 2008 to March 2012 through a PMTCT program in western India. We analyzed the effect of HAART on preterm births, low birth weight, and all adverse pregnancy outcomes combined using univariate and multivariate logistic regression models. Women on HAART had 48% adverse pregnancy outcomes, 25% preterm births, and 34% low birth weight children compared to respectively 32%, 13%, and 22% among women on AZT. Women receiving HAART were more likely to have adverse pregnancy outcomes and preterm births compared to women receiving AZT. Preconception HAART was significantly related to low birth weight children. This study demonstrated increased risk of adverse pregnancy outcomes with protease inhibitor excluded HAART. Prospective studies assessing the impact of HAART on MTCT as measured in terms of HIV-free survival among children are needed.

Trajectories of childbearing among HIV infected Indian women : A sequence analysis approach

Background HIV infection closely relates to and deeply affects the reproductive career of those infected. However, little is known about the reproductive career trajectories, specifically the interaction of the timing of HIV diagnosis with the timing and sequencing of reproductive events among HIV infected women. This is the first study to describe and typify this interaction. Methods Retrospective calendar data of ever married HIV infected women aged 15-45 attending a HIV clinic in Pune, Maharashtra, Western India (N=622) on reproductive events such as marriage, cohabitation with the partner, use of contraception, pregnancy, childbirth and HIV diagnosis were analyzed using sequence analysis and multinomial logistic regression. Results Optimal matching revealed three distinct trajectories: 1) HIV diagnosis concurrent with childbearing (40.7%), 2) HIV diagnosis after childbearing (32.1%), and 3) HIV diagnosis after husband’s death (27.2%). Multinomial logistic regression (trajectory 1 = baseline) showed that women who got married before the age of 21 years and who had no or primary level education had a significantly higher risk of knowing their HIV status either after childbearing or close to their husband’s death. The risk of HIV diagnosis after husband’s death was also higher among rural women and those who were diagnosed before 2005. Conclusions Three distinct patterns of interaction of timing of HIV diagnosis with timing and sequencing of events in the reproductive career were observed that have clear implications for (i) understanding of the individual life planning process in the context of HIV, (ii) formulation of assumptions for estimating HIV infected women in need of PMTCT services, and (iii) provision of care services.

FERTILITY AMONG HIV-INFECTED INDIAN WOMEN: THE BIOLOGICAL EFFECT AND ITS IMPLICATIONS

In India, nearly one million women of childbearing age are infected with HIV. This study sought to examine the biological effect of HIV on the fertility of HIV-infected Indian women. This is relevant for the provision of pregnancy-related counselling and care to the infected women, and for estimating the HIV prevalence among women and children. The study used retrospectively collected data from the National Family Health Survey (2005-2006) and applied a matched case control study design to compare the effect of HIV on conception, pregnancy rates and pregnancy outcomes among HIV-infected (N=69) and HIV-non-infected (N=345) women, both unaware of their HIV status. Pregnancy rates and pregnancy outcomes were compared through non-parametric statistical tests, whereas the effect of HIV on fecundity was studied by analysing the interval between last two pregnancies using Cox regression. The pregnancy rate was observed to be lower among HIV-infected than HIV-non-infected women (RR=0.77). The difference, however, was not statistically significant (p=0.064). There was also no statistically significant difference in the interval between last two pregnancies (p=0.898). Significantly higher number of pregnancies among HIV-infected women resulted in termination because of miscarriage or stillbirths (p=0.004). Therefore, while providing clinical care and counselling to infected women, the possibility of adverse pregnancy outcomes should be considered. Due to the higher rate of adverse pregnancy outcomes, attendance of HIV-infected women at antenatal clinics might be greater, which could lead to overestimation of HIV prevalence derived from antenatal care surveillance sites.

Barriers associated with the utilization of continued care among HIV-infected women who had previously enrolled in a private sector PMTCT program in Maharashtra, India

Prevention of mother-to-child transmission (PMTCT) programs are considered as an entry point to continued care because they provide an opportunity to link an HIV-infected woman, her partner, and child(ren) (if infected) to long-term treatment and care. However, little is known about the factors associated with the utilization of continued care among women who have previously accessed PMTCT services. Better knowledge of the barriers to continued care in HIV-infected women could lead to effective strategies to increase the uptake of post-PMTCT care. This study was designed to examine the factors associated with the utilization of continued care among HIV-infected women enrolled in the PRAYAS PMTCT program in Maharashtra, India, between 2002 and 2011. All consenting women who had completed the receipt of PMTCT services or who were lost to follow-up at least six months prior to the time of data collection were interviewed. Univariate and multivariate analyses were conducted to estimate the associations between not utilizing continued care and hypothesized risk factors using generalized linear models. Of the 688 eligible HIV-positive women, 311 completed a structured interview. Since their exit from the PMTCT program, 59 (19%) had never utilized HIV-related care, 58 (19%) had intermittently utilized HIV-related care, and 194 (62%) had consistently utilized HIV-related care at regular intervals. After adjusting for potential confounders, women with poor HIV-related knowledge (relative risk [RR] = 1.83; 95% CI: 1.15–2.92), women whose partners had never utilized HIV-related care (RR = 4.82; 95% CI: 2.57–9.04), and women who could not afford to travel to the HIV-care facility (RR = 2.36; 95% CI: 1.23–4.53) were less likely to utilize HIV-related care after exiting the PMTCT program. This study highlights the need for enhanced techniques to impart HIV and antiretroviral therapy-related knowledge and underlines the need for improved partner involvement and financial support for travel to HIV facility to increase the uptake of post-PMTCT treatment and care.

Spaces of Disclosure and Discrimination: Case Studies from India

This chapter examines the spaces where HIV status is disclosed and the spaces of discrimination as perceived and experienced by Indian people. A spatial approach is applied to garner the understandings of what makes different spaces accessible/inaccessible, empowering/disempowering and personal/impersonal to disclose an HIV status. Further, we explore time and gender differences in disclosure in the said spaces. Stigma, referred to as an attribute deeply discrediting by Goffman, is understood with the elements of it being feared and enacted. In this chapter, we look at both the perceived and enacted spatiality of discrimination. These spaces include institutional, social, family/kin and interpersonal spaces. We base this chapter on two studies carried out in India in community and institutional settings. The data comprise of ethnographic interviews, focus groups and observations. By focussing on the spatiality of disclosure and discrimination, we do not want just to describe these spaces but make an effort to see how people affected in these spaces can be empowered to manage disclosure and fight discrimination.

Declining HIV prevalence among women attending antenatal care in Pune, India

A declining prevalence of HIV among young women has been reported by the public sector implementing prevention of mother-to-child transmission (PMTCT) programmes, sentinel surveillance sites and research institutions in India. However, there are no reports evaluating such trends from the private healthcare sector. This study is a retrospective analysis of data collected by PRAYAS as a part of the PMTCT programme at Sane Guruji Hospital (SGH), a secondary care hospital in Pune, India. Women attending the antenatal clinic at SGH were screened for HIV following a group counselling session, with an option to opt out. Between January 2003 and March 2008, the overall HIV prevalence was 111/17 578 (0.6%, 95% CI 0.5-0.7%). The HIV prevalence among antenatal women was 1.1% in 2003 and 0.2% in 2008 (i.e. 82% decline in HIV prevalence over the 5-year period) and the odds ratio (OR) of HIV prevalence declined by 0.24 per year from 2003 to March 2008 (OR=0.76, 95% CI 0.69-0.87; P<0.001). The risk of having HIV infection was significantly higher in women aged ≥ 24 years and those who were uneducated. To our knowledge, this is the first report from any private sector health system in India documenting a declining HIV prevalence among antenatal women. Characterising the risk profile of this small percentage of at-risk women will help in planning prevention strategies.