Tanvi Rai

Circular labor migration and HIV in India: exploring heterogeneity in bridge populations connecting areas of high and low HIV infection prevalence.

Background. The emerging human immunodeficiency virus (HIV) epidemics in rural areas of India are hypothesized to be linked to circular migrants who are introducing HIV from destination areas were the prevalence of HIV infection is higher. We explore the heterogeneity in potential roles of circular migrants in driving an HIV epidemic in a rural area in north India and examine the characteristics of the “sustaining bridge population”, which comprises individuals at risk of HIV acquisition at destination and of HIV transmission into networks at origin capable of sustaining an epidemic. Methods. Results of a behavioral survey of 639 male migrants from Azamgarh district, India, were analyzed using χ2 tests and logistic regression. Results. We estimated the size of various subgroups defined by specific sexual behaviors across different locations and over time. Only 20% fit our definition of a sustaining bridge population, with the majority making no apparent contribution to geographical connectedness between high- and low-prevalence areas. However, we found evidence of sexual contacts at origin that could potentially sustain an epidemic once HIV is introduced. Variables associated with sustaining bridge population membership were self-perceived HIV risk, current migrant status, and age. Conclusions. Circular migrants represent a heterogeneous population in terms of their role as a bridge group. Self-perception of heightened risk could be exploited in designing prevention programs.

Patient perspectives on the HIV continuum of care in London: a qualitative study of people diagnosed between 1986 and 2014

Objectives To describe the experiences of the HIV treatment cascade of diagnosis, engagement with care and initiation of treatment from the perspective of patients; we explored whether this differed according to the year of their diagnosis, for example, whether they had experienced HIV care in the pretreatment era. Design Qualitative interview study with framework analysis. Setting Two large HIV adult outpatient clinics in central London. Participants 52 HIV-positive individuals, 41 men, 11 women, purposively sampled to include people who had been diagnosed at different stages in the history of the epidemic classified as four ‘generations’: pre-1996 (preantiretroviral therapy (ART)), 1997–2005 (complex ARTs), 2006–2012 (simpler ARTs) and 2013 onwards (recent diagnoses). Results Some important differences were identified; for earlier generations, the visible illness and deaths from AIDS made it harder to engage with care following diagnosis. Subsequent decisions about starting treatment were deeply influenced by the fear of severe side effects from early ART. However, despite improvements in ART and life expectancy over the epidemic, we found a striking similarity across participants’ accounts of the key stages of the care continuum, regardless of when they were diagnosed. Diagnosis was a major traumatic life event for almost everyone. Fear of testing positive or having low self-perceived risk affected the timing of testing and diagnosis. Engaging with care was facilitated by a flexible approach from services/clinicians. Initiating treatment was a major life decision. Conclusion We found patients’ experiences are influenced by when they were diagnosed, with earliest cohorts facing substantial challenges. However, being diagnosed with HIV and starting treatment continue to be significant life-altering events even in the era of effective, simple treatments. Despite the advances of biomedical treatment, services should continue to recognise the needs of patients for whom the diagnosis and treatment remain significant challenges.

From activism to secrecy: Contemporary experiences of living with HIV in London in people diagnosed from 1986 to 2014.

Successes in biomedicine have transformed HIV from a debilitating and frequently fatal infection to a chronic, manageable condition.

P4.18 Not so normalised – patient perspectives on hiv diagnosis and treatment decisions: results from a large qualitative study in london

Introduction Improvements in treatment and life expectancy have led to HIV being increasingly regarded as “just another chronic disease”. We hypothesised that the experience of being diagnosed and starting treatment for HIV would have changed over the decades of the epidemic to reflect this normalisation. Methods Qualitative interview study of 52 people attending two large HIV clinics in London, purposively sampled to include people diagnosed in “generations” from 1980s to 2015, analysed using framework approach. Results Despite the improvements in antiretroviral therapy (ART) and life expectancy over the last 3 decades, the experience of receiving a diagnosis of HIV remained strikingly similar across the generations, being one of shock and fear of death, recalling thinking that “this is the end” or that “my expiry date was stamped on me now”. This did not vary with level of knowledge or experience of having previous HIV tests. In contrast, the decision to start ART was more complex in the early days when potential gains had to be weighed against side effects and depended on clinical monitoring. For those diagnosed in the 1980s and 90s, it was often seen as a defeat “I fought it all this time on my own, and then finally I had to give in and take a pill. That was kind of depressing”. But in the last decade the decision although easier in some ways was still a major event. People across the generations reported being worried about accidental disclosure through taking medications, fear of the short and long term side effects, and described how taking daily medications became a constant reminder of their HIV status; one participant described starting medication as “worse than being diagnosed” . Conclusion HIV may appear as “just another chronic disease” to some clinicians, but for people being diagnosed and invited to start treatment these are major life events, as they are for many chronic conditions. To ensure good linkage to and retention in care, clinicians should acknowledge this and facilitate appropriate support.

Migration as a risk and a livelihood strategy: HIV across the life course of migrant families in India

ABSTRACT Migrant workers are understood to be vulnerable to HIV. However, little is known about the experience of migration-based households following HIV infection. This qualitative study examined the migration-HIV relationship beyond the point of infection, looking at how it affects livelihood choices, household relationships and the economic viability of migrant families. We conducted semi-structured interviews with 33 HIV-positive migrant men and women recruited from an anti-retroviral therapy (ART) centre in north India. Following infection among the migrant men, contact with free, public-sector HIV services was often made late, after the development of debilitating symptoms, abandonment of migrant work and return to native villages. After enrolment at the ART centre participants’ health eventually stabilised but they now faced serious economic debt, an inflexible treatment regimen and reduced physical strength. Insecure migrant job markets, monthly drug collection and discriminatory employment policies impeded future migration plans. HIV-positive wives of migrants occupied an insecure position in the rural marital household that depended on their husbands’ health and presence of children. The migration-HIV relationship continued to shape the life course of migrant families beyond the point of infection, often exposing them again to the economic insecurity that migration had helped to overcome, threatening their long-term survival.

O07.2 The Changing Relationship Between Migration and HIV Over the Life Course of Affected Households in North India

Background Much research explores the relationship between migration and HIV risk; elsewhere the focus is on how HIV affects household structure and viability. In India, rural-to-urban, circular migrants are targeted with prevention campaigns but little is known about the impact of HIV on livelihoods. Aim To explore the structural and contextual influences on the life course of HIV-affected circular migrant families, focussing on long-term prognosis, and consider implications for programmes. Methods In-depth interviews with HIV-positive patients at an antiretroviral therapy (ART) centre in northern India. Data were analysed using framework and thematic analysis. Results 20 men and 13 women were interviewed. Short-term migration to urban areas secured an improved economic livelihood, but HIV diagnosis was often late following a prolonged period of privately-obtained symptomatic treatments. At eventual HIV diagnosis, most participants faced serious debt and physical degradation. They felt conflicted about future migration – their economic liabilities pushed them towards migrant work, but their poor health and strict treatment regime made them reluctant to leave home. Insecure job markets and discriminatory policies attenuated their employment choices while the opportunity costs of monthly ART centre visits and related medical care mounted up. The role reversal from primary earners and carers to needing care and financial support changed household organisation. Temporary care arrangements gave way to shifts in household composition, with gendered effects. Long term adherence to daily antiretroviral medication and the recommended healthy, regular meals could be compromised by the social and economic consequences of becoming positive. Discussion Migration may increase HIV risk but following infection, HIV regulates future migration. It often increased the need to migrate again and forced some people to make choices that compromised their long-term health. Targeting migrants with prevention, testing and treatment programmes may fail to achieve desired outcomes without the simultaneous implementation of structural interventions.

P1-S2.73 Exploring the relationship between Rural-to-Urban circular migration and HIV: a qualitative study of migrants and persons living with HIV in North India

Background Migrant workers may be at increased risk of acquiring HIV and have been described as a potential bridge between high- and low-prevalence geographic areas and groups. The National AIDS Control Organisation of India has prioritised interventions for migrant workers with the aim of curbing the spread of HIV from high to low prevalence parts of the country. We describe links between migration and HIV and explore variations in risk between migrants. Methods A qualitative study in Allahabad district, Uttar Pradesh, India. Interviews, focus groups and observations were carried out in two rural villages with high temporary out-migration of men, and in an HIV treatment centre in Allahabad. For this study we defined migrants as those who leave and return to their place of origin once or more in a year. Participants included key informants (14), rural migrant men (20), and men and women living with HIV/AIDS (PLHAs) (30). Results PLHA and migrant men described a range of ways in which migration could lead to an increase in the potential or actual risk of acquiring HIV. These included separation from wives and opportunities for other relationships, exposure to sexual abuse in destination workplaces, sex between men, and exposure to unregulated injections. These risks varied according to destination, with less opportunity for sexual risk-taking in factories where men were housed in closely-supervised factory accommodation. HIV in turn affected migration with a particular impact on the ability to make money and care for families. For some men illness or the fear of becoming unwell limited further migration, and thus reduced income; others increased migrant labour in order to plan for an uncertain future for their dependents. An HIV diagnosis meant some lucrative international destinations became inaccessible, so they moved elsewhere for work. Conclusions Labour migration can increase vulnerability to infection for migrants and their families. However, this relationship appears to be more complex than is often assumed. Unprotected heterosexual intercourse may not be the only way in which migration increases HIV risk as there are numerous other risky encounters that migrant workers may have due to their circumstances. Planned programmes to increase HIV awareness and promote condom use at destination and source locations have to be combined with a systematic examination of the effect of social and sexual networks and power relationships in the labour market.