Tarun Bhatnagar

Risk reduction and perceived collective efficacy and community support among female sex workers in Tamil Nadu and Maharashtra, India: the importance of context

Background Empowering sex workers to mobilise and influence the structural context that obstructs risk reduction efforts is now seen an essential component of successful HIV prevention programmes. However, success depends on local programme environments and history. Methods The authors analysed data from the Integrated Behavioural and Biological Assessment Round I cross-sectional survey among female sex workers in Tamil Nadu and Maharashtra. The authors used propensity score matching to estimate the impact of participation in intervention activities on reduction of risk (consistent condom use) and vulnerability (perceived collective efficacy and community support). Results Background levels of risk and vulnerability as well as intervention impact varied widely across the different settings. The effect size ATT of attending meetings/trainings on consistent condom use was as high as 21% in Tamil Nadu (outside of Chennai) where overall use was lowest at 51%. Overall, levels of perceived collective efficacy were low at the time of the survey; perceived community support was high in Tamil Nadu and especially in Chennai (93%) contrasting with 33% in Mumbai. Consistent with previous research, the context of Mumbai seems least conducive to vulnerability reduction, yet self-help groups had a significant impact on consistent condom use (ATT=10%) and were significantly associated with higher collective efficacy (ATT=31%). Conclusions Significant risk reduction can be achieved by large-scale female sex worker interventions, but the impact depends on the history of programming, the complexity of the context in which sex work happens and pre-existing levels of support sex workers perceive from their peers.

Malnutrition in a population of HIV-positive and HIV-negative drug users living in Chennai, South India.

BACKGROUNDnMalnutrition is a strong predictor of poor outcomes in people living with HIV (PLHIV). Drug users are at increased risk of malnutrition regardless of whether or not they are infected with HIV. Little data exists on the nutritional status of drug users (with or without HIV infection) in India.nnnMETHODSnWe describe and compare the nutrition and metabolic status of 107 HIV-positive and 193 HIV-negative male clients of a community-based drop-in center for injection drug users in Chennai, India. Measures of nutrition and metabolic status include body composition, dietary intake, food insecurity, and serum lipid levels.nnnRESULTSnWe found poor overall nutritional status in both the HIV-positive and HIV-negative clients, with HIV-positive men faring worse on some parameters. Both groups had extremely low percent body fat, but levels in HIV-positive participants were significantly lower (6.5% versus 7.9%, p=.01). HIV-positive men also had significantly lower total caloric and fat intakes compared to HIV-negative men. A considerable proportion (70%) of both HIV-positive and HIV-negative drug users were food insecure. HDL cholesterol levels were significantly lower and below normal range in the HIV-positive compared to HIV-negative men.nnnCONCLUSIONSnThe high levels of food insecurity and poor nutritional status in this population, regardless of HIV status, indicates critical need for intervention. Improving nutritional status in those who are infected with HIV prior to initiation of antiretroviral treatment may help patients to reap the full benefits of therapy.

Survival probability and predictors of mortality and retention in care among patients enrolled for first-line antiretroviral therapy, Andhra Pradesh, India, 2008–2011

BACKGROUNDnThe national antiretroviral therapy (ART) initiative in India began in 2004. In order to better inform the national program, we estimated the mean cumulative survival probability and loss to follow-up (LFU) rate among patients initiated on ART.nnnMETHODSnWe identified a cohort of people living with HIV (PLHIV) aged ≥15 years initiated on ART in two ART centres in Hyderabad city, Andhra Pradesh state, India between January 2008 and December 2008. The cohort was followed-up until 31 December 2011 and death and/or LFU were the primary endpoints. Death from any cause during the study period was considered to be the result of HIV infection. We used the Kaplan-Meier estimation method for survival probability and Cox proportional hazard model to identify the predictors.nnnRESULTSnOf the 1690 patients initiated on ART, 259 (15.3%) were transferred out during the study period. Mortality rate was 7.6/100 person-years. Male gender, low CD4 count, history of tuberculosis before initiation of ART, and weight <48 kg were the predictors of mortality. Patients who were LFU were more likely to be males, unemployed, widowed, and had weight below 48 kg.nnnCONCLUSIONnSurvival rates on ART were higher compared to other resource-limited settings. Delayed diagnosis and initiation of ART and co-infection with TB were important predictors for both mortality and retention in care.

Diversity among clients of female sex workers in India: comparing risk profiles and intervention impact by site of solicitation. implications for the vulnerability of less visible female sex workers.

Background It seems generally accepted that targeted interventions in India have been successful in raising condom use between female sex workers (FSWs) and their clients. Data from clients of FSWs have been under-utilised to analyse the risk environments and vulnerability of both partners. Methods The 2009 Integrated Biological and Behavioural Assessment survey sampled clients of FSWs at hotspots in Andhra Pradesh, Maharashtra and Tamil Nadu (n=5040). The risk profile of clients in terms of sexual networking and condom use are compared across usual pick-up place. We used propensity score matching (PSM) to estimate the average treatment effect on treated (ATT) of intervention messages on clients’ consistent condom use with FSW. Results Clients of the more hidden sex workers who solicit from home or via phone or agents had more extensive sexual networks, reporting casual female partners as well as anal intercourse with male partners and FSW. Clients of brothel-based sex workers, who were the least educated, reported the fewest number/categories of partners, least anal sex, and lowest condom use (41%). Consistent condom use varied widely by state: 65% in Andhra Pradesh, 36% in Maharashtra and 29% in Tamil Nadu. Exposure to intervention messages on sexually transmitted infections was lowest among men frequenting brothels (58%), and highest among men soliciting less visible sex workers (70%). Exposure had significant impact on consistent condom use, including among clients of home-based sex workers (ATT 21%; p=0.001) and among men soliciting other more hidden FSW (ATT 17%; p=0.001). In Tamil Nadu no impact could be demonstrated. Conclusion Commercial sex happens between two partners and both need to be, and can be, reached by intervention messages. Commercial sex is still largely unprotected and as the sex industry gets more diffuse a greater focus on reaching clients of sex workers seems important given their extensive sexual networks.

Sexual Behaviors and Partner-Specific Correlates of Heterosexual Anal Intercourse Among Truck Drivers and Their Wives in South India

It is important to know about patterns of sexual behaviors among married couples in order to develop effective HIV prevention strategies for them. Herein we describe the sexual behaviors, estimate prevalence of anal intercourse (AI) among truck drivers (“truckers”) and their wives, and determine partner-specific demographic and behavioral correlates of AI. We carried out a cluster-sampled cross-sectional survey among 18–49xa0year-old wives and their trucker husbands in a south Indian district. Data were collected by same-gender research team members with color-coded computer-assisted interviews. We used random intercept logistic regression to identify the independent correlates of AI. Thirteen percent of 475 wives and 467 truckers reported ever having AI with their spouse. Of those who responded, 55xa0% of 40 wives and 47xa0% of 36 truckers never used condoms during AI. Of those who responded, 22 of 32 wives and 24 of 32 husbands felt that condoms were unnecessary during AI. Reporting ever having AI was associated with younger age and higher education of both husband and wife. AI reported by wives was associated with having sexual partner(s) other than husband (adjusted OR 8.8 [95xa0% CI 3.2–24.0]), correctly answering all HIV knowledge items (adjusted OR 4.9 [95xa0% CI 1.9–12.5]), husband’s sexual debut occurring before marriage (adjusted OR 1.9 [95xa0% CI 1.0–3.5]), and husband’s high HIV risk perception (adjusted OR 2.5 [95xa0% CI 1.2–5.4]). AI reported by truckers was associated with having sex with a male or transgender (adjusted OR 4.0 [95xa0% CI 1.2–13.3]). Reported prevalence of AI was high considering that in India anal sex is non-normative, heavily stigmatized and, criminal. Indian heterosexual mobile populations need to be informed about the greater risk of HIV infection consequent to unprotected AI.

High prevalence of household pesticides and their unsafe use in rural South India

ObjectiveTo estimate the prevalence of usage, unsafe practices and risk perception regarding household pesticides in a rural community of Tamil Nadu, India.Materials and MethodsIn a cross-sectional survey we used a pre-tested questionnaire and trained interviewers to collect information on household pesticide use for the past 6 months from any adult member of randomly selected households.ResultsOut of 143 households, 95% used at least one household pesticide (95% CI: 93.5–99.5) and 94% used at least one household pesticide specifically for mosquito control. The most commonly used pesticides were mosquito coils (75%), mosquito liquid vaporizers (36%), ant-killing powder (24%) and moth/naphthalene balls (18%). The major non-chemical methods of pest control were rat traps (12%) and mosquito bed nets (7.5%). Out of the mosquito coil users, 61% kept the windows and doors closed while the coil was burning. Out of the moth ball users, 88% left them in the place of use till they fully vaporized. Nearly half of the users did not know that household pesticides were harmful to their health and the health of their children.ConclusionsThe use of household pesticides was highly prevalent in this rural community. The prevalence of unsafe practices while handling them was also high. We recommend that the users of household pesticides be educated about the health hazards and about safe practices and non-chemical methods of pest control be promoted.

Seven years of the field epidemiology training programme (FETP) at Chennai, Tamil Nadu, India: an internal evaluation

BackgroundDuring 2001–2007, the National Institute of Epidemiology (NIE), Chennai, Tamil Nadu, India admitted 80 trainees in its two-year Field Epidemiology Training Programme (FETP). We evaluated the first seven years of the programme to identify strengths and weaknesses.MethodsWe identified core components of the programme and broke them down into input, process, output and outcome. We developed critical indicators to reflect the logic model. We reviewed documents including fieldwork reports, abstracts listed in proceedings and papers published in Medline-indexed journals. We conducted an anonymous online survey of the graduates to collect information on self-perceived competencies, learning activities, field assignments, supervision, curriculum, relevance to career goals, strengths and weaknesses.ResultsOf the 80 students recruited during 2001–2007, 69 (86%) acquired seven core competencies (epidemiology, surveillance, outbreaks, research, human subjects protection, communication and management) and graduated through completion of at least six field assignments. The faculty-to-student ratio ranged between 0.4 and 0.12 (expected: 0.25). The curriculum was continuously adapted with all resources available on-line. Fieldwork led to the production of 158 scientific communications presented at international meetings and to 29 manuscripts accepted in indexed, peer-reviewed journals. The online survey showed that while most graduates acquired competencies, unmet needs persisted in laboratory sciences, data analysis tools and faculty-to-student ratio.ConclusionsNIE adapted the international FETP model to India. However, further efforts are required to scale up the programme and to develop career tracks for field epidemiologists in the country.

Sexual behavior, HIV prevalence and awareness among wives of migrant workers: results from cross-sectional survey in rural North India

Background: Migration has been linked to the spread of HIV epidemic from the urban areas of western India to the rural areas of north India. Objectives: This is the first population-based study among the wives of migrant workers of Muzaffarpur district in Bihar with objectives to describe their sexual behavior within marriage, estimate the prevalence of HIV, and to know their awareness regarding HIV/AIDS. Methods: A two-stage cluster survey was conducted by randomly selecting 25 eligible wives from each of the 34 selected villages. A total of 850 wives were interviewed and the blood samples were collected for HIV testing. To determine the factors associated with HIV/AIDS-awareness, we calculated adjusted odds ratios and 95% confidence intervals (CI) using multiple logistic regression analysis. Results: 34 (3%) of 850 wives reported condom use with their husband. HIV prevalence was 0.59% (95% CI: 0.19-1.37%) among the wives of migrant workers. Out of 850 wives, 132 (15.5%) had heard about HIV. Condoms use (OR = 3.21, 95% CI: 1.22-7.90) and premarital sex (OR=7.44, 95% CI: 1.6-33.67) were found significantly positively associated with HIV knowledge of wives. HIV awareness of the wives was significantly associated with age-group 15-24 years, literacy status, and possession of television and husbands’ literacy status. The knowledge about HIV among wives had significant positive impact on condoms use and premarital sex. HIV prevalence among the wives of migrant workers was higher than the prevalence among women in the general population. Education was found to be positively associated with awareness about HIV. Conclusions: Effective interventions are needed for increasing awareness of HIV among wives of migrant workers in Bihar.

Predictors of immunological failure and determinants of suboptimal CD4 testing among adults with HIV on first-line antiretroviral therapy in Andhra Pradesh, India, 2008–2011

BACKGROUNDnFailure of first-line antiretroviral therapy (ART) results in high morbidity and mortality. We identified the predictors of immunological failure and suboptimal CD4 testing among adult people living with HIV (PLHIV) initiated on first-line ART.nnnMETHODSnThe cohort of PLHIV aged ≥ 15 years initiated on first-line ART in Hyderabad city, Andhra Pradesh state, in 2008 was followed-up until 31 December 2011 or until death and/or lost to follow-up (LFU). We estimated cumulative incidence of immunological failure. We explored socio-demographic, clinical, pharmacological and immunological factors to identify the predictors of immunological failure and determinants of suboptimal CD4 testing (<2 tests/year).nnnRESULTSnAmong the 1431 PLHIV, 275 (19.2%) died and 263 (18.4%) were LFU. Of the remaining 893 (62.3%) patients on follow-up, 193 (21.6%) experienced immunological failure; these patients were more likely to be males, illiterate, with a history of pulmonary TB while on ART and taking stavudine-based regimen. Incidence of suboptimal testing ranged between 41 and 60% over 4 years of follow-up. Suboptimal CD4 testing among PLHIV was associated with history of TB prior to initiation of ART and stage 3 and 4 of HIV disease at enrollment.nnnCONCLUSIONSnThere was low immunological failure rate but high incidence of suboptimal CD4 testing. The ART centre staff needs to be more vigilant about 6-monthly CD4 testing for timely detection of immunological failure and appropriate case management.

Sputum conversion and treatment success among tuberculosis patients with diabetes treated under the Tuberculosis Control Programme in an Urban setting in South India

Background: Studies from India on sputum conversion and tuberculosis (TB) treatment outcomes among TB patients with diabetes are limited. Objective: The objective of this study is to estimate the proportion of sputum smear conversion and successful treatment outcomes among diabetic–TB patients treated under Revised National TB Control Programme (RNTCP). Methodology: Information on TB disease, diabetes, sputum conversion, and treatment outcomes were collected from treatment cards of adult TB patients (age >18 years) treated in the District TB Centre TB Unit, Tiruchirapalli, Tamil Nadu from July 1, 2014, to October 31, 2015. Results: Diabetes was documented in 163 (14%) of 1131 TB patients. Sputum conversion was in 107 (94%) of 114 smear positive-TB patients. Successful TB treatment outcome was in 116 (85%) of 136 patients and 107 (86%) of 124 new TB patients. Conclusion: Sputum conversion was as per RNTCP target while treatment success rate among the new TB patients with diabetes was suboptimal.