Vinay Kulkarni

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.

Screening of cervical neoplasia in HIV-infected women in India

Objective:To evaluate an accurate, affordable, and feasible method to screen and treat HIV-infected women so that cervical cancer can be prevented among them. Design:A cross-sectional study was conducted in India in which eligible HIV-infected women underwent visual inspection with acetic acid (VIA), visual inspection with Lugols iodine (VILI), cytology, human papillomavirus (HPV) testing, and colposcopy. Methods:We screened women with cytology, HPV testing, VIA, and VILI. All screened women had colposcopy and women with colposcopic abnormalities had directed biopsies. Women with suspected cervical intraepithelial neoplasia (CIN) on colposcopy were treated with cold coagulation or loop excision. Sensitivity, specificity, and predictive values of the screening tests were calculated. Results:Among 1128 women screened, 55 (4.9%) had CIN2–3 lesions. Sensitivity for VIA, VILI, cytology at atypical squamous cells of undetermined significance (ASCUS) threshold and HPV testing was 83.6, 89.1, 63.3, and 94.6%, and specificity was 88.8, 89.3, 94.5, and 77.4%, respectively, in detecting CIN2/3 lesions. Cytology had significantly lower sensitivity and higher specificity than VIA, VILI, and HPV testing. Sequential testing with VIA/VILI, HPV testing/VIA, HPV testing/VILI, and HPV testing/VIA/VILI had more balanced sensitivity and specificity than the single tests. Cold coagulation was well tolerated and cured 80% of CIN2–3 based on preliminary results at 6-month to 1-year follow-up periods. Conclusions:Sequential testing with VIA and VILI is the most feasible screening approach for cervical cancer screening in HIV-infected women in low-resource countries. When HPV testing becomes feasible and affordable, HPV testing followed by VIA/VILI may be considered.

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.

The Indian Pediatric HIV Epidemic: A Systematic Review

Despite an estimated 70,000 Indian children living with HIV infection, little is known about Indias pediatric HIV epidemic. Generalizations about epidemiology, natural history, and treatment outcomes from other resource-limited settings (RLS) may be inaccurate for several biologic and social reasons. A review of the Indian literature is needed to optimize country-specific HIV management and examine these generalizations. MEDLINE and EMBASE were searched for articles published in English by November 2007 on HIV-infected, Indian children (0-18 years) that detailed epidemiology, natural history, or treatment. Articles with original, extractable data were selected and summarized using descriptive statistics. Of 370 citations, 58 studies were included in this review (median study size 24 children). Significant heterogeneity was noted among the studies. HIV infection was reported nearly twice as often in males (male/female ratio 1.9) and diagnosed earlier (4.7 years) than in other RLS. Over 2% of hospitalized children were reported to be HIV-infected. The reported mortality among HIV-infected newborns of 22% at 18 months was lower than other RLS. Improved anthropometrics were the only consistently reported and comparable benefit of short-term HAART to other RLS. Review of the Indian literature yielded potentially unique epidemiology and natural history compared to other RLS. However, important questions about the accuracy and representativeness of the Indian data limit its generalizability and comparability. Targeted interventions to curb Indias pediatric HIV epidemic require urgent clarification of these findings. If such differences truly exist, management guidelines should be tailored accordingly.

HIV testing among pregnant women living with HIV in India: are private healthcare providers routinely violating women's human rights?

BackgroundIn India, approximately 49,000 women living with HIV become pregnant and deliver each year. While the government of India has made progress increasing the availability of prevention of mother-to-child transmission of HIV (PMTCT) services, only about one quarter of pregnant women received an HIV test in 2010, and about one-in-five that were found positive for HIV received interventions to prevent vertical transmission of HIV.MethodsBetween February 2012 to March 2013, 14 HIV-positive women who had recently delivered a baby were recruited from HIV positive women support groups, Government of India Integrated Counseling and Testing Centers, and nongovernmental organizations in Mysore and Pune, India. In-depth interviews were conducted to examine their general experiences with antenatal healthcare; specific experiences around HIV counseling and testing; and perceptions about their care and follow-up treatment. Data were analyzed thematically using the human rights framework for HIV testing adopted by the United Nations and India’s National AIDS Control Organization.ResultsWhile all of the HIV-positive women in the study received HIV and PMTCT services at a government hospital or antiretroviral therapy center, almost all reported attending a private clinic or hospital at some point in their pregnancy. According to the participants, HIV testing often occurred without consent; there was little privacy; breaches of confidentiality were commonplace; and denial of medical treatment occurred routinely. Among women living with HIV in this study, violations of their human rights occurred more commonly in private rather than public healthcare settings.ConclusionsThere is an urgent need for capacity building among private healthcare providers to improve standards of practice with regard to informed consent process, HIV testing, patient confidentiality, treatment, and referral of pregnant women living with HIV.

cervical cancer screening and treatment of cervical intraepithelial neoplasia in female sex workers using "screen and treat" approach

Objective Female sex workers (FSWs) are at an increased risk of human immunodeficiency virus (HIV) as well as human papillomavirus (HPV) infections and thus have an increased risk of cervical intraepithelial neoplasia (CIN) and cervical cancer. We evaluated the feasibility of “screen and treat approach” for cervical cancer prevention and the performance of different screening tests among FSWs. Methods Women were screened using cytology, VIA (visual inspection with acetic acid), and VILI (visual inspection with Lugol’s iodine) and underwent colposcopy, biopsy, and immediate treatment using cold coagulation, if indicated, at the same visit. Results We screened 300 FSWs of whom 200 (66.67%) were HIV uninfected and 100 (33.34%) were HIV infected. The overall prevalence of CIN 2–3 lesions was 4.7%. But all women with CIN 2–3 lesions were HIV infected, and thus the prevalence of CIN 2–3 lesions in HIV-infected FSWs was 14/100 (14%, 95% confidence interval: 7.2–20.8). All of them screened positive by all three screening tests. Cold coagulation was well tolerated, with no appreciable side effects. Conclusion Cervical cancer prevention by “screen and treat” approach using VIA, followed by ablative treatment, in this high-risk group of women is feasible and can be implemented through various targeted intervention programs.

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.

High prevalence of unwanted pregnancies and induced abortions among HIV-infected women from Western India: need to emphasize dual method use?

This study examines the prevalence, reasons, and predictors of unwanted pregnancies and induced abortions among ever married HIV-infected women attending a care facility in Maharashtra, Western India, and discusses its programmatic and policy implications. Retrospectively collected data of pregnancies conceived after the diagnosis of HIV were analyzed using descriptive and logistic regression techniques. Among the 622 women interviewed, 113 women had 158 pregnancies with known outcomes after HIV diagnosis. Among these pregnancies, 80 (51%) were unwanted and 79 (50%) were voluntarily terminated. Fear of transmitting HIV to the child was a frequently mentioned reason for an unwanted pregnancy (71.8%) and induced abortion (59.5%). Women from urban areas [OR 2.43 (95% CI 1.23–4.79)] and with two or more live births before HIV diagnosis [OR 3.33 (95% CI 1.36–8.20)] were significantly more likely to report an unwanted pregnancy. Women with two or more live births before HIV diagnosis [OR 3.16 (95% CI 1.20–8.35)], who did not know that HIV transmission to the baby can be prevented [OR 3.29 (95% CI 1.48–7.34)] and with an unwanted pregnancy [OR 4.82 (95% CI 2.33–10.00)], were significantly more likely to terminate the pregnancy. Despite increased coverage of antiretroviral treatment, effective provision of reproductive healthcare services to HIV-infected women remains challenging. A high prevalence of unwanted pregnancies and induced abortions and a low level of knowledge about prevention of mother to child transmission (PMTCT) underscore the need for preconception counseling and provision of comprehensive family planning services to HIV-infected women. Enrolling all HIV-infected pregnant women, irrespective of their decision to continue with their pregnancy, in the PMTCT program and discussing with HIV-infected women and their partners at HIV diagnosis a full array of contraceptive methods and not just consistent use of condoms might be helpful in reducing unwanted pregnancies.Young people aged 10-24 years represent a significant proportion (40-70%) of women in low and middle income regions who undergo unsafe abortion. They are more likely than older women to delay seeking appropriate post-abortion care. These delays often result from a lack of knowledge fear of negative provider attitudes and lack of confidentiality an inability to pay lack of transportation fear of the medical procedure and feelings of shame or embarrassment. Young women constituted almost half of patients (49%) treated for severe complications from the estimated 500000 induced abortions performed in Kenya in 2012. More than a quarter of these young patients (26%) received poor quality post-abortion care. Worse 30% of those receiving post-abortion treatment were not offered contraceptives upon discharge; thus increasing their vulnerability to repeat unintended pregnancy. Comprehensive post-abortion care (PAC) is a critical intervention to address complications arising from unsafe abortion – induced pregnancy termination carried out by unskilled personnel or in an environment that does not meet minimal medical standards or both. Comprehensive PAC not only ensures that women receive appropriate treatment for existing complications but also provides an opportunity to prevent future unintended pregnancies through linkages to contraceptive and other reproductive health services. In this briefing paper we summarize key findings from a mystery client survey conducted in 12 public and private health facilities in Nairobi County (Kenya) between April and May 2016 to understand young people’s perceptions of the quality of sexual and reproductive health services provided in these facilities including emergency contraception sexually transmitted infections and medical abortion.