The human immunodeficiency virus epidemic in India. Current magnitude and future projections

Spatial pattern and determinants of HIV infection among adults aged 15 to 54 years in India - Evidence from National Family Health Survey-4 (2015-16)

OBJECTIVE

To assess the spatial pattern and determinants of HIV infection in India.

METHODS

We conducted a secondary data analysis using the National Family Health Survey-4 data obtained from the Demographic Health Survey programme. We accounted for clustering and stratification in the sampling design using the svyset command. Spatial analysis was performed by generating the Moran's I statistic and local indicators for spatial association (LISA) maps. Logistic regression was performed to identify the determinants of HIV infection.

RESULTS

230 213 individuals were included. Prevalence of HIV infection in India was 0.24% (95% CI: 0.21%-0.28%). Being separated/widowed/divorced (aOR = 2.58, 95% CI: 1.22-5.40), living in an urban area (aOR = 2.46, 95% CI: 1.79-3.37), being resident in the North-Eastern (aOR = 4.25, 95% CI: 2.60-6.93), Southern (aOR = 3.13, 95% CI: 1.99-4.91) or Western region (aOR = 2.17, 95% CI: 1.08-4.33), having a history of multiple sexual partners (aOR = 1.99, 95% CI:1.42-2.79), a suspected STI (aOR = 2.32, 95% CI: 1.38-3.90) or self-reported TB (aOR = 7.80, 95% CI: 2.52-24.05) were significantly in association with HIV infection. Moran's I was 0.377, suggesting positive spatial autocorrelation. The LISA cluster map indicated 60 hotspot districts in India, mostly in southern states such as Karnataka, Andhra Pradesh and Telangana followed by north-eastern states such as Nagaland, Manipur, Mizoram, Tripura and Assam.

CONCLUSION

HIV infection among adults aged 15-54 years in India is spatially clustered with the majority occurring in southern and north-eastern states. Hence, region- or district-specific strategies with focused interventions should be adopted.

Using data from 'visible' populations to estimate the size and importance of 'hidden' populations in an epidemic: A modelling technique

We used reported behavioural data from cisgender men who have sex with men and transgender women (MSM/TGW) in Bangalore, mainly collected from 'hot-spot' locations that attract MSM/TGW, to illustrate a technique to deal with potential issues with the representativeness of this sample. A deterministic dynamic model of HIV transmission was developed, incorporating three subgroups of MSM/TGW, grouped according to their reported predominant sexual role (insertive, receptive or versatile). Using mathematical modelling and data triangulation for 'balancing' numbers of partners and role preferences, we compared three different approaches to determine if our technique could be useful for inferring characteristics of a more 'hidden' insertive MSM subpopulation, and explored their potential importance for the HIV epidemic. Projections for 2009 across all three approaches suggest that HIV prevalence among insertive MSM was likely to be less than half that recorded in the surveys (4.5-6.5% versus 13.1%), but that the relative size of this subgroup was over four times larger (61-69% of all MSM/TGW versus 15%). We infer that the insertive MSM accounted for 10-20% of all prevalent HIV infections among urban males aged 15-49. Mathematical modelling can be used with data on 'visible' MSM/TGW to provide insights into the characteristics of 'hidden' MSM. A greater understanding of the sexual behaviour of all MSM/TGW is important for effective HIV programming. More broadly, a hidden subgroup with a lower infectious disease prevalence than more visible subgroups, has the potential to contain more infections, if the hidden subgroup is considerably larger in size.

Determinants of consistently high HIV prevalence in Indian Districts: A multi-level analysis

INTRODUCTION

Factors associated with persistently high Human Immunodeficiency Virus (HIV) prevalence levels in several districts of India are not well understood. This study was undertaken to determine the association of socio-demographic characteristics, economic factors, awareness about HIV and Sexually Transmitted Infections (STIs), and condom use with consistently high HIV prevalence in the Indian districts and to ascertain whether these associations differed across various regions of India.

METHODS

This study was carried out including all 640 districts of India. Secondary analysis of data obtained from the Census of India-2011, HIV Sentinel Surveillance in India and District Level Household Survey-III was done. Population profile, socio-economic characteristics, levels of HIV/STI/condom awareness and condom use, were compared between the districts with and without consistently high HIV prevalence. Due to the presence of collinearity among predictor variables, we used principal component analysis and the principal component scores were included as covariates for further analysis. Considering the districts at level 1 and the regions at level 2, multi-level analysis was done by generalised linear mixed models. Variance partition coefficient and median odds ratio were also calculated.

RESULTS

Sixty-three districts with consistently high HIV prevalence were found clustered in the South and the North-east regions of India. Population size, density and urbanisation were found to be positively associated with consistently high HIV prevalence in these districts. Higher levels of literacy, better socio-economic status, higher proportion of population in reproductive age group and late marriages were positively associated with consistently high HIV prevalence in all regions of India except in the Southern region. Higher levels of knowledge about the role of condoms in HIV prevention and condom use were associated with low HIV prevalence at the district level.

CONCLUSIONS

Considerable heterogeneity among factors associated with consistently high HIV prevalence at the district level in different regions of India necessitates special region-specific strategies for HIV control. Increasing awareness about HIV alone is not sufficient for controlling the HIV epidemic and there is a need to raise knowledge levels about preventive measures against HIV and promote the use of condoms amongst population.

HIV drug resistance following a decade of the free antiretroviral therapy programme in India: A review

OBJECTIVE

The objective of this review was to assess the burden of HIV drug resistance mutations (DRM) in Indian adults exposed to first-line antiretroviral therapy (ART) as per national guidelines.

METHODS

An advanced search of the published literature on HIV drug resistance in India was performed in the PubMed and Scopus databases. Data pertaining to age, sex, CD4 count, viral load, and prevalence of nucleoside reverse transcriptase inhibitor (NRTI)/non-nucleoside reverse transcriptase inhibitor (NNRTI) DRM were extracted from each publication. Year-wise Indian HIV-1 reverse transcriptase (RT) sequences were retrieved from the Los Alamos HIV database and mutation analyses were performed. A time trend analysis of the proportion of sequences showing NRTI resistance mutations among individuals exposed to first-line ART was conducted.

RESULTS

Overall, 23 studies (1046 unique RT sequences) were identified indicating a prevalence of drug resistance to NRTI and NNRTI. The proportion of RT sequences with any DRM, any NRTI DRM, and any NNRTI DRM was 78.39%, 68.83%, and 73.13%, respectively. The temporal trend analysis of individual DRM from sequences retrieved during 2004-2014 indicated a rising trend in K65R mutations (p=0.013).

CONCLUSIONS

Although the overall burden of resistance against first-line ART agents remained steady over the study decade, periodic monitoring is essential. There is the need to develop an HIV-1 subtype C-specific resistance database in India.

Risking the Future: Unprotected Intercourse and HIV/AIDS Knowledge among Female Commercial Sex Workers in Central Bangladesh

This study examined levels of AIDS knowledge and condom practices in a sample of female commercial sex workers (CSWs) in Bangladesh. The 284 subjects were questioned about AIDS knowledge using a 12-item AIDS knowledge and patterns of condom use questionnaire. The subjects had a moderate knowledge of AIDS with 61.5 percent of the sample responding correctly to 6 or more of the 12 AIDS knowledge questions. Those with high levels of AIDS knowledge used condoms at a higher rate than those with low levels of AIDS knowledge. These CSWs were predominantly young (36.6 percent) and illiterate (62.7 percent). Street-based CSWs were at greatest risk for acquiring HIV; many reported less frequent use of condom than brothel-based CSWs. The majority knew that condoms offered protection against HIV/AIDS, although only 11 percent reported using condoms prior to the day of survey. Misconception and confusion were identified regarding modes of transmission and prevention.

Community-Based Sexual Risk Prevention Program for SRI Lankan Youth: Influencing Sexual-Risk Decision Making

This article describes the design, implementation, and evaluation of a sexual-risk prevention program focused on the development of individual competencies and cultural norms promoting healthy sexual decision making. The community-based peer-facilitated intervention targeted adolescents and young adult men and women in Sri Lanka, who participated in small-group activities targeting sexual knowledge, attitudes, and practices; risk perception; and sexual-risk decision making. The intervention and evaluation tools were based on formative research data collected from members of the target population. Researchers from Sri Lanka and North America collaborated with local community health workers and community members in formative data collection and program development. The pilot intervention project was successful in improving sexual-risk perception and decision making, and (for women) knowledge of condoms and sexual terminology. The use of group process showed promise as a tool for fostering negotiation of perspectives and consensus building regarding sexuality and sexual risks. The lessons learned from this project can inform the development of culture-specific sexual-risk prevention programs worldwide.

Citizenship in a time of HIV: Understanding medical adult male circumcision in South Africa

Medical adult male circumcision has been shown to offer men significant protection against HIV infection during peno-vaginal sex. This has resulted in calls for a national roll-out of medical adult male circumcision in South Africa, a rights-based constitutional democracy. This article explores the ways that the potential tensions between this call to circumcise as a practice of good health citizenship and the guaranteed right to bodily integrity are negotiated in interviews with 30 urban-based men in Johannesburg. The results suggest that despite its demonstrable biological efficacy, these tensions may paralyse decision- and policy-makers in grappling with the potential scaling up of medical adult male circumcision for HIV prevention in South Africa.

Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis

BACKGROUND

Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall effectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention.

METHODS

We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the first 4 years (2004-07 or 2005-08 dependent on the district) and the full 10 years (2004-13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the effectiveness estimates. Using regression analysis, we extrapolated the prevention effect in the districts covered by IBBAs to all 69 Avahan districts.

FINDINGS

In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32700 HIV infections (95% credibility interval 17900-61600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62800 (32000-118000) averted infections, and extrapolation suggested that 202000 (98300-407000) infections were averted across all 69 Avahan districts in South India, increasing to 606000 (290000-1 193000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted.

INTERPRETATION

This is the first assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The findings suggest that substantial preventive effects can be achieved by targeted behavioural HIV prevention initiatives.

FUNDING

Bill & Melinda Gates Foundation.

An observational study of the pattern of HIV infection in a specified rural area of India with special reference to migratory laborers

OBJECTIVE

Determination of the pattern of HIV/AIDS in patients attending voluntary confidential counseling and testing center (VCCTC) and prevention of parent-to-child transmission (PPTCT) center of a low-prevalence district of Eastern India. To find out high-risk group and interventional strategy for prevention.

METHOD

Cross-sectional exploratory secondary data analysis from the VCCTC and PPTCT register.

RESULT

Of the 1348 participants, 160 (11.86%) adults were HIV seropositive. Prevalence in males and females was 9.8% and 20.7%, respectively. Among 22 (1.63%) seropositive children, transmission was vertical in 18 (81.8%). Seventy-one (88.75%) positive adult males were migratory goldsmiths working in Mumbai and other big cities. They were clustered in a particular locality (Daspur).

CONCLUSION

Goldsmiths migrated from Daspur to big cities are the bridge populations who are responsible for higher prevalence of HIV in their families and locality. Interventional strategies targeted at this high-risk group are suggested.

Domestic violence and forced sex among the urban poor in South India: implications for HIV prevention

This article examined the prevalence of physical and sexual violence among 1,974 married women from 40 low-income communities in Chennai, India. The authors found a 99% and 75% lifetime prevalence of physical abuse and forced sex, respectively, whereas 65% of women experienced more than five episodes of physical abuse in the 3 months preceding the survey. Factors associated with violence after multivariate adjustment included elementary/middle school education and variables suggesting economic insecurity. These domestic violence rates exceed those in prior Indian reports, suggesting women in slums may be at increased risk for HIV and other sexually transmitted infections.

Increasing prevalence of HIV, and persistent high-risk behaviours among drug users in Bangladesh: need for a comprehensive harm reduction programme

INTRODUCTION AND AIMS

The aim of this study was to examine trends in HIV and related risk behaviours in drug users in Bangladesh, the effects of prevention and harm reduction initiatives that have already been undertaken and to highlight immediate needs.

DESIGN AND METHODS

Journal publications, conference abstracts and proceedings were collected and reviewed. As there were relatively few published papers, the grey literature was also reviewed. Experts involved in the development and evaluation of current programmes or policy were contacted for official reports, policy documents or unpublished materials. The trends in injecting and sexual risk behaviours were tabulated.

RESULTS

Periodic behavioural and serosurveillance on recognised sentinel groups shows clearly that HIV prevalence among injecting drug users has been increasing steadily. In the capital city, the HIV prevalence among injecting drug users is close to the level of a concentrated epidemic (4.9%). While harm reduction strategies have brought a scope of reduction of injecting-related risk behaviours, the persistent high rates of needle sharing and high prevalence of sexual risk behaviours remains alarming. Non-injecting drug users have maintained a low prevalence of HIV but their high-risk sexual behaviours and transformation into injecting drug users with time are of concern.

DISCUSSION AND CONCLUSIONS

There are substantial gaps between current needs and the ongoing prevention and harm reduction activities. There is a pressing need for a comprehensive harm reduction programme and review of any policies and laws which may impede this.

Estimation of the predictive role of plasma viral load on CD4 decline in HIV-1 subtype C-infected subjects in India

BACKGROUND

Plasma viral load has been shown to be a meaningful prognostic marker for disease progression in untreated, HIV-1 subtype B-infected subjects in United States and Western Europe and therefore used as a prognostic marker for disease progression. Because of high expenses of commercially available viral load assays, the role of viral load in disease progression has not been evaluated in HIV-1 subtype C-infected patients in India.

METHODS

We developed an inexpensive real-time reverse transcriptase-polymerase chain reaction assay to quantify viral load in plasma of HIV-1 subtype C-infected subjects from India and used it in a longitudinal analysis of viral load and CD4 cell number in HIV-infected subjects from Calcutta, India.

RESULTS

The real-time reverse transcriptase-polymerase chain reaction assay can quantify plasma viral load with a linear range of detection from 10 to 10 HIV-1 RNA copies per input. Longitudinal analysis of viral load in a cohort of 39 subjects over an average period of approximately 3 years indicates that 1-log increase in HIV-1 RNA level was associated with a decline of 67 CD4 cell count. Furthermore, HIV-1 RNA level between 500 and 50,000 copies per milliliter would predict a 12.9% decrease in CD4 cell count per year, whereas HIV-1 RNA levels above 50,000 copies HIV-1 RNA per milliliter would predict a 25.3% decrease in CD4 cells per year. In addition, we estimated that the mean incubation period of disease development, as defined by the loss of CD4 below 200, is 8.2 years.

CONCLUSION

Our report on the level of viral load on predicting CD4 decline in Indian subjects with HIV-1 provides an additional important tool to the physicians for treating and planning a therapeutic strategy to control HIV-1 infection in India.

HIV rates and risk behaviors are low in the general population of men in Southern India but high in alcohol venues: results from 2 probability surveys

BACKGROUND

As the HIV epidemic continues to expand in India, empiric data are needed to determine the course of the epidemic for high-risk populations and the general population.

METHODS

Two probability surveys were conducted in Chennai slums among a household sample of men and alcohol venue patrons ("wine shops") to compare HIV and other sexually transmitted disease (STD) prevalence and to identify STD behavioral risk factors.

RESULTS

The wine shop sample (n = 654) had higher rates of HIV and prevalent STDs (HIV, herpes simplex virus 2 [HSV-2], syphilis, gonorrhea, or chlamydia) compared with the household sample (n = 685) (3.4% vs. 1.2%, P = 0.007 and 21.6% vs. 11.8%, P < 0.0001, respectively). High-risk behaviors in the household sample was rare (<4%), but 69.6% of wine shop patrons had >2 partners, 58.4% had unprotected sex with a casual partner, and 54.1% had exchanged sex for money in the past 3 months. A multivariate model found that older age, ever being married, ever being tested for HIV, and having unprotected sex in the past 3 months were associated with STD prevalence in wine shop patrons.

CONCLUSIONS

Prevalent HIV and STDs, and sexual risk behaviors are relatively low among the general population of men. We found that men who frequent alcohol venues practice high-risk behaviors and have high rates of STDs, including HIV, and may play an important role in expanding the Indian epidemic.

Risk factors for HIV infection in males who have sex with males (MSM) in Bangladesh

Background

Recent surveillance data from Bangladesh indicate rising HIV infection among intravenous drug users (IDU) in the country. We suggest a likely association between HIV risk factors in this group and other groups, such as males who have sex with males (MSM).

Methods

Data on MSM in Bangladesh was collected and analyzed from numerous primary and secondary sources, including government ministries, non-profit health organizations, and personal communications.

Results

The overall prevalence of HIV in Bangladesh is relatively low, but surveillance data indicate that infection has reached significant proportions in certain high-risk groups and may soon spread to other groups, specifically MSM.

Conclusion

The epidemiology of HIV infection in other countries suggests that increasing rates of HIV in higher-risk populations can precede an epidemic in the general population. We review the data concerning MSM, IDU and HIV in Bangladesh from a variety of sources and propose ways to prevent HIV transmission.

Age, sex, and HIV seroprevalence among individuals from different parts of India tested for HIV infection in a nongovernmental setting

India has a large population of HIV-infected individuals, but the amount of information available about this population is small and not commensurate with the population's size. Here, we report the age and sex for 11,925 individuals tested for HIV infection in a nongovernmental setting over a 36-month period. The samples were derived from 161 sites located in different parts of the country and the odds of HIV infection among males was 2.27 times that for females. Of the samples from males and females tested, 50 and 65%, respectively, were in the 16-35 year age group. Of the seropositive samples excluding less than 1 year of age, 92% were in the 16-50 year age group. Analysis of this testing data provides limited but valuable information on the HIV epidemic in India.

HIV-1 subtype C dissemination in southern Brazil

OBJECTIVES

To describe the molecular and epidemiological profile of HIV-1 in patients followed at the University Hospital of Rio Grande, Brazil.

DESIGN AND METHODS

A cross-sectional study was conducted from September to December 2002. Plasma viral RNA of 85 patients was extracted and protease and reverse transcriptase genes were polymerase chain reaction-amplified and sequenced. Sequences were subtyped and examined to antiretroviral resistance mutations. Laboratory data and past history of antiretroviral treatment were also collected.

RESULTS

Most viruses were either subtype B (42%) or subtype C (45%). No risk behaviour, sexual orientation or laboratory parameter was associated with any specific subtype, but subtype C tended to be more frequently found in women (P = 0.06). The prevalence of subtype C has increased over the HIV/AIDS epidemic, accounting for almost 60% of cases diagnosed in 2002. Intra-subtype genetic distances were smaller in subtype C than in subtype B, suggesting a more recent introduction of the former in the epidemic. Of patients under treatment, 60% had at least one antiretroviral drug resistance mutation, but no mutation was specifically associated with any HIV-1 subtype. Only one resistance mutation each was found in drug-naive patients with subtypes B and C.

CONCLUSION

Despite the fact that subtype C appeared in southern Brazil more recently than subtype B, it is now the predominant strain in Rio Grande. The epidemic spread of subtype C could be taking place in Brazil, and possibly in south America, a phenomenon similar to that seen in other countries where this subtype is now totally dominant.

Usefulness of routine preoperative testing: a prospective single-observer study

STUDY OBJECTIVE

The purpose of this study is to determine whether routine preoperative testing has a usefulness not previously recognized in a small preliminary study to decide if such a hypothesis might be worthy of testing in a larger study.

DESIGN

Single-observer, prospective, observational study.

SETTING

Tertiary-care referral center in South India that performs 11 preoperative tests on each patient.

PATIENTS

One hundred twenty-seven adult patients scheduled for elective neurosurgery.

INTERVENTIONS

Patients were studied to determine whether outcome was influenced by laboratory tests, which were either indicated by health history elicited by a computerized rule-based questionnaire or unindicated by patient history.

MEASUREMENT AND MAIN RESULTS

Of the 1395 tests performed preoperatively, 513 (36.8%) were indicated and 882 (63.3%) were unindicated. Of 513 indicated tests, 17 (3.3%) prompted changes in patient care; 8 (0.91%) of 882 unindicated tests (P < .001) prompted changes in care. All patients with anemia, significant electrocardiographic abnormalities, or HIV infection were detected by the computerized questionnaire. Among the changes in care prompted by unindicated tests, 4 patients received diabetic therapy or counseling, and 4 patients with abnormal silhouettes on chest radiograph had nonbeneficial echocardiography. Only screening for diabetes seemed to have usefulness as a routine preoperative test in this patient population.

CONCLUSION

Although the incidence of unindicated preoperative screening tests is still more than 50%, no previously unidentified benefit was found to support this persistence of unwarranted testing. The limited number of patients in this study necessitates a larger study to ensure greater certainty before such a recommendation is made to the public. If similar results in another but larger study involving similar design, simple changes in the system of preoperative care may save the health care system the considerable expense of unwarranted testing.

HIV infection and high-risk behaviors in opioid dependent patients: the Indian context

Various risk behaviors promote the spread of HIV in drug addicts. Reflecting the substantial regional and geographic differences in the impact of HIV, its prevalence rates vary from country to country. In view of increasing reports of injection drug-uses (IDUs) from different parts of India, the study was aimed to examine and investigate the difference in prevalence rates of seropositivity between IDUs and non-IDUs in patients of drug dependence and to compare the pattern of risk behaviors due to sexual and drug use practice in IDUs and non-IDUs. A high HIV seroprevalence of 8.3% between IDUs and 1.8% in non-IDUs was found. The study findings suggest a trend towards drug-related risks being higher than sex-related risks in IDUs.

High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India

OBJECTIVE

To estimate HIV and sexually transmitted disease (STD) prevalence and behavioral risk characteristics of men who have sex with men (MSM) in Chennai, India.

METHODS

A cross-sectional population-based random sample survey was conducted in 2001. Randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors through face-to-face interviews. Sera and urine were examined for syphilis, HIV-1, gonorrhea, and chlamydia. Logistic regression analyses were used to assess associations between MSM status and HIV infection and to identify risk characteristics of MSM.

RESULTS

Of 774 men, 46 reported (5.9%) sex with other men. MSM were more likely to be seropositive for HIV (odds ratio [OR] = 8.57; 95% confidence interval [CI]: 1.83, 40.23) and were more likely to have a history of STD (OR = 2.66; 95% CI: 1.18, 6.02) than non-MSM. Men who used illicit drugs in past 3 months (adjusted odds ratio [AOR] = 4.01; 95% CI: 1.92, 8.41), ever exchanged money for sex (AOR = 3.93; 95% CI: 1.97, 7.84), or were ever tested for HIV (AOR = 3.72; 95% CI: 1.34, 10.34) were significantly more likely to report sex with men.

CONCLUSIONS

MSM in Chennai slums are at high risk for HIV. HIV prevention strategies aimed at changing unsafe drug and sexual practices should target the general population of men, with specific attention to areas with high rates of MSM.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

HIV/AIDS knowledge, beliefs, and behavior among women of childbearing age in India

This study investigated the relationships of health beliefs and HIV/AIDS knowledge with frequency of condom use among women of childbearing age in four major Indian cities. Surveys were completed by 210 women attending six primary health care centers. Among the sexually active women (N = 139), 68% noted rare or no use of condoms during intercourse. Perceived benefits (p < .05) and normative efficacy in requesting condom use (p = .01) were related to a greater frequency of condom use. About 54% of women knew that breast milk could transmit HIV, but fewer than a third were aware that an HIV-positive mother does not always infect her infant at delivery. Most participants endorsed HIV testing for women prior to pregnancy. Approximately three fourths of participants advocated abortion for HIV-seropositive pregnant women. Intervention efforts may benefit from dispelling misconceptions about AIDS (particularly regarding vertical transmission), emphasizing perceived benefits and women's efficacy in requesting condom use, increasing the availability of HIV testing, and highlighting choices for seropositive women of reproductive age as alternatives to abortion.

In vitro hypersusceptibility of human immunodeficiency virus type 1 subtype C protease to lopinavir

In order to characterize the impact of genetic polymorphisms on the susceptibility of subtype C strains of human immunodeficiency virus type 1 to protease inhibitors (PIs), a subtype B protease that originated from an infectious clone was modified through site-directed mutagenesis to include the amino acid residue signatures of subtype C viruses (I15V, M36I, R41K, H69K, L89 M) with (clone C6) or without (clone C5) an I93L polymorphism present as a molecular signature of the worldwide subtype C protease. Their susceptibilities to commercially available PIs were measured by a recombinant virus phenotyping assay. We could not detect any differences in the 50% inhibitory concentration (IC(50)s) of amprenavir, indinavir, ritonavir, saquinavir, and nelfinavir for the clones analyzed. However, we did observe hypersusceptibility to lopinavir solely in clone C6, which includes the I93L substitution (a 2.6-fold decrease in the IC(50) compared to that for the subtype B reference strain). The same phenotypic behavior was observed for 11 Brazilian and South African clinical isolates tested, in which only subtype C isolates carrying the I93L mutation presented significant hypersusceptibility to lopinavir.

Behavioral risk factors for STD/HIV transmission in Bangladesh's trucking industry

To examine behaviors that could influence STD/HIV transmission in Bangladesh's trucking industry, a survey was orally administered to 388 truck drivers/helpers at Tejgaon truck stand in Dhaka. A two-tiered sampling strategy was used: 38 trucking agencies were randomly selected and a mean of 10.2 subjects was recruited from each agency. Focus group and in-depth interviews were also conducted. The focus was on behaviors that affect (i) exposure to STD/HIV infection, (ii) efficiency of transmission of infection and (iii) duration of infectiousness. The findings illustrated that intravenous drug use was not an important risk factor; only 1 subject had used drugs intravenously. Sexual risk behaviors, however, were prevalent: the mean number of sexual partners in the past year was 4.57 (SD=8.70) and in the past 3 months was 1.82 (SD=3.27). Premarital and extramarital sex was common, often with commercial sex workers (CSW); 54% of all subjects had relations with at least 1 CSW in the past year. In a multiple logistic regression analysis, subjects who engaged in other types of socially risky behavior (drinking alcohol, ingesting or smoking recreational drugs, having sex with other men) were significantly (p<0.05) more likely to have had sex with a CSW in the past year. While 7.2% of subjects had a male sex partner in the past year, 21% had ever had one (likely youthful experimentation for most). Condom use was very infrequent: of the 343 subjects who had ever had sexual intercourse only 31% had ever used a condom and most of those subjects had used only once or occasionally. Having sex with CSWs, being married, having heard of AIDS and age were significantly associated (p<0.05) with ever use of condoms. Frequently, subjects who had genital symptoms either did not have those symptoms treated at all or treated in a timely fashion, and over 1/3 did not change their sexual behavior while infected. To reduce the potential for the spread of STD/HIV in this population, appropriate treatment practices for sexually transmitted infections need to be encouraged and condom use promoted, particularly in the context of casual sexual relations.

A specific subtype C of human immunodeficiency virus type 1 circulates in Brazil

OBJECTIVE

To characterize the subtype C strains of HIV type 1 that circulate in Brazil, especially those originated from the southern part of the country.

DESIGN AND METHODS

One hundred and twelve HIV-1-positive subjects had their plasma viral RNA extracted. Protease (PR) and reverse transcriptase (RT) genomic regions were polymerase chain reaction-amplified and sequenced for subtype determination. Subtype C strains were selected and compared to other strains of this subtype from the database, and specific amino acid signature patterns were searched.

RESULTS

Brazilian subtype C viruses form a very strong monophyletic group when compared to subtype C viruses from other countries and presented specific signature amino acids. Recombinants between subtype C and B viruses have been documented in areas of co-circulation. The incidence of primary PR and RT inhibitor resistance mutations in drug-naïve subjects was observed. An increasing number of secondary resistance mutations was also seen, some of which are characteristic of subtype C-related sequences.

CONCLUSIONS

Introduction of subtype C of HIV-1 in Brazil was likely a single event of one or a mixture of similarly related strains. Recombination between subtype C and B viruses is an ongoing process in the country. Primary and secondary drug resistance mutations were observed, although some of the secondary mutations could be associated with subtype C molecular signatures. Subtype-specific polymorphisms of PR and RT sequences found in this subtype C Brazilian variant might influence this emergence and have an impact on HIV treatment and on vaccine development in the country.

Extent and speed of spread of HIV infection in India through the commercial sex networks: a perspective

India has the world's highest number of HIV/AIDS infections for any country outside Africa. Eighty-five per cent of HIV transmission in India occurs through heterosexual contact. One billion population, a large number of female sex workers, high prevalence of sexually transmitted infection (STIs) and low condom use make a potent combination for explosive growth of the epidemic. Taking available estimates of the number of female sex workers (FSWs), their work patterns, prevalence of HIV and STIs and condom use among them in 1999 as the base, and adopting reasonable infectivity rates, this paper attempts to present a model to estimate the spread of HIV infection in commercial sex networks until 2005. HIV infections in commercial sex networks are estimated to increase from the 1999 level of approximately 2.49 million to about 3.93 million by 2005 in a favourable scenario, and to 6.87 million in a worse scenario. Spread of HIV is influenced in the short term by condom use and prevalence of STIs, and these are the only factors that can be manipulated to limit the spread of the infection.

Human immunodeficiency virus type 1 env sequences from Calcutta in eastern India: identification of features that distinguish subtype C sequences in India from other subtype C sequences

India is experiencing a rapid spread of human immunodeficiency virus type 1 (HIV-1), primarily through heterosexual transmission of subtype C viruses. To delineate the molecular features of HIV-1 circulating in India, we sequenced the V3-V4 region of viral env from 21 individuals attending an HIV clinic in Calcutta, the most populous city in the eastern part of the country, and analyzed these and the other Indian sequences in the HIV database. Twenty individuals were infected with viruses having a subtype C env, and one had viruses with a subtype A env. Analyses of 192 subtype C sequences that included one sequence for each subject from this study and from the HIV database revealed that almost all sequences from India, along with a small number from other countries, form a phylogenetically distinct lineage within subtype C, which we designate C(IN). Overall, C(IN) lineage sequences were more closely related to each other (level of diversity, 10.2%) than to subtype C sequences from Botswana, Burundi, South Africa, Tanzania, and Zimbabwe (range, 15.3 to 20.7%). Of the three positions identified as signature amino acid substitution sites for C(IN) sequences (K340E, K350A, and G429E), 56% of the C(IN) sequences contained all three amino acids while 87% of the sequences contained at least two of these substitutions. Among the non-C(IN) sequences, all three amino acids were present in 2%, while 22% contained two or more of these amino acids. These results suggest that much of the current Indian epidemic is descended from a single introduction into the country. Identification of conserved signature amino acid positions could assist epidemiologic tracking and has implications for the development of a vaccine against subtype C HIV-1 in India.

Ocular and systemic lesions in children with HIV

The spectrum of ocular lesions in children with HIV infection is different from that seen in adults. Ocular lesions in pediatric AIDS patients have not been studied in India. We analyzed the clinical profile, demographic characteristics, ocular and systemic lesions in children with AIDS seen in a referral eye institute in India. The clinical profile and demographic features were studied and complete ocular examination was done. Systemic findings were evaluated at an AIDS care center and recorded in a precoded proforma. Out of the 218 cases of HIV infection seen at our hospital between December 1993 and October 1999, 12 (5.50%) were below 15 years of age. Seven (58.33%) were males and 5 (41.66%) were females with the mean age of 6.5 years and median age of 6.2 years. Vertical transmission was the most common mode of infection (58.33%). Seven (58.33%) of these patients had systemic infection, the most common being pulmonary tuberculosis (42.85%). Ocular lesions were found in 6 (50%) patients. The most common ocular lesions were anterior uveitis and cytomegalovirus retinitis (CMV) (33%) followed by retinal detachment (16.66%) and vitreous hemorrhage (16.66%). High prevalence of ocular lesions in pediatric AIDS patients in India in a referral eye centre was observed. The most common lesions were anterior uveitis followed by CMV retinitis. The management in such cases was often challenging in a developing country like India.

Developing an interactive STD-prevention program for youth: lessons from a north Indian slum

An intervention developed to teach young men in the urban slums of Lucknow, India, about sexually transmitted diseases is described in detail. This community-based intervention was designed to impart core educational messages and to address preexisting ideas about sexual health and STD-prevention practices among participants. Indicators of knowledge recorded before and after the intervention are presented and evaluated against the scores of a control group. Levels of sexual activity and factors associated with risky sex are discussed. The intervention was successful in raising the young men's awareness of STDs significantly in all areas except for the length of time that symptoms take to manifest following risky sex and the ineffectiveness of washing one's genitals after sex to avoid acquiring STDs. Lessons learned during the intervention are described as a means of informing future STD-education programs, and issues requiring prompt attention are identified.

Behaviours and expectations in relation to sexual intercourse among 18-20 year old Asians and non-Asians

OBJECTIVES

To begin to map the reported behaviours and attitudes of young Britons of south Asian origin that may have implications for sexual health. "South Asian" refers to people able to trace their ancestry from the Indian subcontinent (that is, India, Pakistan, and Bangladesh), henceforth referred to as "Asian".

DESIGN

A cross sectional study of sexual behaviour using self report measures in a self complete section of a social survey administered by trained interviewers in 1996.

SETTING

Greater Glasgow, Scotland.

SUBJECTS

Sample (n = 824) originally recruited aged 14-15 in 1992 in secondary schools in Greater Glasgow and subsequently traced through general practitioner registration for 1996 survey. 492 Asians and non-Asians aged 18-20 years old eventually interviewed in their own homes.

MAIN OUTCOME MEASURES

Self reported experience of sexual intercourse, age at first intercourse, and contraceptive practice over year before interview.

METHODS

Measures of sexual behaviour and attitudes were elicited through a self complete questionnaire filled out in the presence of, and returned to, a trained social interviewer.

RESULTS

Asians, and particularly Asian women, were far less likely to report having had heterosexual intercourse. Those Asian women who had had intercourse were likely to do so for the first time at an older age, and with an older partner, than the non-Asian women. Asian women were less likely to report using the pill than non-Asian women, irrespective of their marital status, and Asian men were less likely than non-Asian men to report using condoms. Asian sexual abstinence was reported to be for religious reasons, which were not important for non-Asians. In contrast with non-Asians, Asians saw themselves as likely to be married with children within the next 5 years. Asian men considered the ideal age to marry for men and women to be younger than the non-Asian men's average estimate. Asian and non-Asian women suggested a similar ideal age for men to marry, but Asian women considered a younger age appropriate for women than did non-Asian women.

CONCLUSIONS

The higher level of sexual abstinence among Asians, and particularly women, has implications for the delivery of sexual health services to the minority who are sexually active before marriage. The underreporting of condom use by Asian men compared with their non-Asian counterparts, suggests a failure of the existing sexual health education and health services to reach minority ethnic young men which may be remedied by collaborative work with institutions currently used by the Asian community.

Behavioural risk factors for HIV/AIDS in a low-HIV prevalence Muslim nation: Bangladesh

A review of published and unpublished data indicates the prevalence of high-risk behaviours for HIV transmission in segments of the Bangladeshi population. These include casual unprotected sex, heterosexual as well as between males, prior to and after marriage. Intravenous drug use (IVDU) exists though illicit drugs are more commonly inhaled. There is a fear, however, that inhalers may turn to injecting drugs, as is common in neighbouring countries. The lack of public awareness of HIV/AIDS, and misconceptions about the disease, may contribute to continued high-risk behaviours by segments of the population and, thus, to the spread of HIV. Bangladesh's proximity to India and Myanmar (countries with high HIV endemicity and a rapidly growing number of cases) increases fears of an epidemic in Bangladesh. This proximity will only be a risk factor, however, if high-risk contacts occur between nationals of these countries.

Oral manifestations of HIV infection in a group of predominantly ethnic Chinese

A total of 32 HIV-infected, predominantly ethnic Chinese individuals from Hong Kong were examined for oral mucosal lesions over a period of 1 year. The commonest oral lesion found was minor aphthous ulceration (27.4%), while xerostomia (17.8%), ulceration NOS (not otherwise specified; 12.3%), hairy leukoplakia (11.0%) and erythematous candidiasis (6.9%) were less frequent; Kaposi's sarcoma was notable for its absence. When the relationship between the number of oral lesions with age, risk group, medication taken, CDC staging and CD4+ count of the study group was investigated, a significantly higher number of oral lesions was associated with use of AZT, homosexuals and CDC stage IV; in contrast, a smaller number of lesions was found in those on antiparasitics and multivitamins (all P<0.05). When compared with studies from other parts of the world, the frequency of oral lesions appeared to be less common in the current study group. However, due to a lack of similar studies from the Asian region, especially in ethnic Chinese, it is not clear whether this difference could be attributed to racial, social or geographic factors.

Surveillance for the impact in the UK of HIV epidemics in South Asia

OBJECTIVES

To determine whether, because of the extensive recent spread of HIV infection in South Asia, South Asians (those people who classify themselves as Indian, Pakistani, Bangladeshi or Sri Lankan in origin) resident in the UK were at increased risk of HIV infection and to review current surveillance systems for detecting any such increase.

DESIGN

Analysis of: ethnic grouping and probable country of infection recorded on voluntary confidential reports of AIDS cases and newly diagnosed HIV infections; blood donation testing data; reports of imported gonorrhoea infections; country of birth data from the unlinked anonymous (UA) survey of Sexually Transmitted Disease (STD) clinic attenders; district of residence data from the UA survey of pregnant women; ethnic grouping of prevalent diagnosed HIV infections.

RESULTS

Few reported AIDS cases or HIV infections were found in people of South Asian ethnic origin and few reported HIV or gonorrhoea infections were associated with exposure in South Asia. Data derived from the UA programme suggested as yet no increase in HIV prevalence in either STD clinic attenders born in South Asia or in pregnant women resident in districts containing substantial numbers of ethnic South Asians.

CONCLUSIONS

There was no evidence that South Asians resident in the UK are currently at greater risk of HIV infection than people of white ethnicity or, therefore, that south Asian heterosexuals are a group deserving priority in HIV prevention. However, as rapid spread of HIV infection is being recorded in the Indian subcontinent, continuous monitoring is necessary. This will be facilitated by improved collection of ethnic group information in all surveillance activities.

Ethnic minorities and their vulnerability to AIDS in a border state of India

To successfully stall the spread of HIV/AIDS among the ethnic minorities in India, it is imperative that we not only understand the complexity of issues in India with regard to HIV spread among ethnic groups but also comprehend that straightforward measures that might have worked in the context of other countries may not work in the Indian context. The authors present field work data and the results of interviews with 635 opinion leaders from eight 'tribal groups' from the north eastern border state of Manipur in India where a high rate of HIV infection is reported among the IDUs (intravenous drug users). The study found community support for AIDS, sex and drug education, along with an increasing perception of social vulnerability. Even though respondents perceive the threat of infection, few feel that they are personally susceptible. As HIV/AIDS prevention programmes compete with other socioeconomic conditions, the prevention blue print must be tailored to meet diverse demands in the study area and of the ethnic minorities in India.

Full-length human immunodeficiency virus type 1 genomes from subtype C-infected seroconverters in India, with evidence of intersubtype recombination

The development of an effective human immunodeficiency virus type 1 (HIV-1) vaccine is likely to depend on knowledge of circulating variants of genes other than the commonly sequenced gag and env genes. In addition, full-genome data are particularly limited for HIV-1 subtype C, currently the most commonly transmitted subtype in India and worldwide. Likewise, little is known about sequence variation of HIV-1 in India, the country facing the largest burden of HIV worldwide. Therefore, the objective of this study was to clone and characterize the complete genome of HIV-1 from seroconverters infected with subtype C variants in India. Cocultured HIV-1 isolates were obtained from six seroincident individuals from Pune, India, and virtually full-length HIV-1 genomes were amplified, cloned, and sequenced from each. Sequence analysis revealed that five of the six genomes were of subtype C, while one was a mosaic of subtypes A and C, with multiple breakpoints in env, nef, and the 3' long terminal repeat as determined by both maximal chi2 analysis and phylogenetic bootstrapping. Sequences were compared for preservation of known cytotoxic T lymphocyte (CTL) epitopes. Compared with those of the HIV-1LAI sequence, 38% of well-defined CTL epitopes were identical. The proportion of nonconservative substitutions for Env, at 61%, was higher (P < 0.001) than those for Gag (24%), Pol (18%), and Nef (32%). Therefore, characterized CTL epitopes demonstrated substantial differences from subtype B laboratory strains, which were most pronounced in Env. Because these clones were obtained from Indian seroconverters, they are likely to facilitate vaccine-related efforts in India by providing potential antigens for vaccine candidates as well as for assays of vaccine responsiveness.

Methods and meanings in anthropological, epidemiological and clinical encounters: the case of sexually transmitted disease and human immunodeficiency virus control and prevention in India

Rapid assessment procedures informed by anthropology are increasingly commonly being utilised in the formulation of a range of international disease control and prevention strategies. Refinement of these rapid procedures has narrowly focused on their methods, in contrast with the broader potential scope of context-based anthropological contributions. The control of HIV and other sexually transmitted diseases (STDs) in India is used to illustrate the potential role of anthropologically informed insights and investigations in the development of effective interventions, with particular reference to the examples of syndromic management, symptom presentation and treatment provision. The paper argues for anthropological epidemiological and clinical studies to be properly integrated in order to fulfil their substantial potential for interdisciplinary illumination.

Comparative Perspectives on Living With HIV/AIDS in Late Life

The effects of HIV/AIDS on different societies spanning the globe are only beginning to be described. This article describes HIV/AIDS's emerging impact and consequences for families and societies around the globe, with a primary focus on middle-aged and older members. It first provides the current data on the evolving international profile of the HIV/AIDS epidemic. Then, using primary sources and published data, it explores three contrasting nation/state settings (Uganda, Thailand, and India) to describe the cultural, social structural, and family consequences of HIV/AIDS. Findings include identification of emerging and potential strains on core cultural practices related to social integration at the community and family levels, as well as shifts in normative role relationships between multiple generations. Direct and indirect challenges to core moral and ethical issues beyond those simply related to infectious disease prevention and treatment are also identified. Finally, this article draws on these explorations to formulate several key priorities for future research and practice related to HIV/AIDS among older adults.

Incidence of HIV and sexually transmitted diseases (STD) in a cohort of HIV-negative men who have sex with men (MSM)

OBJECTIVE

To determine the prevalence of sexually transmitted diseases (STD) and incidence of and risk factors for STD, including HIV-1, among a cohort of HIV-negative men who have sex with men (MSM).

SETTING

Seattle, Washington, United States.

PARTICIPANTS

Prospective cohort of 578 HIV-negative MSM in which risk factors for acquiring a STD over 12 months follow-up were evaluated using a cumulative incidence analysis.

MAIN OUTCOME MEASURES

Baseline tests obtained were: herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) Western blots, hepatitis B, and syphilis serologies; anorectal and pharyngeal Neisseria gonorrhoeae (GC) cultures; first-catch urine for leukocyte esterase (LE) and Chlamydia trachomatis (CT) ligase chain reaction (LCR). Men with a positive urine LE had urethral GC cultures obtained. The following outcomes were measured over 12 months follow-up: incident symptomatic bacterial STD (urethritis, proctitis, epididymitis), HSV-1 and HSV-2 seroconversion, and HIV-1 seroconversion. The 31 incident cases of STD (men with bacterial STD) were compared with those 489 men without symptomatic bacterial STD or seroconversion to HSV-1, HSV-2 or HIV-1 infection.

RESULTS

Bacterial STD were found in nine participants at enrollment; there were two cases of nonchlamydial urethritis, two cases of nonchlamydial epididymitis, and five cases of asymptomatic GC infection. At enrollment, HSV-2 antibodies were detected in 149 (26.0%) of 572 men and prior hepatitis B infection in 145 (34.8%) of 417 unvaccinated men. During the 1-year of follow-up, 31 men (5.7/100 person-years) had 34 episodes of a symptomatic bacterial STD syndrome (urethritis, epididymitis or proctitis). Urethritis was the most common STD syndrome, detected in 29 men, of whom 10 had GC and 19 had nongonococcal urethritis. In the 1-year of follow-up, five participants seroconverted to HIV-1 (1.3/100 person-years), four to HSV-2 (1.0/100 person-years), and seven to HSV-1 (4.3/100 person-years). Unprotected insertive anal sex [odds ratio (OR) 2.6; 95% confidence interval (CI) 1.2-5.6]; and nitrite inhalant ('poppers') use (OR, 2.3; 95% CI, 1.0-5.0) were independently associated with incident STD.

CONCLUSIONS

STD and HIV infection continue to be acquired even in a city with an overall low bacterial STD prevalence and among educated MSM receiving regular HIV screening and risk-reduction. Urethritis was the most common STD detected, and public health messages aimed at MSM need to emphasize safe insertive as well as receptive sexual practices.

A case-control analysis of risk factors in HIV transmission in South India

A case-control study was done among patients attending our clinic for sexually transmitted diseases in South India to assess risk factors for human immunodeficiency virus (HIV) infection. Of 5,876 patients tested, 105 (1.79%) were HIV antibody positive (87 men, 18 women) by enzyme-linked immunosorbent assay and Western blot. They were compared with an equal number of age- and sex-matched patients without HIV antibody. Risk factors significant in the crude odds ratio analysis were occupation (truck drivers and truck cleaners), age at first exposure, and sexual contact with commercial sex workers. In the logistic regression analysis, only a history of past genital ulcer was a significant risk factor. Other important findings of this study were that (a) the spread of HIV to women is mostly from their infected husbands and (b) regular condom use was reported by less than 8% of patients and controls. Obviously, the current methods of education of the population are far from adequate.

Dried sera for confirming blood-borne virus infections (HCV, HTLV-I, HIV & HBsAg)

For safe blood transfusion, developing countries face considerable problems including serological screening and confirmation of blood-borne virus infections (HCV, HTLV-I, HIV and HBsAg). Confirmation tests are not only costly but also require sophisticated techniques and expertise. In order to provide this support we have attempted to perform a virus antibody confirmation test on samples dried on blotting paper (BP). Forty-nine sera derived from selected patients and donors from Bombay, and nine donors' sera from Bellarussia were transported on BP. In control experiments, dilutions of antibody-positive sera (HIV, HTLV-I & HCV) and 'blinded' HTLV-I antibody-positive and antibody-negative donors were applied on BP. Eluates from snipped BP were tested initially by screening tests, and the reactives were subjected to confirmatory tests for three types of virus antibody tests (HCV, HTLV-I & HIV) by blotting methods and neutralisation tests for HBsAg. There was considerable reduction of titres in dry sera but all BP-derived dry specimens gave excellent qualitative concordance with their liquid-equivalent sera, and the HTLV-I-positive donor was identified and reconfirmed correctly. Presence of only HCV antibody was confirmed in all the nine selected Bellarussian donors. Blood donors in Bombay had 3% HIV antibody, 6% HBsAg and none had HCV antibody, while selected patients showed substantially higher levels of these markers: HIV-antibody 64%, HBsAg 57% and HCV-antibody 17% confirmed positive. The cause of this high level remains to be established. Dry samples received by post seem to be an economical approach to a first step in providing some levels of independent confirmation of reactives in developing countries.

Global burden of the HIV pandemic

Within the global pandemic of HIV infection there are many different epidemics, each with its own dynamics and each influenced by many factors including time of introduction of the virus, population density, and cultural and social issues. Effective management strategies depend on knowledge of all these factors. By the year 2000, WHO projections are that 26 million persons will be infected with HIV, more than 90% of whom will be in developing countries. To control AIDS, countries must not only promote changes in individual behaviour but also address social issues such as unemployment, rapid urbanisation, migration, and the status of women.

Risk factors for HIV infection in people attending clinics for sexually transmitted diseases in India

OBJECTIVE

To investigate the risk factors for HIV infection in patients attending clinics for sexually transmitted diseases in India.

DESIGN

Descriptive study of HIV serology, risk behaviour, and findings on physical examination.

SUBJECTS

2800 patients presenting to outpatient clinics between 13 May 1993 and 15 July 1994.

SETTING

Two clinics and the National AIDS Research Institute, in Pune, Maharashtra State, India.

MAIN OUTCOME MEASURE

HIV status, presence of sexually transmitted diseases, and sexual behaviour.

RESULTS

The overall proportion of patients infected with HIV was 23.4% (655/2800); 34% (184) of the women and 21% (459) of the men were positive for HIV infection. Of the 560 women screened, 338 (60%) had a reported history of sex working, of whom 153 (45%) were infected with HIV-1. The prevalence of HIV-1 infection in the 222 women who were not sex workers was 14%. The significant independent characteristics associated with HIV infection based on a logistic regression analysis included being a female sex worker, sexual contact with a sex worker, lack of formal education, receptive anal sex in the previous three months, lack of condom use in the previous three months, current or previous genital ulcer or genital discharge, and a positive result of a Venereal Disease Research Laboratory test.

CONCLUSIONS

In India the prevalence of HIV infection is alarmingly high among female sex workers and men attending clinics for sexually transmitted diseases, particularly in those who had recently had contact with sex workers. A high prevalence of HIV infection was also found in monogamous, married women presenting to the clinics who denied any history of sex working. The HIV epidemic in India is primarily due to heterosexual transmission of HIV-1 and, as in other countries, HIV infection is associated with ulcerative and non-ulcerative sexually transmitted diseases.