Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

V. M. L, Dutta S, Devi HS, Vardhana Rao Mendu V, Kant S, Pandey A, Reddy DCS, Mehendale S, Rajan S. Diversity in HIV epidemic transitions in India: An application of HIV epidemiological metrices and benchmarks

Background

The Joint United Nations Programme on AIDS (UNAIDS) has emphasized on the incidence-prevalence ratio (IPR) and incidence-mortality ratio (IMR) to measure the progress in HIV epidemic control. In this paper, we describe the status of epidemic control in India and in various states in terms of UNAIDS’s recommended metrices.

Method

The National AIDS Control Programme (NACP) of India spearheads work on mathematical modelling to estimate HIV burden based on periodically conducted sentinel surveillance for providing guidance to program implementation and policymaking. Using the results of the latest round of HIV Estimations in 2019, IPR and IMR were calculated.

Results

National level IPR was 0.029 [0.022–0.037] in 2019 and ranged from 0.01 to 0.15 in various States and Union Territories (UTs). Corresponding Incidence-Mortality Ratio was at 0.881 [0.754–1.014] nationally and ranged between 0.20 and 12.90 across the States/UTs.

Conclusions

Based on UNAIDS recommended indicators for HIV epidemic control, namely IPR and IMR; national AIDS response in India appears on track. However, the program success is not uniform and significant heterogeneity as well as expanding epidemic was observed at the level of States or UTs. Reinforcing States/UTs specific and focused HIV prevention, testing and treatment initiatives may help in the attainment of 2030 Sustainable Development Goals of ending AIDS as a public health threat by 2030.

Sub-regional Trend of HIV Infection Among Antenatal Clinic Attendees in Andhra Pradesh (2003-2019)

INTRODUCTION

The analyses of local risks at sub-national levels and tailored interventions are being emphasized for effective HIV management. Andhra Pradesh (AP) is a high HIV prevalence state in India, with the second-highest number of People with HIV (PWH) and a consistent decline in HIV prevalence at the state level. Probing further into the region and district-wise levels and trends of HIV prevalence will provide critical insights into sub-regional epidemic patterns. Hence, this paper analyzes the regional and district-level trends of HIV prevalence among pregnant women attending antenatal clinics (ANC) from 2003 to 2019 in AP, South India.

METHODS

HIV prevalence data collected from pregnant women in AP during HIV Sentinel Surveillance (HSS) between 2003 and 2019 was used for trend analysis. The consistent sites were grouped into three regions (Coastal Andhra, Rayalaseema and Uttar Andhra), totaling 39 sites, including 21 rural and 18 urban sites. Regional and district-level HIV prevalence was analyzed using the Chisquare trend test, and spatial analysis was done using QGIS software. For the last three HSS rounds, HIV prevalence based on sociodemographic variables was calculated to understand the factors contributing to HIV positivity in each region.

RESULTS

In total, 143,211 pregnant women were recruited. HIV prevalence in AP was 0.30% (95% CI: 0.22 - 0.39) in 2019. The prevalence was 0.31%, 0.35% and 0.22% in Coastal Andhra, Rayalaseema and Uttar Andhra, respectively. HIV prevalence had significantly (P < 0.05) declined in all regions. The overall trend indicated that the HIV prevalence was higher among older pregnant women and in urban regions. However, recent trends consistently report HIV positivity among young and new pregnant mothers, illiterates, and rural regions.

CONCLUSION

The overall trend indicated that the HIV prevalence was higher among older pregnant women and in urban regions. However, recent trends consistently report HIV positivity among young and new pregnant mothers, illiterates, and rural regions. Identifying the contextual risk patterns associated with HIV transmission will further improve HIV preventive and management programs among the general population.

District-level HIV estimates using the spectrum model in five states of India, 2017

Decentralized response has been the hallmark of the National AIDS Control Programme in India. District-level HIV burden estimates quantifying the distribution of the epidemics are needed to enhance this decentralized response further to monitor the progress on prevention, testing, and treatment interventions. In this paper, we describe the methodology and results of district-level estimates using the Spectrum model piloted in 5 states of India under National AIDS Control Programme.Using state spectrum model for HIV estimations 2017, we disaggregated state results by the district in pilot states. Each district was considered a subepidemic and HIV epidemic configuration was carried out in its general population as well as in key population. We used HIV surveillance data from antenatal clinics and routine pregnant women testing to model the general population's epidemic curve. We used HIV prevalence data available from HIV sentinel surveillance and integrated biological and behavioral surveys to inform the epidemic curve for key population. Estimation and projection packgage classic platform was used for the curve fitting. District-wide estimates extracted from subpopulation summary in Spectrum results section were used to calculate relative burden for each district and applied to approved State HIV Estimations 2017 estimates.No district in Tamil Nadu had an adult HIV prevalence of higher than 0.5% except for one, and the epidemic seems to be declining. In Maharashtra, the epidemic has shown a decline, with all except 5 districts showing an adult prevalence of less than 0.50%. In Gujarat and Uttar Pradesh, few districts showed rising HIV prevalence. However, none had an adult prevalence of higher than 0.50%. In Mizoram, 6 of 8 districts showed a rising HIV trend with an adult prevalence of 1% or more in 5 districts.Disaggregation of state-level estimates by districts provided insights on epidemic diversity within the analyzed states. It also provided baseline evidence to measure the progress toward the goal of end of AIDS by 2030.

Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India

The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ² value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ² value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ² value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 –maximum 68; IQR 31–57) and 38 year (minimum 18 –maximum 78; IQR 29–50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5–12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, ‘unsafe injection exposure during treatment-seeking’(AOR 6.61, 95% CI 1.80–24.18) and ‘receipt of intramuscular injection in last five years’ (AOR 7.20, 95% CI 1.48–34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.

Acceptability of HIV Oral Self-Test Among Men Having Sex With Men and Transgender Population: A Qualitative Investigation From Pune, India

Globally HIV-self-test is considered as an important tool to end AIDS. However, several countries, including India, are yet to adopt such a strategy. Against this background, we conducted a qualitative inquiry exploring acceptability of an HIV-oral-self-test (HIVOST) among MSM and TG communities in the district of Pune, India. Discussions were facilitated around an HIVOST kit developed in-country. Most of the participants expressed familiarity with the concept of self-test. They realised that confirmatory diagnostic test would be required following a positive HIVOST screening result. Discrimination from health care workers, crowded environment, lack of privacy and delay in getting reports were hurdles faced during HIV testing at public healthcare facilities. Contrastingly, quick results, painless technique and no-blood-draw were perceived advantages of HIVOST. Innovative suggestions were obtained on how-to-do instruction modalities, kit distribution venues and redressing of apprehensions. Such qualitative responses indicated interest and encouraging level of acceptance around HIVOST among study participants.

Sustained progress, but no room for complacency: Results of 2015 HIV estimations in India

Background & objectives:

Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results.

Methods:

Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs.

Results:

India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also.

Interpretation & conclusions:

While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.

Mitigating circumstances: A model-based analysis of associations between risk environment and infrequent condom use among Chinese street-based sex workers

Background

Little is known about how freelance street-based sex workers navigate condom use while soliciting. Traditional behavioural model may fail to account for the complex risk environment that most street-based sex workers work within. We examine first the association of self-efficacy and the infrequent condom use, then we investigated the roles of clients and venues frequented on this association.

Method

Using a purposive chain-referral sampling method, we surveyed 248 street-based sex workers in Shanghai. The survey focused on sex workers HIV risk factors, sex work patterns, HIV knowledge, and related HIV self-efficacy. Clients types and behaviours, and characteristics of the venues frequented by these commercial sex workers were also collected. We conducted a series of multiple logistic regression models to explore how the association between a sex worker’s self-efficacy with infrequent condom use change as client and venue characteristics were added to the models.

Results

We find that within the basic model, low self-efficacy was marginally associated with infrequent condom use (54.9% vs. 45.1%, AOR = 1.70, 95% CI = 0.95–3.03). As client- and venue- characteristics were added, the associations between self-efficacy and condom use were strengthened (AOR = 2.10 95% CI = 1.12–3.91 and 2.54 95% CI = 1.24–5.19 respectively). Those who reported middle-tiered income were more likely to report infrequent condom use compared to their peers of high income (AOR = 3.92 95% CI = 1.32–11.70) whereas such difference was not found between low income and high income sex workers. Visiting multiple venues and having migrant workers as clients were also associated with infrequent condom use.

Conclusion

Our findings suggest sex worker’s self-efficacy matters in their HIV risk behaviours only when environment characteristics were adjusted. Risk environment for street-based sex workers are complex. Programming addressing behavioural changes among female sex workers should adopt holistic, multilevel models with the consideration of risk environments.

Programmatic mapping to determine the size and dynamics of sex work and injecting drug use in Mauritius

HIV in Mauritius is in a concentrated phase. Most HIV infection is among key populations (KPs) including female sex workers (FSW), people who inject drugs (PWID), men who have sex with men (MSM), and transgender sex workers (TGSW). The objective of this research was to use geographical mapping to determine the precise locations, typologies and population estimates of each KP in Mauritius. From May to July 2014 a programmatic mapping approach determined national estimates and information on the specific locations, "hotspots", frequented by KPs in Mauritius. Data were collected through multiple levels of activity. Key informants provided information about hotspots where KPs congregated and were actively engaged in risky behaviours. Validation of hotspots was done by engaging KPs. A total of 17 248 KP members were estimated spread over 1 964 hotspots in Mauritius. The largest KP was PWID with an estimate of 7 598 (range: 4 091-6 223), followed by 6 223 (range: 5 090-7 456) FSWs, spread over 694 and 731 hotspots respectively. A total of 2 020 (range: 1 595-2 446) MSM and 294 geographic MSM hotspots, and 1 407 TGSWs (range: 1 165-1 649) distributed over 245 hotspots. This research provided Mauritius with validated KPs size estimations and provided the first national data on KP hotspots and operational dynamics. The use of these data will strengthen HIV prevention, intervention, and programme planning in the country through focusing efforts to systematically target high-risk areas.

HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions

Introduction

A strategic approach to the application of HIV prevention interventions is a core component of the UNAIDS Fast Track strategy to end the HIV epidemic by 2030. Central to these plans is a focus on high‐prevalence geographies, in a bid to target resources to those in greatest need and maximize the reduction in new infections. Whilst this idea of geographical prioritization has the potential to improve efficiency, it is unclear how it should be implemented in practice. There are a range of prevention interventions which can be applied differentially across risk groups and locations, making allocation decisions complex. Here, we use mathematical modelling to compare the impact (infections averted) of a number of different approaches to the implementation of geographical prioritization of prevention interventions, similar to those emerging in policy and practice, across a range of prevention budgets.

Methods

We use geographically specific mathematical models of the epidemic and response in 48 counties and major cities of Kenya to project the impact of the different geographical prioritization approaches. We compare the geographical allocation strategies with a nationally uniform approach under which the same interventions must be applied across all modelled locations.

Results

We find that the most extreme geographical prioritization strategy, which focuses resources exclusively to high‐prevalence locations, may substantially restrict impact (41% fewer infections averted) compared to a nationally uniform approach, as opportunities for highly effective interventions for high‐risk populations in lower‐prevalence areas are missed. Other geographical allocation approaches, which intensify efforts in higher‐prevalence areas whilst maintaining a minimum package of cost‐effective interventions everywhere, consistently improve impact at all budget levels. Such strategies balance the need for greater investment in locations with the largest epidemics whilst ensuring higher‐risk groups in lower‐priority locations are provided with cost‐effective interventions.

Conclusions

Our findings serve as a warning to not be too selective in the application of prevention strategies. Further research is needed to understand how decision‐makers can find the right balance between the choice of interventions, focus on high‐risk populations, and geographical targeting to ensure the greatest impact of HIV prevention.

Achieving scale rapidly in public health: Applying business management principles to scale up an HIV prevention program in India

Numerous public-health interventions have demonstrated effectiveness in pilots or on a small scale, but have proven challenging to scale up for population-level impact. Avahan, the Bill & Melinda Gates Foundation's HIV prevention program in 6 states of India, confronted the challenge of rapidly scaling up services to reach 300,000 people most at risk of HIV. This meant working in diverse and complex environments with marginalized and largely hidden populations. This case report presents a number of business-management principles that the foundation drew upon to successfully scale up this public-health program: 1) strategy development through market segmentation and complexity analysis, 2) a dynamic and evolving strategy, 3) developing an implementation and management structure to match the strategy, 4) standardization with flexibility, 5) generating demand to balance supply, 6) a customer-centric approach, and 7) data-driven management. Lessons learned from this experience include the crucial role of data in guiding decision-making and strategic and programmatic change; the need for a central body to set strategy; a willingness to change course when experience and data demonstrate the need; and the importance of partnering with program beneficiaries at all stages of program design, operation, evaluation and sustainability. We believe these lessons are applicable to other development programs that seek to foster widespread and sustainable program benefits at scale.

Gender-based power and couples' HIV risk in Uttar Pradesh and Uttarakhand, north India

CONTEXT

Gender inequality is a long-recognized driver of the HIV epidemic. However, few studies have investigated the association between gender-based power and HIV risk in India, which has the world's third largest HIV epidemic.

METHODS

Population-based data collected in 2003 from 3,385 couples residing in Uttar Pradesh and Uttarakhand, North India, were used to examine associations between gender-based power (wife's autonomy and husband's inequitable gender attitudes) and indicators of couples' HIV risk (whether the husband had had premarital sex with someone other than his eventual spouse, extramarital sex in the past year or STI symptoms in the past year). Structural equation modeling was used to create composite variables for the gender-based power measures and test their associations with HIV risk measures.

RESULTS

Twenty-four percent of husbands had had premarital sex, 7% had had extramarital sex in the past year and 6% had had STI symptoms in the past year. Structural equation models indicated that wives who reported higher levels of autonomy were less likely than other wives to have husbands who had had extramarital sex in the past year (direct association) or STI symptoms in the past year (indirect association). Moreover, husbands who endorsed more inequitable gender attitudes were more likely than others to report having had premarital sex with someone other than their spouse, which in turn was associated with having had extramarital sex and STI symptoms in the past year.

CONCLUSIONS

If the associations identified in this study reflect a causal relationship between gender-based power and HIV risk behavior, then HIV prevention programs that successfully address inequitable gender roles may reduce HIV risks in North India.

Strengthening government management capacity to scale up HIV prevention programs through the use of Technical Support Units: lessons from Karnataka state, India

A Technical Support Unit of managerial and technical experts, embedded in but distinct from the government, provided support in 5 key areas: strategic planning; monitoring and evaluation; supportive supervision; training; and information, education, and communication. This model likely contributed to effective and rapid scale up of Karnataka state's HIV prevention program. A clear mandate, close collaboration, and well-defined roles were keys to success.

Scaling up HIV prevention programming among key populations (female sex workers and men who have sex with men) has been a central strategy of the Government of India. However, state governments have lacked the technical and managerial capacity to oversee and scale up interventions or to absorb donor-funded programs. In response, the national government contracted Technical Support Units (TSUs), teams with expertise from the private and nongovernmental sectors, to collaborate with and assist state governments. In 2008, a TSU was established in Karnataka, one of 6 Indian states with the highest HIV prevalence in the country and where monitoring showed that its prevention programs were reaching only 5% of key populations. The TSU provided support to the state in 5 key areas: assisting in strategic planning, rolling out a comprehensive monitoring and evaluation system, providing supportive supervision to intervention units, facilitating training, and assisting with information, education, and communication activities. This collaborative management model helped to increase capacity of the state, enabling it to take over funding and oversight of HIV prevention programs previously funded through donors. With the combined efforts of the TSU and the state government, the number of intervention units statewide increased from 40 to 126 between 2009 and 2013. Monthly contacts with female sex workers increased from 5% in 2008 to 88% in 2012, and with men who have sex with men, from 36% in 2009 to 81% in 2012. There were also increases in the proportion of both populations who visited HIV testing and counseling centers (from 3% to 47% among female sex workers and from 6% to 33% among men who have sex with men) and sexually transmitted infection clinics (from 4% to 75% among female sex workers and from 7% to 67% among men who have sex with men). Changes in sexual behaviors among key populations were also documented. For example, between 2008 and 2010, the proportion of surveyed female sex workers in 9 districts reporting that they used a condom at last intercourse rose from 60% to 68%; in 6 districts, the proportion of surveyed men who have sex with men reporting that they used a condom at last anal sex increased from 89% to 97%. The Karnataka experience suggests that TSUs can help governments enhance managerial and technical resources and leverage funds more effectively. With careful management of the working and reporting relationships between the TSU and the state government, this additional capacity can pave the way for the government to improve and scale up programs and to absorb previously donor-funded programs.

Maximising the effect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study

BACKGROUND

Epidemiological data show substantial variation in the risk of HIV infection between communities within African countries. We hypothesised that focusing appropriate interventions on geographies and key populations at high risk of HIV infection could improve the effect of investments in the HIV response.

METHODS

With use of Kenya as a case study, we developed a mathematical model that described the spatiotemporal evolution of the HIV epidemic and that incorporated the demographic, behavioural, and programmatic differences across subnational units. Modelled interventions (male circumcision, behaviour change communication, early antiretoviral therapy, and pre-exposure prophylaxis) could be provided to different population groups according to their risk behaviours or their location. For a given national budget, we compared the effect of a uniform intervention strategy, in which the same complement of interventions is provided across the country, with a focused strategy that tailors the set of interventions and amount of resources allocated to the local epidemiological conditions.

FINDINGS

A uniformly distributed combination of HIV prevention interventions could reduce the total number of new HIV infections by 40% during a 15-year period. With no additional spending, this effect could be increased by 14% during the 15 years-almost 100,000 extra infections, and result in 33% fewer new HIV infections occurring every year by the end of the period if the focused approach is used to tailor resource allocation to reflect patterns in local epidemiology. The cumulative difference in new infections during the 15-year projection period depends on total budget and costs of interventions, and could be as great as 150,000 (a cumulative difference as great as 22%) under different assumptions about the unit costs of intervention.

INTERPRETATION

The focused approach achieves greater effect than the uniform approach despite exactly the same investment. Through prioritisation of the people and locations at greatest risk of infection, and adaption of the interventions to reflect the local epidemiological context, the focused approach could substantially increase the efficiency and effectiveness of investments in HIV prevention.

FUNDING

The Bill & Melinda Gates Foundation and UNAIDS.

The HIV epidemic and prevention response in Tigrai, Ethiopia: a synthesis at sub-national level

BACKGROUND

This study, the first of its kind carried out at sub-national level in Ethiopia, was conducted in order to understand the dynamics of HIV transmission at regional and district level in Tigrai, Ethiopia; and to assess the adequacy of the HIV prevention response.

METHODS

Routine data from health centres, data from available published and grey literature and studies, and primary qualitative information were triangulated to draw an updated picture of the HIV epidemic, HIV response and resource allocation in Tigrai.

RESULTS

HIV prevalence in Tigrai was 1.8% in 2011 (EDHS). ANC data show that there has been a continuous decline in the prevalence of HIV in both urban and rural areas (urban: 14.9% in 2001 to 5.0% in 2009; rural: 5.2% in 2001 to 1.3% in 2009, ANC surveillance data). Variability in prevalence by zone and by district was observed. Possible reasons for higher prevalence include the presence of mobile seasonal workers, highly urbanized centres, a high concentration of economic activity and connecting roads and large commercial farms. Sex workers, seasonal farm workers and HIV negative partners in discordant couples were identified as being at higher risk. There is no evidence that programme planning is done on the basis of geographical variations in HIV prevalence and there are gaps in programmes and services for certain high risk population groups.

CONCLUSION

Considerable efforts have been invested in the HIV prevention response in Tigrai however, these efforts do not fully respond to the actual needs. For a more effective and targeted HIV prevention response, studies and data syntheses need to be carried out at sub-national level in order to accurately identify local specificities and plan accordingly. Resources should be targeted towards areas where transmission is linked to sex work, mobility and the mobile labour workforce.

An assessment of an HIV prevention intervention among people who inject drugs in the states of Manipur and Nagaland, India

BACKGROUND

The present study describes an assessment of a large-scale intervention, "Avahan", using an evaluation framework that assesses the program coverage, changes in injection patterns, condom use, and STI and HIV prevalence among People Who Inject Drugs (PWID) in two states of India - Manipur and Nagaland.

METHODS

Program monitoring data and results from two rounds of a cross sectional biological and behavioural surveys in 2006 (Round 1) and 2009 (Round 2) were used. The sample included 839 and 860 PWIDs from Manipur and 821 and 829 PWIDs from Nagaland in Round 1 and Round 2 respectively for current analysis. Bivariate and multivariate analyses were done to measure the changes in behavioural and biological outcomes between the two rounds and to examine the association between programme exposure and behavioural outcomes.

RESULTS

In Manipur, about 77% of the PWIDs were contacted by the peer educators/outreach workers every month and about 18% of the PWIDs visited the clinic every month by March 2010. In Nagaland, however, the proportion of PWIDs visiting the clinic monthly remained low (11% in March 2010). PWIDs in both states were more likely to report 'consistent safe injection practice in the last six months' in Round 2 compared to Round 1 (Manipur: adjusted odds ratio (aOR): 1.88, 95% confidence intervals (CI): 1.46-2.43; Nagaland: aOR: 2.35, 95% CI: 1.86-2.80) PWIDs were also more likely to report consistent condom use with regular partners in Round 2. The prevalence of Hepatitis B virus (HBV) increased in Round 2 in Manipur (11% vs 6%, p<0.001) and Nagaland (8% vs 6%, p=0.05). The prevalence of Hepatitis C virus (HCV) was high and did not change, either in Manipur (67.3% vs 69.9%, p=0.42) and Nagaland (14.7% vs 15.1%, p=0.82). Similarly, the prevalence of HIV did not change significantly between the two Rounds either in Manipur (27.8% in Round 1 vs 29.2% in Round 2, p=0.59) or in Nagaland (1.2% in Round 1 and 1.6% in Round 2 of the IBBA, p=0.82).

CONCLUSION

Improvements in safe injection practices and consistent condom use with regular partners suggest effectiveness of prevention efforts. However, increase in HBV prevalence and non-decline in HCV and HIV prevalence in both the states also underscore the need to continue and intensify targeted interventions (such as Hepatitis B vaccination, needle exchange programmes, condom distribution) for long term risk reduction among PWID population.

Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs

Voluntary medical male circumcision (VMMC) is capable of reducing the risk of sexual transmission of HIV from females to males by approximately 60%. In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended making VMMC part of a comprehensive HIV prevention package in countries with a generalized HIV epidemic and low rates of male circumcision. Modeling studies undertaken in 2009-2011 estimated that circumcising 80% of adult males in 14 priority countries in Eastern and Southern Africa within five years, and sustaining coverage levels thereafter, could avert 3.4 million HIV infections within 15 years and save US$16.5 billion in treatment costs. In response, WHO/UNAIDS launched the Joint Strategic Action Framework for accelerating the scale-up of VMMC for HIV prevention in Southern and Eastern Africa, calling for 80% coverage of adult male circumcision by 2016. While VMMC programs have grown dramatically since inception, they appear unlikely to reach this goal. This review provides an overview of findings from the PLOS Collection "Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up." The use of devices for VMMC is also explored. We propose emphasizing management solutions to help VMMC programs in the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. Our recommendations include advocating for prioritization and funding of VMMC, increasing strategic targeting to achieve the goal of reducing HIV incidence, focusing on programmatic efficiency, exploring the role of new technologies, rethinking demand creation, strengthening data use for decision-making, improving governments' program management capacity, strategizing for sustainability, and maintaining a flexible scale-up strategy informed by a strong monitoring, learning, and evaluation platform.

Alarming epidemics of human immunodeficiency virus and hepatitis C virus among injection drug users in the northwestern bordering state of Punjab, India: prevalence and correlates

In this study 1155 injection drug users (IDUs) receiving targeted intervention in five cities of Punjab were surveyed; three cities (Amritsar, Taran-Taran, Batala) were in districts sharing an international border with Pakistan and the other two were Jalandhar and Ludhiana. Information on socio-demography, substance use and sexual practices were collected; blood samples were tested for biologic markers. HIV and HCV antibody (HCVAb) prevalences in injection drug users were 29 and 49%, respectively. Of the HCVAb-seroreactive IDUs, 33% had HIV as well. HIV prevalence in young IDUs (≤19 years), estimated as surrogate for HIV incidence, was high at 12% and HCVAb in this subgroup was 27%. Herpes simplex virus 2 antibody (IgG) was detected in 10% of IDUs; 2% had syphilis. Alcohol use prevalence was high and frequency of use concerning. In multivariate analyses, 'city of residence closer to international border' and '>1 year duration of injecting drugs were associated with HIV and HCVAb. Furthermore, 'irregular supply of syringes and needles' was associated with HCVAb seroreactive status of IDUs (adjusted odds ratio 1.7; 95% CI 1.3-2.3;P < 0.001), and 'any genital disease symptom within the last year' (adjusted odds ratio 2; 95% CI 1.4-2.9;P < 0.001) was associated with HIV infection. Alcohol and sexual risk reduction, strengthening of needle-syringe exchange, reducing injecting duration and clinical management of HIV, HCV and HIV/HCV co-infection appear as four core programme needs.

HIV prevalence in China: integration of surveillance data and a systematic review

BACKGROUND

Asian HIV epidemics are concentrated among particular behavioural groups, but large variations exist in epidemic types, timing, and geographical spread between countries and within countries, especially in China. We aimed to understand the complexity of HIV epidemics in China by systematically analysing prevalence trends by data source, region, population group, and time period.

METHODS

We collected HIV prevalence data from official national sentinel surveillance sites at the provincial level from Jan 1, 1995, to Dec 31, 2010. We also searched PubMed, VIP Chinese Journal Database (VIP), China National Knowledge Infrastructure, and Wanfang Data from Jan 1, 1990, to Dec 31, 2012, for independent studies of HIV prevalence. We integrated both sets of data, and used an intraclass correlation coefficient test to assess the similarity of geographical pattern of HIV disease burden across 31 Chinese provinces in 2010. We investigated prevalence trends (and 95% CIs) to infer corresponding incidence by region, population group, and year.

FINDINGS

Of 6850 articles identified by the search strategy, 821 studies (384,583 drug users, 52,356 injecting drug users, 186,288 female sex workers, and 87,834 men who have sex with men) met the inclusion criteria. Official surveillance data and findings from independent studies showed a very similar geographical distribution and magnitude of HIV epidemics across China. We noted that HIV epidemics among injecting drug users are decreasing in all regions outside southwest China and have stabilised at a high level in northwest China. Compared with injecting drug users, HIV prevalence in female sex workers is much lower and has stabilised at low levels in all regions except in the southwest. In 2010, national HIV prevalence was 9·08% (95% CI 8·04-10·52) in injecting drug users and 0·36% (0·12-0·71) in female sex workers, whereas incidence in both populations stabilised at rates of 0·57 (0·43-0·72) and 0·02 (0·01-0·04) per 100 person-years, respectively. By comparison, HIV prevalence in men who have sex with men increased from 1·77% (1·26-2·57) in 2000, to 5·98% (4·43-8·18) in 2010, with a national incidence of 0·98 (0·70-1·25) per 100 person-years in 2010. We recorded strong associations between HIV prevalence among at-risk populations in each province, supporting the existence of overlap in risk behaviours and mixing among these populations.

INTERPRETATION

HIV epidemics in China remain concentrated in injecting drug users, female sex workers, and men who have sex with men. HIV prevalence is especially high in southwest China. Sex between men has clearly become the main route of HIV transmission.

Are female sex workers able to negotiate condom use with male clients? The case of mobile FSWs in four high HIV prevalence states of India

Introduction

Condom promotion among female sex workers (FSWs) is a key intervention in India’s National AIDS Control Program. However, there is limited understanding of how FSWs negotiate condom use with male clients, particularly in the context of their mobility for sex work. The objective of this study is to examine the factors associated with the mobile FSWs’ ability to refuse unsafe sex and successfully negotiate condom use with unwilling male clients.

Methods

Data for 5498 mobile FSWs from a cross-sectional survey conducted in 22 districts of four states in southern India were analyzed. Questions assessed FSWs’ ability to refuse clients unprotected sex, convince unwilling clients for condom use and negotiate condom use in a new location. Logistic regression models were constructed to examine the association between socio-demographics, economic vulnerability, sex work practice, and program exposure and condom negotiation ability.

Results

A majority of FSWs (60%) reported the ability to refuse clients for unprotected sex, but less than one-fifth reported the ability to successfully convince an unwilling client to use a condom or to negotiate condom use in a new site. Younger and older mobile FSWs compared to those who were in the middle age group, those with longer sex work experience, with an income source other than sex work, with program exposure and who purchased condoms for use, reported the ability to refuse unprotected sex, to successfully negotiate condom use with unwilling clients and to do so at new sites.

Conclusion

FSWs need to be empowered to not only refuse unprotected sex but also to be able to motivate and convince unwilling clients for condom use, including those in new locations. In addition to focusing on condom promotion, interventions must address the factors that impact FSWs’ ability to negotiate condom use.

Scale-up of a comprehensive harm reduction programme for people injecting opioids: lessons from north-eastern India

PROBLEM

Harm reduction packages for people who inject illicit drugs, including those infected with human immunodeficiency virus (HIV), are cost-effective but have not been scaled up globally. In the north-eastern Indian states of Manipur and Nagaland, the epidemic of HIV infection is driven by the injection of illicit drugs, especially opioids. These states needed to scale up harm reduction programmes but faced difficulty doing so.

APPROACH

In 2004, the Bill & Melinda Gates Foundation funded Project ORCHID to scale up a harm reduction programme in Manipur and Nagaland.

LOCAL SETTING

In 2003, an estimated 10 000 and 16 000 people were injecting drugs in Manipur and Nagaland, respectively. The prevalence of HIV infection among people injecting drugs was 24.5% in Manipur and 8.4% in Nagaland.

RELEVANT CHANGES

By 2012, the harm reduction programme had been scaled up to an average of 9011 monthly contacts outside clinics (80% of target); an average of 1709 monthly clinic visits (15% of target, well above the 5% monthly goal) and an average monthly distribution of needles and syringes of 16 each per programme participant. Opioid agonist maintenance treatment coverage was 13.7% and retention 6 months after enrolment was 63%. Antiretroviral treatment coverage for HIV-positive participants was 81%.

LESSONS LEARNT

A harm reduction model consisting of community-owned, locally relevant innovations and business approaches can result in good harm reduction programme scale-up and influence harm reduction policy. Project ORCHID has influenced national harm reduction policy in India and contributed to the development of harm reduction guidelines.

Prevention of Parent to Child Transmission (PPTCT) program data in India: an emerging data set for appraising the HIV epidemic

BACKGROUND

Evidence based resource allocation and decentralized planning of an effective HIV/AIDS response requires reliable information on levels and trends of HIV at national and sub-national geographic levels. HIV sentinel surveillance data from antenatal clinics (HSS-ANC) has been an important data source to assess the HIV/AIDS epidemic in India, but has a number of limitations. We assess the value of Prevention of Parent to Child Transmission (PPTCT) programme data to appraise the HIV epidemic in India.

METHODS/FINDINGS

HIV data from PPTCT sites were compared to HSS-ANC and general population level surveys at various geographic levels in the states of Karnataka, Maharashtra and Andhra Pradesh. Chi-square tests were used to ascertain statistical significance. PPTCT HIV prevalence was significantly lower than HSS-ANC HIV prevalence (0.92% vs. 1.22% in Andhra Pradesh, 0.65% vs. 0.89% in Karnataka, 0.52% vs. 0.60% in Maharashtra, p<0.001 for all three states). In all three states, HIV prevalence from PPTCT centres that were part of the sentinel surveillance was comparable to HSS-ANC prevalence but significantly higher than PPTCT centres that were not part of the sentinel surveillance. HIV prevalence from PPTCT data was comparable to that from general population surveys. In all three states, significant declines in HIV prevalence between 2007 and 2010 were observed with the PPTCT data set. District level analyses of HIV trends and sub-district level analysis of HIV prevalence were possible using the PPTCT and not the HSS-ANC data sets.

CONCLUSION

HIV prevalence from PPTCT may be a better proxy for general population prevalence than HSS-ANC. PPTCT data allow for analysis of HIV prevalence and trends at smaller geographic units, which is important for decentralized planning of HIV/AIDS programming. With further improvements to the system, India could replace its HSS-ANC with PPTCT programme data for surveillance.

Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model

Background:

Mumbai is one of the most populous and high HIV prevalence cities in India. It has witnessed substantial changes in HIV-risk behaviors and a decline in HIV prevalence among high-risk groups during the past decade.

Aim:

To examine the changing pattern in the number of new HIV infections by transmission routes in Mumbai during 2000-2017.

Methods:

We used the Asian Epidemic Model by dividing the adult population (aged 15 and above) into seven subgroups: brothel-based and non-brothel based female sex workers (FSWs), heterosexual clients of FSWs, men who have sex with men/transgendered people (MSM), injecting drug users (IDUs), general women and general men. The MSM subgroup included homosexual and bisexual men.

Results:

New HIV infections among adults reduced by 86% during 2000-2010. The highest decline was among FSWs and their heterosexual clients (95%-98%), followed by MSM (82%), general women (77%), IDUs (51%) and general men (42%). Most new HIV infections during 2011-2017 are expected to occur among general women (1666) and general men (977) followed by MSM (715). Bisexual men were estimated to contribute about 14% of the new HIV infections among general women in 2010 and this proportion was estimated to increase to 19% in 2017.

Discussion:

HIV prevention programs for MSM and the general population need to be strengthened. Ensuring early detection of HIV, and higher levels of consistent condom use by HIV-infected men and women are essential to prevent new HIV infections in future.