Diversity of hepatitis C virus infection among HIV-infected people who inject drugs in India

The availability of generic direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has prompted many low-and-middle-income countries to launch HCV elimination programs. Because the efficacy of some of these generic DAAs varies by HCV viral subtype, information on subtype distribution can contribute important information to these elimination programs. We conducted a cross-sectional serosurvey to characterize HCV subtype diversity among HIV positive people who inject drugs (PWID) across 14 cities in India. Of 801 HIV positive PWID sampled, 639 tested HCV antibody positive (78.9%). Among 105 samples sequenced, genotype 3 (58.1%) was the most commonly observed followed by genotype 1 (36.2%) and genotype 6 (5.7%). Of the genotype 3 infections, 65% were subtype 3a and 35% were subtype 3b. Of the genotype 1 infections, 94% were subtype 1a and 6% were subtype 1b. All genotype 6 samples were subtype 6n. There was some variability in genotype diversity depending on geographic region and PWID epidemic stage with greater diversity observed in older PWID epidemics. One sequence, HY018, did not cluster with any known reference sequences in phylogenetic analysis. Nearly 80% of HIV infected PWID across India are co-infected with HCV, and subtype prevalence and genetic diversity varied by region and PWID epidemic stage. HCV elimination programs in India will need to consider HCV subtype.

561. Co-occurring Psychosocial Barriers to Viral Suppression Among Men Who Have Sex with Men (MSM) in India

Background

There is a paucity of data on factors associated with viral suppression in representative populations of HIV-positive MSM in low-middle income country (LMIC) settings. We characterized factors associated with viral suppression among a community-recruited sample of MSM across India with a particular focus on depression, alcohol use and recreational drug use.

Methods

Of 10,024 MSM recruited using respondent-driven sampling (RDS) from 10 Indian cities between August 2016 and April /2017, 1,460 were HIV-positive and eligible for ART. Alcohol dependence was defined as AUDIT score ≥15; severe depression as PHQ-9 score ≥15; recreational drug use included both injection and non-injection use of drugs common in India, excluding marijuana. Prevalence ratios (aPrR) were obtained using multivariable Poisson regression incorporating RDS2 weights and accounting for clustering by site.

Results

Median age was 37 years, 34.1% had at least high school education and 66.0% reported monthly income >$115. Prevalence of viral suppression among HIV+ ART eligible MSM was 66.2% overall, ranging from 35.2% in Bhopal to 76.1% in Madurai with no regional trends. Prevalence of severe depression was 4.0%, alcohol dependence 66.3% and recreational drug use 9.5%. Viral suppression was significantly more common among those who were older and had higher treatment literacy. In analyses that adjusted for these factors and sexual identity, those who reported drug use and had evidence of severe depression had a significantly lower likelihood of being virally suppressed (aPrR 0.38; [95% CI: 0.16–0.89]) than those with neither (P-value for interaction = 0.05). Similarly, compared with those who used neither alcohol nor drugs, those using both had a lower prevalence of viral suppression (aPrR: 0.61; [95% CI: 0.40–0.94]) although the interaction did not achieve statistical significance (P = 0.07).

Conclusion

In this population of MSM in an LMIC, recreational drug use appeared to be a key barrier to achieving viral suppression. Moreover, the impact of drug use was greater in the context of co-occurring severe depression or co-occurring alcohol dependence. It is critical that HIV programming in India and other resource-limited settings incorporate interventions to address these conditions in differentiated care models to maximize viral suppression.

Disclosures

All authors: No reported disclosures.

Overlap between harm reduction and HIV service utilisation among PWID in India: Implications for HIV combination prevention

BACKGROUND

In some regions, HIV incidence is rising among people who inject drugs (PWID). Combination prevention approaches are well suited to PWID who face multiple sources of HIV risk. This analysis investigates patterns of utilisation to basic HIV services (HIV counselling and testing [HCT], antiretroviral therapy [ART]) as well as harm reduction programs (needle and syringe exchange programs [NSEP] and opioid agonist therapy [OAT]) among PWID and how utilisation of harm reduction services is associated with HIV-related care seeking behaviours.

METHODS

Respondent-driven sampling was used to recruit 14,481 PWID across 15 cities in India. Sampling-weighted multilevel logistic regression models assessed associations between utilisation of harm reduction service and HCT and ART use among those indicated (90.3% and 5.0% of full sample, respectively). We considered both recent (prior year) and ever use of services.

RESULTS

Overall, 42.3% reported prior HIV testing and 57.9% of eligible persons reported ART initiation, but overlap with NSEP and OAT use was limited. In adjusted models, recent and ever use of both NSEP and OAT were significantly associated with recent and ever HCT utilisation, respectively; however, harm reduction utilisation was not associated with ART initiation among eligible participants.

CONCLUSIONS

Harm reduction services may play a key role in linking PWID with HIV testing; however, they were not associated with ART initiation among eligible individuals. Moreover, a large majority who utilised NSEP and OAT were not engaged in optimal HIV care or prevention, highlighting missed opportunities and a need for stronger linkages between NSEP/OAT and HIV care and treatment, particularly among those actively injecting. These findings provide key insights to better understand how services can be linked or combined to optimise service utilisation among PWID.

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India

Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.

Mobile phones and sex work in South India: the emerging role of mobile phones in condom use by female sex workers in two Indian states

The aim of this study was to examine female sex workers' solicitation of clients using mobile phones and the association between this and condom use with clients. Cross-sectional data were utilised to address the study's aim, drawing on data collected from female sex workers in Calicut, Kerala, and Chirala, Andhra Pradesh. Use of mobile phone solicitation was reported by 46.3% (n = 255) of Kerala participants and 78.7% (n = 464) of those in Andhra Pradesh. Kerala participants reporting exclusive solicitation using mobile phones demonstrated 1.67 times higher odds (95% CI: 1.01-2.79) of inconsistent condom use than those reporting non-use of mobile phones for solicitation. However, those reporting exclusive solicitation through mobile phones in Andhra Pradesh reported lower odds of inconsistent condom use (OR: 0.03; 95% CI: 0.01-0.26) than those not using mobile phones for solicitation. Findings indicate that solicitation of clients using mobile phones facilitates or hampers consistency in condom use with clients depending on the context, and how mobile phones are incorporated into solicitation practices. Variations in sex work environments, including economic dependence on sex work or lack thereof may partially account for the different effects found.

Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities

BACKGROUND

HIV transmission in India is primarily heterosexual and there is a concentrated HIV epidemic among female sex workers (FSWs). Earlier reports demonstrate that many FSWs consume alcohol regularly before sexual encounters. This qualitative study is part of a larger quantitative study designed to assess alcohol consumption patterns among female sex workers and their association with sexual risk taking. Here we investigate the environmental influence, reasons for and consequences of consuming alcohol in the FSW population.

METHODS

Trained staff from two Non-Governmental Organizations in Andhra Pradesh and Kerala conducted semi-structured interviews with 63 FSWs in Chirala, Andhra Pradesh (n = 35) and Calicut, Kerala (n = 28) following extensive formative research, including social mapping and key informant interviews, to assess drinking patterns and sexual risk behaviors.

RESULTS

FSWs reported consuming alcohol in multiple contexts: sexual, social, mental health and self-medication. Alcohol consumption during sexual encounters with clients was usually forced, but some women drank voluntarily. Social drinking took place in public locations such as bars and in private locations including deserted buildings, roads and inside autorickshaws (motorcycle taxis). Consequences of alcohol consumption included failure to use condoms and to collect payments from clients, violence, legal problems, gastrointestinal side effects, economic loss and interference with family responsibilities.

CONCLUSION

FSWs consume alcohol in multilevel contexts. Alcohol consumption during transactional sex is often forced and can lead to failure to use condoms. Social drinkers consume alcohol with other trusted FSWs for entertainment and to help cope with psychosocial stressors. There are multiple reasons for and consequences of alcohol consumption in this population and future interventions should target each specific aspect of alcohol use.

Two sides of the same story: alcohol use and HIV risk taking in South India

This qualitative study examines the role of alcohol in sexual risk among male migrant workers and female sex workers in two South Indian states. Most men reported using alcohol for increased energy and courage prior to their sexual experiences and to reduce feelings of loneliness and isolation. Sex workers, on the other hand, often stated that they avoided alcohol prior to sex in order to stay alert and reduce the risk of violence. Both groups reported that drinking often increased male aggression and reduced condom use. Research is needed to examine the prevalence of these patterns as well as factors associated with sexual risk and violence, in order to develop targeted interventions for these groups. Future risk reduction programs may benefit from addressing safer ways of meeting the needs expressed by the participants. This may include strategies to defuse volatile situations, safe ways of improving the sexual experience, and interventions aimed at alleviating loneliness and isolation for migrants.

The profile of injection drug users in Chennai, India: identification of risk behaviours and implications for interventions

We characterize the demographics, injection practices and risk behaviours of 1,158 injection drug users (IDUs) in Chennai, the capital of Tamil Nadu in southern India, who were recruited during 2005-2006 by community outreach. The median age was 35 years; the majority of IDUs were male, of Tamil ethnicity and married, and earning less than US$75 per month. Most (76%) had injected in the prior month. The median age at first injection was 25 years; the most common drug injected was heroin (80%) followed by buprenorphine. High risk behaviours were common and included needle-sharing, unsafe disposal, and inappropriate cleaning of needles as well as limited condom use. IDUs in India need to be educated on harm reduction and safe-injection practices; Pharmacies could serve as potential venues for HIV prevention interventions among IDUs in India, as most IDUs obtain their needles from pharmacies without prescription.

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.