Brief Report: HIV Pre-Exposure Prophylaxis Awareness and Use Among Adolescents in Kenya

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool; however, use among adolescents is thought to be low. To determine the unmet need and opportunity to expand use, we assessed awareness, prior use, and willingness to take PrEP among Kenyan adolescents.

METHODS

The Maneno Yetu study recruited a community-based sample of adolescents aged 15-19 years (N = 3061) in Kisumu for a survey using respondent-driven sampling.

RESULTS

Overall, 50% of adolescents had heard of PrEP and 2% had used PrEP. Girls were more likely than boys to have heard of PrEP (53.4% vs. 45.1%; P < 0.001) and used PrEP (3.6% vs. 0.3%; P < 0.001). Among participants, 14% engaged in transactional sex and 21% experienced forced sexual contact. PrEP use was higher among adolescents who engaged in transactional sex (4.8% vs. 0.6%; P < 0.001) and experienced forced sexual contact (2.7% vs. 0.7%; P < 0.001) compared with those who did not. Among adolescents with no prior use, 53% were willing to consider using PrEP, although girls were less willing than boys (49.7% vs. 55.9%; P = 0.001).

CONCLUSIONS

PrEP is an important prevention tool, especially for adolescents whose circumstances potentially expose them to HIV-positive or unknown status sexual partners, yet remains underused, particularly in resource-limited settings. Although many expressed willingness to use PrEP, low awareness and use highlight the need to expand HIV prevention education and services tailored for adolescents. Our finding that boys were more willing to use PrEP suggests campaigns should also be designed to reach male youth to narrow the gender gap and expand uptake in the adolescent population.

Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India

Background

Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India.

Methods

We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses.

Results

Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication.

Conclusions

Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India.

Effect of collaborative care intervention on productivity losses among people with comorbid common mental disorders and cardiovascular disease in rural Karnataka

Introduction

Common mental disorders (CMD) and cardiovascular diseases (CVD), common health problems among patients seeking primary healthcare, contribute to high economic productivity losses. Collaborative care programs for CMDs and CVDs have shown improvement in clinical outcomes for both conditions; however, data on productivity outcomes are scarce. Objective: Effect of integrated collaborative care on productivity among people with comorbid CMD and CVD in rural Karnataka primary health clinics.

Methods

Participants were recruited within a randomized trial in rural South India, where patients received either collaborative or enhanced standard care. In this substudy, 303 participants were followed for 3 months and assessed with the iMTA Productivity Cost Questionnaire (iPCQ).

Results

We found a reduction in the proportion of individuals reporting productivity loss at 3 months (66%) compared to baseline (76%; P = 0.002). Productivity losses decreased from INR 30.3 per person per day at baseline to 17.7 at 3 months. Reductions were similar in the two treatment conditions.

Conclusion

Medical intervention may foster reduced productivity losses among patients with CMD and CVD. Collaborative care did not translate into higher reductions in productivity losses than "enhanced standard care."

Correlates for the severity of suicidal risk in participants with common mental disorders with comorbid chronic medical conditions in rural primary healthcare settings in India

Context

Suicide is on the rise in low- and middle-income countries (LMICs), including India. There are limited studies assessing factors linked to the severity of suicidal risk in patients with depression and comorbid chronic medical disorders in primary healthcare (PHC) settings.

Aim

This study examines factors linked to suicidal risk among participants in a cluster randomized controlled trial of collaborative care intervention (Healthier Options through Empowerment (HOPE Study)).

Settings and Design

The setting was at 49 PHC in the rural Ramanagara District of Karnataka State in southern India. Study eligibility criteria included being ≥30 years with at least mild depression or generalized anxiety disorder and at least one medical condition (cardiovascular disorder or type 2 diabetes mellitus).

Methods and Material

The severity of suicidal risk at baseline was assessed using the Mini International Neuropsychiatric Interview (MINI), and other measures included the severity of depression (Patient Health Questionnaire-9-items (PHQ-9)), the severity of anxiety (Generalized Anxiety Disorder Scale-7-items (GAD-7)), disability, social support, quality of life, number of comorbid chronic medical illnesses, and body mass index (BMI).

Statistical Analysis Used

Chi-square tests and independent-samples t-tests were used to compare the demographic and clinical characteristics of the no-low and mod-high suicidal risk groups. Logistic regression analysis was used to identify correlates associated with the mod-high suicidal risk group.

Results

Mod-high suicidal risk was significantly positively associated with the severity of depression and disability and significantly negatively associated with social support.

Conclusion

The severity of depression, higher disability scores, and lower social support were found to be independent correlates of mod-high suicidal risk. Screening, managing depression, and facilitating social support for patients with chronic medical illness in PHC settings may reduce suicidal risk.

The Influence of Transmission-Based and Moral-Based HIV Stigma Beliefs on Intentions to Discriminate Among Ward Staff in South Indian Health Care Settings

HIV stigma is comprised of several beliefs, including transmission fears and moral judgments against affected communities. We examined the relationships among HIV-related stigma beliefs, endorsement of coercive measures for people living with HIV (PLWH), and intentions to discriminate. We sought to understand to what degree the different stigma beliefs shape support for restrictive policies and discriminatory intentions. Data were drawn from the baseline assessment of DriSti, a cluster randomized controlled trial of an HIV stigma reduction intervention in Indian healthcare settings (NCT02101697). Participants completed measures assessing transmission fears and moral judgments of HIV, endorsement of coercive measures against PLWH (public disclosure of HIV status, refusal of healthcare services, marriage and family restrictions, required testing, and sharing of HIV information in a clinic), and intentions to discriminate against PLWH in professional and personal settings. We utilized multivariate regression modeling with backward elimination to identify the coercive measures and behavioral intentions most strongly associated with moral judgments. 1540 ward staff members completed the assessment. Participants had relatively high perceptions of transmission fears (M = 1.92, SD = 0.79) and moral judgments (M = 1.69, SD = 0.83); endorsed more intentions to discriminate in professional (M = 6.54, SD = 2.28) than personal settings (M = 2.07, SD = 1.49), and endorsed approximately half of all coercive measures (M = 9.47, SD = 2.68). After controlling for transmission fears, perceptions of stronger moral judgments against PLWH were significantly associated with higher endorsement of coercive measures related to refusing services (β = 0.10, t = 4.14, p < 0.001) and sharing patients' HIV status in clinics (β = 0.07, t = 3.04, p = 0.002), as well as with stronger behavioral intentions to discriminate in professional settings (β = 0.05, t = 2.20, p = 0.022). HIV stigma interventions for hospital-based ward staff in India need to focus on both transmission fears and moral judgments that underlie prejudicial beliefs. While the moral judgments are not technically related to risk in a hospital setting, our findings suggest that personnel will continue to discriminate in their professional work so long as these beliefs bear on their decisions and actions.

Is self-reported adherence a valid measure of glycaemic control among people living with diabetes in rural India? A cross-sectional analysis

BACKGROUND

Visual analogue scale (VAS) is one of the simplest to measure medication adherence. It has neither been widely used for Non communicable diseases (NCD) nor validated for in the Indian setting. We examined the validity of self-reported medication adherence measures in relation to HbA1C in a rural population with diabetes mellitus (DM).

METHODS

Participants with DM was administered VAS, Diabetes Self-Management Questionnaire (DMSQ) and assessed for missed pills. Descriptive statistics and logistic regression analysis were done.

RESULTS

We recruited 1347 participants and 84% of them reported being 100% adherent as per VAS and 83.8% stated that they did not miss any pills. However, 58.2% of participants who reported having 100% adherence had poor glycaemic control, as did 58.1% of those who did not miss any pills. None of the diabetic self-care measures was significantly associated with glycaemic control.

CONCLUSION

We found a lack of association between self-reported adherence measures and glycaemic control in participants with DM suggesting that self-reported adherence scales may not be valid in this population.

Standard Precautions are for everyone: The role of HIV stigma and implications for nursing education in India

Background and objective

Standard Precautions (SP) are infection control procedures universally applicable to every patient. Though SP reduces disease transmission, their implementation is dependent on the knowledge and skills of healthcare workers (HCWs). Poor knowledge regarding the appropriate use of SP can cause fear among HCWs, leading to stigma and discrimination while treating people living with HIV (PLWH). Stigma and discrimination are known barriers for PLWH to access HIV care services. The aim of the study was to assess nursing student knowledge of SP, SP self-efficacy and SP perceived efficacy of nursing students, and (2) to assess the association between SP knowledge, perceived efficacy, and intention to utilize unwarranted precautions, like using double gloves while treating PLWH.

Methods

This paper analyzes baseline (non-randomized) data of a cluster randomized controlled trial amongst 1868 Indian nursing students. Data was collected using computer-administered structured questionnaire. The associations between the measures were done using multiple, logistic and poisson regression models.

Results

Although 97% nursing students could identify SP, only 35.5% understood that they need to be used with all patients. Awareness of the importance of using SP with all patients was positively associated with self-efficacy. Students performing high-risk tasks frequently were significantly more likely to be confident in their ability to correctly use SP, but also had higher intention to use unwarranted precautions.

Conclusions

Existing teaching and training programs for HCWs need to provide clear guidelines and emphasize on the correct use of SP with all patients. This will increase both skills and confidence in their abilities (self-efficacy).

Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study)

BACKGROUND

Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions.

METHODS

We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time.

RESULTS

Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up.

CONCLUSIONS

The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.

Elevated homocysteine and depression outcomes in patients with comorbid medical conditions in rural primary care

We examined the association of elevated concentration of total homocysteine (tHcy) with the severity of depression in patients diagnosed with depression and comorbid chronic medical conditions in rural primary care settings in Karnataka. Participants were included from the control arm of a cluster-randomized controlled trial designed to evaluate the effects of using a collaborative care model to integrate screening and treatment of primary health center patients. tHcy was assayed at baseline, and depression severity scores were assessed using the Patient Health Questionnaire (PHQ-9) 6 months later. There was no difference in the mean PHQ-9 score between those with (mean PHQ = 7.4) and without (mean PHQ = 7.6) elevated tHcy levels (P = 0.67).

The effect of mental health training on the knowledge of common mental disorders among medical officers in primary health centres in rural Karnataka

Background

Deficits in knowledge regarding identification and treatment of common mental disorders (CMD) and stigmatizing attitudes towards CMDs exist among primary care physicians in India.

Objectives

We aimed to assess the gain in knowledge of CMDs among primary health centre (PHC) doctors, after they underwent training in the identification and treatment of CMDs, and to assess the relationship between the gain in knowledge and demographic variables. We also assessed attitudes towards depression among PHC doctors who underwent training.

Methods

We assessed knowledge of CMDs among 38 PHC doctors before and after training using a multiple-choice questionnaire (MCQ). The training session included didactic teaching and case-based discussions.

Results

The post-test mean score was significantly higher compared to the pre-test mean score (P < 0.0001), indicative of a significant mean gain in knowledge of CMDs among PHC doctors following training. Significant improvements were noted on the questions assessing identification of CMDs, knowledge of depressive symptoms and identification of panic attacks, post-training (all P < 0.05). Participants with lower pre-test scores had greater improvements in knowledge post-training. Around half of the PHC doctors endorsed negative attitudes towards depression.

Conclusions

We demonstrated the efficacy of a training programme for PHC doctors in improving their knowledge of CMDs. Stigmatizing attitudes towards depression were present among around half the PHC doctors even after the training. This has implications for the strategy of integrating mental healthcare into primary care, with the overall goal of reducing the treatment gap for CMDs.

Awareness of the Use of Standard Precautions during Care of People Living with HIV by Ward Attendants in Indian Hospitals

Context:

Standard precautions (SP) are infection prevention practices universally used during patient care to lower infection transmission.

Aims:

The aim of the study was to (1) assess Indian ward attendants' (WAs) knowledge, perceived efficacy, and self-efficacy regarding SP and (2) examine correlates of SP self-efficacy and intent to use unnecessary precautions during care of people living with HIV.

Subjects and Methods:

Data are sourced from a face-to-face baseline survey of a stigma-reduction trial among 1859 WAs from Indian hospitals. Percentages were used to describe categorical variables means and standard deviations for continuous variables. Multiple regressions examined associations between measures.

Results:

WAs who had heard of SP had 44% higher odds of confidently using SP than those who had not heard of them. Those aware of universal SP use were 43% more likely to feel confident in using SP but also reported greater intent to use unnecessary precautions.

Conclusions:

Hospitals could implement SP training for WAs, as their knowledge of universal use was lacking.

COVID-19 Vaccine Hesitancy Among PLWH in South India: Implications for Vaccination Campaigns

BACKGROUND

The global effort to end the Severe Acute Respiratory Syndrome - Coronavirus 2 pandemic will depend on our ability to achieve a high uptake of the highly efficacious vaccines in all countries. India recently experienced an unprecedented transmission surge, likely fueled by a premature reopening, the highly transmissible delta variant, and low vaccination rates. Indian media have reported high degrees of vaccine hesitancy, which could interfere with efforts to prevent future surges, making it crucial to better understand the reasons for such reluctance in vulnerable populations, such as people living with HIV.

METHODS

We conducted telephone interviews with 438 people living with HIV who were participants in a longitudinal cohort, designed to examine and validate novel antiretroviral therapy ART adherence measures. Interviews were conducted in January and February 2021 and covered COVID-19-related questions on confidence in vaccine safety and efficacy, worries of vaccine side effects, trust in COVID-19 information from specific sources, and intent to get vaccinated.

RESULTS

Over one-third of participants (38.4%, n = 168) met our definition of "vaccine hesitant" by reporting being either unlikely to get vaccinated at all or wanting to wait. Vaccine hesitancy was associated with lack of confidence in vaccine safety, concerns about side effects and efficacy, and distrust in common sources of vaccine-related information.

DISCUSSION

These results highlight several challenges for vaccination efforts. Campaigns may benefit from using trusted sources, including antiretroviral therapy center staff, providing clear information about safety and efficacy and emphasizing the role of vaccines in preventing severe disease, hospitalizations and death, and the reduction of forward transmission to unvaccinated household members.

Risk factors for severity of depression in participants with chronic medical conditions in rural primary health care settings in India

Background

Depression and chronic medical disorders are strongly linked. There are limited studies addressing the correlates of the severity of depression in patients with co-morbid disorders in primary care settings. This study aimed to identify the socio-demographic and disease-specific risk factors associated with the severity of depression at baseline among patients participating in a randomized controlled trial (HOPE study).

Methods

Participants were part of a randomized controlled trial in 49 primary care health centers in rural India. We included adults (≥ 30 years) with at least mild Depression or Anxiety Disorder and at least one Cardiovascular disorder or Type 2 Diabetes mellitus. They were assessed for the severity of depression using the PHQ-9, severity of anxiety, social support, number of co-morbid chronic medical illnesses, anthropometric measurements, HbA1c, and lipid profile.

Results

Proportionately there were more women in the moderate category of depression than men. Ordinal logistic regression showed co-morbid anxiety and a lower level of education significantly increased the odds of more severe depression, while more social support was significantly negatively associated with depression severity in women. In men, anxiety was positively associated with greater depression severity; while reporting more social support was negatively associated with depression.

Limitations

This is a cross-sectional study and thus, no causal conclusions are possible.

Conclusions

Anxiety and poor social support in both genders and lower educational levels in women were associated with increased severity of depression. Early identification of risk factors and appropriate treatment at a primary care setting may help in reducing the morbidity and mortality associated with depression.

Mental health of women living with HIV and its impact on child development in Andhra Pradesh, India

Global literature examining the association between mental health of women living with HIV (WLWH) and child development is scarce. In this study, we examined the relationship between mothers' mental health and their children's social development outcomes 6 months later. Data for these analyses come from several waves of interviews of 600 WLWH in the South Indian state of Andhra Pradesh, India. These women were enrolled in a 2×2 factorial clinical trial designed to assess the impact of food supplementation and nutrition education, both in addition to ASHA support, on adherence to ART and improved health outcomes for the women and one of their children. They were assessed on food security, stigma, social support, quality of life, depressive symptoms and child development outcomes. Results of longitudinal GEE regression analysis indicate that mother's depressive symptoms were significantly negatively associated with child's social quotient 6 months later. These findings have important implications for targeted health interventions, integrating mental health, both for WLWH and their children in India.

HIV Transmission Worry Predicts Discrimination Intentions Among Nursing Students and Ward Staff in India

Health facility stigma impedes HIV care and treatment. Worry of contracting HIV while caring for people living with HIV is a key driver of health facility stigma, however evidence for this relationship is largely cross-sectional. This study evaluates this relationship longitudinally amongst nursing students and ward staff in India. Worry of contracting HIV and other known predictors of intent to discriminate were collected at baseline and 6 months in 916 nursing students and 747 ward staff. Using fixed effects regression models, we assessed the effect of key predictors on intent to discriminate over a 6-month period. Worry of contracting HIV predicted intent to discriminate for nursing students and ward staff in care situations with low and high-risk for bodily fluid exposure, confirming prior cross-sectional study results and underscoring the importance of addressing worry of contracting HIV as part of health facility HIV stigma-reduction interventions.

Reduction in Stigma Drivers Partially Mediates the Effect of a Stigma Reduction Intervention Among Nursing Students in India: The DriSti Cluster Randomized Controlled Trial

BACKGROUND

HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes toward marginalized groups vulnerable to HIV. The DriSti intervention, consisted of 2 sessions with videos and interactive exercises on a computer tablet and one interactive face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma, and discrimination among nursing students (NS) and ward staff and tested in a cluster randomized trial.

SETTING

This report focuses on second and third year NS recruited from a range of nursing schools that included private, nonprofit, and government-run nursing schools in south India.

RESULTS

Six hundred seventy-nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (P < 0.001) and in the number of situations in which NS intended to discriminate against PLWH (P < 0.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers.

CONCLUSIONS

This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.

Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India

Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.

Reducing HIV stigma among healthcare providers in India using a partly tablet-administered intervention: the DriSti trial

HIV stigma has long been recognized as a significant barrier in the worldwide fight against HIV. Across cultures, stigma has been shown to cause psychological distress and act as a barrier to engagement in care. Health professionals can serve as a crucial source of HIV stigma, with drivers that include fears and transmission misconceptions and pre-existing negative attitudes towards marginalized groups. To increase their impact, stigma reduction interventions need to be scalable and sustainable as well as adaptable to different cultural contexts. The DriSti intervention was designed to meet these needs through an easily adaptable, mostly tablet-administered, interactive intervention delivered to ward staff (n = 1,557) and nursing students (n = 1,625) in 62 Indian institutions, using a cRCT design, with wait-list controls. Six-month outcome analyses, showed significant reductions in misconceptions (p < .001) and worry about acquiring HIV at work (p < .001). Intervention participants also reported significantly greater reductions in endorsement of coercive policies (p < .001) and in the number of situations in which they intended to discriminate against PLWH (p < .001) than control participants. This brief, scaleable intervention could be adapted for similar populations in the region, using different mHealth platforms and thus has important implications for current global stigma reduction initiatives and training curricula.

Examining engagement in care of women living with HIV in South India

HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided.

The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India

HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.

Alcohol Use and Experiences of Partner Violence Among Female Sex Workers in Coastal Andhra Pradesh, India

This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW's defiance. In multivariate logistic regressions, frequency of FSW's alcohol use was associated with abuse by clients and primary partner, whereas partner's alcohol use was only significant for abuse by primary partner, not clients.

Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India

We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0-5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.

Disclosure of HIV Status to Infected Children in South India: Perspectives of Caregivers

This study was designed to examine the rates of HIV serostatus disclosure in a sample of HIV-infected children in the state of Karnataka in South India, their reactions to learning their HIV-positive status and the reasons for and barriers to disclosure from the point of view of their caregivers. We enrolled 233 HIV-infected children, aged 5-18 years and their caregivers between July 2011 and February 2013 at HIV clinics in three tertiary care centers. Caregiver interviews included information about demographic characteristics, medical history, type of disclosure to the child and other related factors, including disclosure barriers. Three quarters (n = 185) of the caregivers reported that there had been no disclosure to the child, 15.4% (n = 38) reported partial disclosure (e.g. telling the child he or she had a 'chronic illness') and only 9.7% (n = 24) reported full disclosure, at a mean age of 10.9 (SD: 2.5) years. Caregivers, who planned to disclose in the future, stated on average that 16 years would be the right age. Those who favored a later disclosure reported that they feared strong negative emotional reactions from the child (p = 0.03) and social isolation (p < 0.001) following disclosure. These results show that that the level of full disclosure is low among South Indian youth living with HIV, and that when disclosure occurs, it is most likely to be partial. The majority of children who learned their status had been informed by a health-care provider, possibly reflecting the difficulty for a caregiver of having this conversation. The caregivers reported multiple disadvantages of disclosure, mostly because of fears of stigma and discrimination. Despite some evidence from the literature that disclosure can have positive effects on a child's health, it is thus clear that we need to develop, implement and evaluate community-based stigma reduction programs to reduce the social barriers to disclosure.

Alcohol use, expectancies and HIV-related sexual risk: a cross-sectional survey of male migrant workers in South India

Male migrant workers (MMWs) in India are vulnerable to developing alcohol-related problems and engaging in unprotected sex, putting them at risk of HIV. Research has shown that alcohol-related expectancies mediate vulnerability to alcoholism. We examined which expectancies were associated with sexual risk and drinking. We surveyed 1085 heterosexual MMWs in two South Indian municipalities, assessing expectancies, sex under the influence, and unprotected sex with female sex workers (FSW) and casual female partners in the prior 30 days. Men more strongly endorsed positive than negative expectancies (t = 53.59, p < .01). In multivariate logistic regression, the expectancy of having more fun helped drive the combination of alcohol and unprotected sex with FSW partners (OR = 1.22, p < .05), whereas the expectancy of better sex helped drive a similar combination with casual partners (OR = 1.24, p < .01). Men concerned about alcohol-induced deficits were less likely to drink with FSW partners (OR = 0.81, p < .01), but more likely to have unprotected sex with them (OR = 1.78, p < .01). To reduce risk, MMWs would benefit from combination prevention approaches that use behavioral strategies to address drinking norms and awareness of risk, while using biomedical strategies to reduce viral transmission when risk does occur.

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.

Quality of Life Among Women Living With HIV in Rural India

A cross-sectional examination was conducted on quality of life (QOL) among women living with HIV (WLWH) in rural Andhra Pradesh, India. Baseline data were collected from 400 WLWH and their children. QOL was measured with 10 items from the Quality of Life Enjoyment and Satisfaction Questionnaire. Findings revealed low QOL scores; on a scale from 0 to 3, the mean QOL score was 0.38 (SD = 0.30). Depression symptoms were reported by 25.5%, internalized stigma was high, and most reported little to no social support. Multivariable analysis revealed positive associations between QOL and CD4+ T cells (b = .0011, p = .021) and social support (b = .260, p < .0001), and a negative relationship between QOL and internalized stigma (b = -.232, p < .0001). Interventions focused on improving QOL for WLWH should incorporate strategies to improve social support and adherence to antiretroviral therapy, while mitigating internalized stigma.

Breaking Bad News: Patient Preferences and the Role of Family Members when Delivering a Cancer Diagnosis

BACKGROUND

Western physicians tend to favour complete disclosure of a cancer diagnosis to the patient, while non-Western physicians tend to limit disclosure and include families in the process; the latter approach is prevalent in clinical oncology practice in India. Few studies, however, have examined patient preferences with respect to disclosure or the role of family members in the process.

MATERIALS AND METHODS

Structured interviews were conducted with patients (N=127) in the medical oncology clinic of a tertiary referral hospital in Bangalore, India.

RESULTS

Patients ranged in age from 18-88 (M=52) and were mostly male (59%). Most patients (72%) wanted disclosure of the diagnosis cancer, a preference significantly associated with higher education and English proficiency. A majority wanted their families to be involved in the process. Patients who had wanted and not wanted disclosure differed with respect to their preferences regarding the particulars of disclosure (timing, approach, individuals involved, role of family members). Almost all patients wanted more information concerning their condition, about immediate medical issues such as treatments or side effects, rather than long-term or non-medical issues.

CONCLUSIONS

While most cancer patients wanted disclosure of their disease, a smaller group wished that their cancer diagnosis had not been disclosed to them. Regardless of this difference in desire for disclosure, both groups sought similar specific information regarding their cancer and largely favoured involvement of close family in decision making. Additional studies evaluating the influence of factors such as disease stage or family relationships could help guide physicians when breaking bad news.

Sexual identity and behavior in an online sample of Indian men who have sex with men

Indian men who have sex with men are disproportionately impacted by HIV. While prevention efforts to date have focused on men who visit drop-in centers or physical cruising sites, little is known about men who are meeting sexual partners on virtual platforms. This paper explores issues related to sexual identity and sexual behaviors in an online sample of men who identified as gay (n = 279) or bisexual (n = 123). There were significant differences in outedness between the two groups, with 48% of bisexually identified men reporting that they were out to "no one" and 82% stating that they present themselves as heterosexual to family and friends. Corresponding rates for gay-identified men were 15% and 41%, respectively (both p < .001). Twenty-nine percent of bisexually identified men reported being married, compared to only 3% of the gay-identified men (p < .001). Bisexually identified men were also more likely to report having exclusively insertive anal sex (49% vs 30% p < .001), while gay-identified men were more likely to report exclusively receptive anal sex (41% vs 13% p < .0001). Rates of unprotected anal sex (UAS) in the two groups were similar; however, married men were significantly more likely to report unprotected vaginal sex (76% vs 35%, p < .012). Positive attitudes toward UAS and lower self-efficacy were associated with sexual risk in both groups; however, substance use was associated with sexual risk only among bisexually identified men. These findings show that a large proportion of Indian bisexually identified men lead closeted lives, especially in their interactions with friends and family, with the vast majority presenting as heterosexual. The lower condom use with wives may be due to societal pressures to have children. The results suggest that bisexually identified men may benefit from targeted programs and non-directive, non-judgmental individual or couples counseling which emphasizes condom use with both male and female partners.

Stigmas, symptom severity and perceived social support predict quality of life for PLHIV in urban Indian context

Background

Multiple variables have been studied in relation to health-related quality of life (HRQoL), but research has not integrated the contributions of different variables in a single model that allows to compare them. This study, carried out with people living with HIV/AIDS in India, sought to develop a prediction model considering various predictors previously found to be related to HRQoL, namely sociodemographic factors, HIV symptoms, social support, stigmas and avoidant coping.

Methods

A sample of 961 HIV-positive persons from Bengaluru and Mumbai participated in this cross-sectional study, completing a sociodemographic questionnaire along with HRQoL, HIV symptoms, disclosure expectations, disclosure avoidance, social support and internalized, felt, vicarious and enacted stigma scales. Bivariate associations were obtained (correlations, ANOVAs and t tests) and a multiple regression analysis was performed.

Results

Results show that, when all variables are considered together, being married, widowed or deserted, symptom intensity, internalized stigma, disclosure avoidance and enacted stigma contribute negatively to predict HRQoL. On the other hand, being employed, good disclosure expectations and good social support contribute positively to predict HRQoL. Almost half of the variance in HRQoL was explained by this model.

Conclusions

Interventions seeking to increase HRQoL in people living with HIV/AIDS in India would benefit from addressing these aspects.

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.

Sequence and structural analyses of NSP4 proteins from human group A rotavirus strains detected in Tunisia

BACKGROUND

The NSP4 protein of group A rotavirus (RVA) has been recognized as a viral enterotoxin and plays important roles in viral pathogenesis and morphogenesis. Domains involved in structural and functional interactions have been proposed mainly based on the simian SA11 strain.

METHODS

NSP4 has been classified into 15 different genotypes (E1-E15), and the aim of this study was to analyze the sequences of 46 RVA strains in order to determine the aminoacid (aa) differences between E1 and E2 genotypes. Another aspect was to characterize the structural and physicochemical properties of these strains.

RESULTS

Comparison of deduced aa sequences of the NSP4 protein showed that divergences between NSP4 genotypes E1 and E2 were mostly observed in the VP4-binding, the interspecies variable domain (ISVD) and the double-layered particle (DLP) binding domains. Interestingly, uncommon variations in residues 131 and 138, which are known to be important aa in pathogenesis, were found in one unusual animal derived strain belonging to the E2 genotype. Concerning the structural aspect, no significant differences were noted.

CONCLUSION

The presence of punctual aa variations in the NSP4 genotypes may indicate that NSP4 mutates mainly via accumulation of point mutations.

Reducing HIV stigma among nursing students: a brief intervention

HIV stigma can be devastating and is common among health care providers, particularly nurses. The objectives of this study were to (a) assess the acceptability and feasibility of a brief stigma-reduction curriculum among a convenience sample of Indian nursing students and (b) examine the preliminary effect of this curriculum on their knowledge, attitudes, and intent to discriminate. At baseline, 57% of students had at least one misconception about HIV transmission, 38% blamed people living with HIV for their infection, and 87% and 95% demonstrated intent to discriminate while dispensing medications and drawing blood, respectively. Following the curriculum, HIV-related knowledge increased while blame, endorsement of coercive policies, and intent to discriminate decreased significantly. In addition, more than 95% of participants described the curriculum as practice changing. This brief intervention resulted in decreased stigma levels and was also highly acceptable to the nursing students. Next steps include rigorous evaluation in a randomized controlled trial.

Quality of life and psychosocial well-being among children living with HIV at a care home in Southern India

This study was designed to evaluate the quality of life (QOL) of children living with HIV at an institutional care home in Bangalore, India. The Sneha Care Home is a unique residence that provides educational and community support with a focus on physical, nutritional, medical, and psychological care for orphans and vulnerable children. Cross-sectional health measures and interview data were collected from 97 residents including 52 boys and 45 girls between 5 and 12 years of age (mean age = 9). QOL was measured with the Pediatric Quality of Life 4.0 (PedsQL) Inventory. Caregivers perceived children to have an overall higher QOL than was self-reported by children (total score 83 vs. 78). Our findings indicated self-reported QOL decreased with age of the child, while caregiver-reported QOL increased with age, suggesting a need to ensure greater psychological support for older children. Physical measures showed the children's clinical severity of disease remained well controlled living in this residential, values-based care home.

Suboptimal adherence associated with virological failure and resistance mutations to first-line highly active antiretroviral therapy (HAART) in Bangalore, India

This study was conducted to examine the relationship between adherence, viral load (VL) and resistance among outpatients receiving highly active antiretroviral therapy (HAART) in Bangalore, India. In total, 552 outpatients were recruited and VL testing was conducted for all study participants. HIV-1 genotypic resistance testing was performed for 92 participants with a VL ≥ 1000 copies/ml. Interpretation of resistance mutations was performed according to the Stanford database. Past-month adherence and treatment interruptions for >48 h were assessed via self-report. At baseline, 34 participants (6%) reported <95% past-month adherence and 110 (20%) reported a history of >48 h treatment interruptions. Combining the two adherence measures, 22% of participants were classified as 'suboptimally adherent'. In total, 24% of study participants (n = 132) had a detectable VL. Among the 92 samples sent for resistance testing, 68% had at least one nucleoside reverse transcriptase inhibitor (NRTI) mutation, with M184V being the most common (62%) and with 48% having thymidine analogue mutations. Moreover, 72% had at least one non-nucleoside reverse transcriptase inhibitor (NNRTI) mutation and 23% had three or more NNRTI mutations. Both adherence measures were significantly associated with VL (P < 0.001). Suboptimal adherence was significantly associated with resistance mutations (P < 0.02). The findings illustrate for the first time the strong association between suboptimal adherence, treatment failure and drug resistance to first-line HAART in India. The predictive value of standard adherence measures was improved by including treatment interruption data. The observed mutations can jeopardise future treatment options, especially in light of limited access to second-line treatments. To develop effective adherence interventions, research is needed to examine culturally-specific reasons for treatment interruptions.

Differences in testing, stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru, India

Approximately 2.4 million people in India are living with HIV. Gender inequality affects HIV prevention, detection, and management. The purpose of this paper was to describe gender differences in the experience of living with HIV in Bengaluru, India. A subsample of n = 313 (159 men and 154 women) from a larger cohort was used for these analyses. Participants were recruited through AIDS service organizations. They completed an interviewer-administered survey assessing HIV testing experience, types of stigma, and perceived consequences of stigmatization. The majority of men (67%) reported getting HIV tested because of illness, while women were more likely to be tested after learning their spouse's HIV-positive status (42%). More men (59%) than women (45%, p<0.05) were tested in private care settings. Men reported significantly higher mean levels of internalized stigma (men: M=0.71, SD = 0.63; women: M=0.46, SD = 0.55; p<0.001), whereas the women reported significantly higher scores for enacted stigma (men: M=1.30, SD = 1.69; women: M=2.10, SD = 2.17; p<0.001). These differences remained significant after controlling for potential socio-demographic covariates. Following their diagnosis, more women reported moving out of their homes (men: 16%; women: 26%; p<0.05). More men (89%) than women (66%; p<0.001) reported to have modified their sexual behavior after being diagnosed. These findings suggest that the experience of living with HIV and HIV stigma varies by gender in this population. Suggestions for a gender-based approach to HIV prevention and stigma reduction are provided.

Long-term efficacy of first line antiretroviral therapy in Indian HIV-1 infected patients: a longitudinal cohort study

Background

Short term efficacy of combination antiretroviral therapy (cART) in resource-constrained settings is comparable to that found in western studies. However, long term data are limited. India has the third largest HIV infected population in the world but the long-term outcome of first line therapy according to the national guidelines has not been evaluated yet. Therefore, we conducted a long-term longitudinal analysis of the efficacy of the national first-line therapy in India from an observational cohort of Indian patients in two different clinical settings.

Methodology/Principal Findings

A total 323 patients who had been on ART for a median of 23 months and achieved virological suppression <100 copies/ml by their study baseline visit, were included and followed for two years. Blood samples were collected every six months for viral load and CD4 count. Drug resistance genotyping was performed when the viral load was >2000 copies/mL. Adherence and treatment interruptions (>48 h) were assessed via self-report. In the studied patients, the median duration of viral suppression was 44 months; 15.8% of patients showed viral rebound, and 2.8% viral failure. Viral rebound or failure was significantly negatively related to perfect adherence (100% adherence and no treatment interruption >48 hrs). Virological re-suppression in the subsequent visit was observed in three patients without any change in therapy despite the presence of key mutations.

Conclusion/Significance

Our study reports for the first time, a good long-term response to the first line therapy for a median of nearly four years although a less than perfect adherence increases the risk for treatment failure and subsequent drug resistance development. The empirical findings in this study also indicate the overall success of the Indian ART program in two different settings which likely are representative of other clinics that operate under the national guidelines.

Equine G3P[3] rotavirus strain E3198 related to simian RRV and feline/canine-like rotaviruses based on complete genome analyses

Equine group A rotavirus (RVA) strains are the most important cause of gastroenteritis in equine neonates and foals worldwide, and G3P[12] and G14P[12] are epidemiologically the most important genotypes. The genotype constellation of an unusual Argentinean G3P[3] RVA strain (RVA/Horse-wt/E3198/2008/G3P[3]) detected in fecal samples of a diarrheic foal in 2008 was shown to be G3-P[3]-I3-R3-C3-M3-A9-N3-T3-E3-H6. Each of these genotypes has been found typically in feline and canine RVA strains, and the genotype constellation is reminiscent to those of Cat97-like RVA strains. However, the phylogenetic analyses revealed only a distant relationship between E3198 and known feline, canine and feline/canine-like human RVA strains. Surprisingly, a rather close relationship was found between E3198 and simian RVA strains RVA/Simian-tc/USA/RRV/1975/G3P[3] for at least 5 gene segments. RRV is believed to be a reassortant between a bovine-like RVA strain and a RVA strains distantly related to feline/canine RVA strains. These analyses indicate that E3198 is unlikely to be of equine origin, and most likely represents a RVA interspecies transmitted virus, possibly in combination with one or more reassortments, from a feline, canine or related host species to a horse. Further studies are in progress to evaluate if this strain was a single interspecies transmission event, or if this strain started to circulate in the equine population.

Blame, symbolic stigma and HIV misconceptions are associated with support for coercive measures in urban India

This study was designed to examine the prevalence of stigma and its underlying factors in two large Indian cities. Cross-sectional interview data were collected from 1,076 non-HIV patients in multiple healthcare settings in Mumbai and Bengaluru, India. The vast majority of participants supported mandatory testing for marginalized groups and coercive family policies for PLHA, stating that they “deserved” their infections and “didn’t care” about infecting others. Most participants did not want to be treated at the same clinic or use the same utensils as PLHA and transmission misconceptions were common. Multiple linear regression showed that blame, transmission misconceptions, symbolic stigma and negative feelings toward PLHA were significantly associated with both stigma and discrimination. The results indicate an urgent need for continued stigma reduction efforts to reduce the suffering of PLHA and barriers to prevention and treatment. Given the high levels of blame and endorsement of coercive policies, it is crucial that such programs are shaped within a human rights framework.

Stigma is associated with delays in seeking care among HIV-infected people in India

BACKGROUND

Stigma shapes the lives of people living with HIV and may affect their willingness to seek medical care. But treatment delays can compromise health and increase the risk of transmission to others.

PURPOSE

To examine whether the 4 stigma manifestations--enacted (discrimination), vicarious (hearing stories of discrimination), felt normative (perceptions of stigma's prevalence), and internalized (personal endorsement of stigma beliefs)--were linked with delays in seeking care among HIV-infected people in India.

METHODS

A cross-sectional survey was conducted with 961 HIV-positive men and women in Mumbai and Bengaluru.

RESULTS

Enacted and internalized stigmas were correlated with delays in seeking care after testing HIV positive. Depression symptoms mediated the associations of enacted and internalized stigmas with care-seeking delays, whereas efforts to avoiding disclosing HIV status mediated only the association between internalized stigma and care-seeking delays.

CONCLUSION

It is vital to develop stigma reduction interventions to ensure timely receipt of care.

Reasons for and correlates of antiretroviral treatment interruptions in a cohort of patients from public and private clinics in southern India

Understanding the prevalence and correlates of treatment interruptions (TIs) in resource-limited settings is important for improving adherence. HIV-infected adults on highly active antiretroviral therapy (HAART) in Bangalore, India, were enrolled into a prospective cohort study assessing HAART adherence. Participants underwent a structured interview assessing adherence, including occurrence of TI > 48 hours since HAART initiation, length of TI, and self-reported reasons for TI. Serum HIV viral load (VL) and CD4 was measured at 6-month intervals. Baseline data are presented in this article. For the 552 participants mean age was 37.8, 32% were female, 70% were married, 45% earned < $2/day. Eighty-four percent were on nevirapine-based antiretroviral therapy; median duration on HAART was 18 months (range: 1-175) and median CD4 count was 318 cells/µl (IQR: 195-460) at time of study enrollment. Twenty percent (n=110) reported at least one TI; of these, 33% (n=36) reported more than one TI. Median length of most recent TI was 10 days (range: 2-1095). TI was associated with a higher probability of having VL > 400 copies/ml (43% versus 12%; p<0.001). After controlling for time on HAART, TI was more likely among those who were unmarried (OR: 1.9; CI: 1.2-3.1), those treated in a private clinic setting (OR: 2.7; CI: 1.6-4.6 compared with public, and OR: 4.1; CI: 1.9-9.0 compared with public-private setting), and those on efavirenz-based therapy (OR: 2.0; CI: 1.1-3.6). The most common self-reported reason for TI was "side effects" (n=28; 25%), followed by cost of therapy (n=24; 22%). We discuss implications for both individual and structural level interventions to reduce TIs.

High rates of adherence and treatment success in a public and public-private HIV clinic in India: potential benefits of standardized national care delivery systems

Background

The massive scale-up of antiretroviral treatment (ART) access worldwide has brought tremendous benefit to populations affected by HIV/AIDS. Optimising HIV care in countries with diverse medical systems is critical; however data on best practices for HIV healthcare delivery in resource-constrained settings are limited. This study aimed to understand patient characteristics and treatment outcomes from different HIV healthcare settings in Bangalore, India.

Methods

Participants from public, private and public-private HIV healthcare settings were recruited between 2007 and 2009 and were administered structured interviews by trained staff. Self-reported adherence was measured using the visual analogue scale to capture adherence over the past month, and a history of treatment interruptions (defined as having missed medications for more than 48 hours in the past three months). In addition, CD4 count and viral load (VL) were measured; genotyping for drug resistance-associated mutations was performed on those who were in virological failure (VL > 1000 copies/ml).

Results

A total of 471 individuals were included in the analysis (263 from the public facility, 149 from the public-private facility and 59 from the private center). Private facility patients were more likely to be male, with higher education levels and incomes. More participants reported ≥ 95% adherence among public and public-private groups compared to private participants (public 97%; private 88%; public-private 93%, p < 0.05). Treatment interruptions were lowest among public participants (1%, 10%, 5% respectively, p < 0.001). Although longer clinic waiting times were experienced by more public participants (48%, compared to private 27%, public-private 19%, p < 0.001), adherence barriers were highest among private (31%) compared with public (10%) and public-private (17%, p < 0.001) participants. Viral load was detectable in 13% public, 22% private and 9% public-private participants (p < 0.05) suggesting fewer treatment failures among public and public-private settings. Drug resistance mutations were found more frequently among private facility patients (20%) compared to those from the public (9%) or public-private facility (8%, p < 0.05).

Conclusions

Adherence and treatment success was significantly higher among patients from public and public-private settings compared with patients from private facilities. These results suggest a possible benefit of the standardized care delivery system established in public and public-private health facilities where counselling by a multi-disciplinary team of workers is integral to provision of ART. Strengthening and increasing public-private partnerships can enhance the success of national ART programs.

Treatment switching in South Indian patients on HAART: what are the predictors and consequences?

Early identification and management of treatment failure on highly active antiretroviral therapy (HAART) is crucial in maintaining a sustained response to therapy in HIV infection. However, HIV viral load (VL) and resistance testing, and second-line HAART regimens, are unaffordable to many patients in India, leaving them with limited treatment options. Predictors and reasons for antiretroviral switching, therefore, are likely to differ in settings of varying resources. A one-year, observational study of patients receiving antiretroviral therapy was conducted in a private, non-profit hospital in Bangalore. This paper examines the predictors and consequences of antiretroviral treatment switching in this setting and explores reasons for switching in a subset of patients. Data on demographics, drug regimens, adherence, and physical and psychosocial outcomes were collected quarterly. Tests of VL and CD4 cell counts were performed every six months. One-third of the patients switched therapy during the study period. Baseline predictors of switching included lower CD4 cell counts and more physical symptoms. Contrary to studies in other settings, a high VL did not predict treatment switching, and only a minority of those experiencing drug failure were switched to second-line regimens. Both groups (switchers and non-switchers) improved significantly over time with respect to CD4 counts and psychological well-being, and showed a reduction in physical and depressive symptoms. Any differences between the groups were no longer significant at the end of the study, once we controlled for baseline levels. Clinical, policy, and research implications of these findings are discussed within the context of resource-limited settings.

Depression is not an inevitable outcome of disclosure avoidance: HIV stigma and mental health in a cohort of HIV-infected individuals from Southern India

Previous research has shown that HIV stigma in India can be characterized by a framework dividing manifestations into enacted (discrimination), vicarious (hearing stories of discrimination), felt normative (perceptions of stigma's prevalence), and internalized stigma (personal endorsement of stigma beliefs). We examined whether this framework could explain associations among stigma, efforts to avoid HIV serostatus disclosure, and depression symptoms in a cohort of 198 HIV-infected individuals from Southern India who were followed up for one year as part of a study of antiretroviral adherence. Prior studies had suggested that disclosure avoidance was a primary outcome of stigma and that impaired well-being was a primary outcome of disclosure avoidance. Analyses from our longitudinal research revealed that the pattern of associations among stigma, disclosure avoidance, and depression symptoms remained consistent over time. Enacted and vicarious stigmas were correlated with felt normative stigma beliefs. In turn, felt normative stigma was correlated with disclosure avoidance. And, enacted stigma, internalized stigma, and disclosure avoidance were all associated with depression symptoms. However, even though the overall framework held together, internalized stigma and depression symptoms dropped significantly over time while other components remained unchanged. These findings suggest that, although HIV stigma may limit disclosure, it does not invariably lead to psychological maladjustment. Amidst ongoing perceptions and experiences of stigma, HIV-positive individuals can achieve significant improvements in their acceptance of the disease and in mental well-being.

The decrease in procarboxypeptidase U (TAFI) concentration in acute ischemic stroke correlates with stroke severity, evolution and outcome

BACKGROUND AND OBJECTIVES

Procarboxypeptidase U (proCPU, TAFI) concentration in plasma is potentially related to thrombotic tendency, and elevated proCPU levels have been reported in ischemic stroke patients. Improved insight into the role of proCPU in acute ischemic stroke is essential for the development of more adequate therapeutics that may include carboxypeptidase inhibitors. In this study we investigated whether the plasma concentration of proCPU and the proCPU kinetic profile in acute ischemic stroke are related to initial stroke severity, stroke evolution in the subacute phase and long-term stroke outcome.

METHODS

Plasma concentration of proCPU was assessed in 136 stroke patients at admission (7.5 h after stroke onset), at 24 h, at 72 h and at day 7 after stroke onset. We evaluated the relation between change in proCPU concentrations and (a) stroke severity (patients with TIA vs. stroke patients, NIHSS score at admission), (b) stroke evolution (stroke progression, infarct volume at 72 h), and (c) stroke outcome (mRS score at month 3).

RESULTS

ProCPU concentration decreased significantly in the first 72 h after stroke onset and thereafter returned to baseline. This biphasic time course, with its nadir at 72 h, was more pronounced in patients with severe stroke, unfavourable stroke evolution in the first 72 h and poor long-term outcome.

CONCLUSIONS

The decrease in proCPU concentration in the first 72 h after stroke onset correlates with more severe stroke, unfavourable stroke evolution, and poor long-term stroke outcome.