Which Intervention Synergies Maximize AGYW's HIV Outcomes? A Classification and Regression Tree Analysis of Layered HIV Prevention Programming

INTRODUCTION

Intersecting behavioral, social, and structural factors increase adolescent girls' (AG) and young women's (YW) HIV vulnerability. Yet, understanding of optimal intervention synergies remains limited. We identified intervention combinations that statistically maximized reductions in AGYW's HIV-related risk.

METHODS

Using data collected in 2018 with Zambian AG (n = 487, aged 15-19 years) and YW (n = 505, aged 20-25 years) after 12-14 months exposure to Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (multisectoral HIV program), we used classification and regression trees to explore relationships between interventions (safe space/social asset building [SAB] and provision of/linkage to youth-friendly health services [YFHS], education social protection [Educ], economic social protection [Econ]) and HIV-related outcomes (HIV testing, consistent condom use, transactional sex, and sexual violence experience from partners and nonpartners).

RESULTS

Overall, 59.9% completed SAB and 81.5%, 35.4%, and 29.6% received YHFS, Educ, and Econ, respectively. For AG, HIV testing improved (from 73% to 83%) with exposure to all interventions, condom use improved with Econ (from 33% to 46%), transactional sex reduced with SAB + Educ, and sexual violence from partners and nonpartners reduced with Educ and SAB, respectively. For YW, HIV testing increased with Educ (from 77% to 91%), condom use increased with SAB + YFHS (from 36% to 52%), transactional sex reduced with combinations of all interventions, and sexual violence from partners reduced with YFHS and from nonpartners with SAB + Econ.

CONCLUSIONS

Tailored interventions might be more effective than uniform combination intervention packages in reducing AGYW's HIV risk. AG benefitted most from SAB and/or Educ while YFHS, Educ, and/or SAB reduced YW's HIV-related risk. Educational and asset-building interventions could have the greatest impact on AGYW's HIV risk.

Reduced reward responsiveness in treatment resistant depression of middle-aged adults: Association with carotid artery stiffness and tetrahydrobiopterin

Nearly one third of the population diagnosed with major depressive disorder (MDD) fail to respond to two or more antidepressant drugs of adequate dose and duration. This necessitates identification of confounding psychological and physiological factors that could contribute to treatment resistant depression (TRD). The present longitudinal study investigated the influence of behavioural inhibition system (BIS) and behavioural approach system (BAS) in treatment resistance. Further, the association of depression severity with physiological factors contributing to arterial stiffness was also investigated. Baseline data was acquired from 101 middle-aged (36-56 years) patients on immediate diagnosis with MDD using DSM-V criteria. Follow ups were conducted at 06 months and 12 months during treatment. Psychological assessment battery at baseline and follow ups comprised of Hamilton depression rating (HAM-D) for depression severity, WHODAS-2 and BIS-BAS score. Atherosclerosis and central arterial stiffness were measured by intima-media thickness of internal carotid artery and brachial-ankle pulse wave velocity. Physiological factors influencing central vascular function viz., body-mass index, estimated glomerular filtration rate, HbA1c, central systolic and diastolic blood pressure, heart rate and tetrahydrobiopterin were also investigated. Our results show lower reward responsiveness (BAS-RR) and higher BIS scores in TRD patients along with differentially higher intima-media thickness of left internal carotid artery. Higher depression severity at all stages of the study was correlated with lower tetrahydrobiopterin and BAS-RR scores. We, therefore, suggest that vascular depression resulting due to increased intima-media thickness of left carotid artery and lower tetrahydrobiopterin could be contributing factors for treatment resistance in middle-aged MDD patients.

National guidelines for data quality in surveys: An overview

Good quality health, nutrition and demographic survey data are vital for evidence-based decision-making. Existing literature indicates system specific, data collection and reporting gaps that affect quality of health, nutrition and demographic survey data, thereby affecting its usability and relevance. To mitigate these, the National Data Quality Forum (NDQF), under the Indian Council of Medical Research (ICMR) - National Institute of Medical Statistics (NIMS) developed the National Guidelines for Data Quality in Surveys delineating assurance mechanisms to generate standard quality data in surveys. The present article highlights the principles from the guidelines for informing survey researchers/organizations in generating good quality survey data. It describes the process of development of the national guidelines, principles for each of the survey phases listed in the document and applicability of them to data user for ensuring data quality. The guidelines may be useful to a broad-spectrum of audience such as data producers from government and non-government organizations, policy makers, research institutions, as well as individual researchers, thereby playing a vital role in improving quality of health, nutrition and demographic data ecosystem.

Climate change vulnerability, and health of women and children: Evidence from India using district level data

OBJECTIVE

To understand how climate change vulnerability is associated with women and children's health (WCH) at the district level in India.

METHODS

The district-specific climate change vulnerability index was mapped to the district level NFHS-5 data (N = 674). Fractional regression and spatial analyses were performed to examine the strength of association and the presence of geographic clustering.

RESULTS

Bivariate analysis revealed that the levels of WCH indicators were lower in districts with a high vulnerability index than in those with a low vulnerability index. Multivariable analyses suggested that with a 1% increase in the vulnerability index, the proportion of modern contraceptive use was reduced by 0.22, four or more prenatal care visits by 0.14, postnatal care by 0.11, and full immunization by 0.12; whereas wasting and underweight proportions increased by 0.07 and 0.10, respectively. The spatial analysis found that in about 70-118 districts, mostly in eastern India, where climate vulnerability was high the WCH outcomes were also poor.

CONCLUSION

There is a macro-level association between climate change vulnerability and WCH, as districts that had high levels of climate change vulnerability also performed poorly in WCH. There is a need for an integrated approach that considers geography-specific climate change threats to develop health programs.

Survey implementation process and interviewer effects on skipping sequence of maternal and child health indicators from National Family Health Survey: An application of cross-classified multilevel model

Implementing a large-scale survey involves a string of intricate procedures exposed to numerous types of survey errors. Uniform and systematic training protocols, comprehensive survey manuals, and multilayer supervision during survey implementation help reduce survey errors, providing a consistent fieldwork environment that should not result in any variation in the quality of data collected across interviewers and teams. With this background, the present study attempts to delineate the effect of field investigator (FI) teams and survey implementation design on the selected outcomes. Data on four of the bigger Empowered Action Group (EAG) states of India, namely Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan, were obtained from the fourth round of the National Family Health Survey (NFHS-4) for analysis. A fixed-effect binary logistic regression model was used to assess the effect of FI teams and survey implementation design on the selected outcomes. To study the variation in the outcome variables at the interviewer level, a cross-classified multilevel model was used. Since one interviewer had worked in more than one primary sampling unit (PSU) & district and did not follow a perfect hierarchical structure, the cross-classified multilevel model was deemed suitable. In addition, since NFHS-4 used a two-stage stratified sampling design, two-level weights were adjusted for the models to compute unbiased estimates. This study demonstrated the presence of interviewer-level variation in the selected outcomes at both inter- and intra-field agencies across the selected states. The interviewer-level intra-class correlation coefficient (ICC) for women who had not availed antenatal care (ANC) was the highest for eastern Madhya Pradesh (0.23) and central Uttar Pradesh (0.20). For ‘immunisation card not seen’, Rajasthan (0.16) and western Uttar Pradesh (0.13) had higher interviewer-level ICC. Interviewer-level variations were insignificant for women who gave birth at home across all regions of Uttar Pradesh. Eastern Madhya Pradesh, Rajasthan, and Bihar showed higher interviewer-level variation across the selected outcomes, underlining the critical role of agencies and skilled interviewers in different survey implementation designs. The analysis highlights non-uniform adherence to survey protocols, which implies that not all interviewers and agencies performed in a similar manner in the field. This study recommends a refined mechanism for field implementation and supervision, including focused training on the challenges faced by FIs, random vigilance, and morale building. In addition, examining interviewer-level characteristics, field challenges, and field agency effects may also highlight the roots of interviewer-level variation in the data. However, based on the interviewer's performance in the field, the present study offers an intriguing insight into interviewer-level variations in the quality of data.

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With uniform survey implementation strategies, the interviewer should not have any effect in explaining the maternal and child health variables.

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Skipping of selected maternal and child health indicators curtails informativeness of the survey. Results confirms that information on vaccination card, antenatal care, maternal policy information, delivery cost and postnatal checkups have been skipped with negative response to opening questions.

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Cross-classified multilevel model confirms the presence of interviewer-level variation. The interviewer-level intra-class correlation coefficient (ICC) for ‘immunization card not seen’ was found to be highest in Rajasthan and western Uttar Pradesh.

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Interviewer-level variations were found to be not significant for women who gave birth at home across all the regions of Uttar Pradesh whereas the interviewer-level variations for women who had not availed ANC was found to be highest for eastern Madhya Pradesh central Uttar Pradesh. Results emphasizes that not all interviewers and agencies performed in a similar manner in the field.

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The study recommends a refined mechanism for field implementation and supervision, including focused training on challenges faced by field investigators, random vigilance, and morale building.

Assessing layered HIV prevention programming: optimizing outcomes for adolescent girls and young women

OBJECTIVE

To assess how exposure to multiple, layered interventions predicts HIV-related outcomes among adolescent girls (15-19 years) and young women (20-24 years) in Kenya.

DESIGN

Survey data from adolescent girls and young women (n = 736) with 14-16 months of engagement with DREAMS, a comprehensive HIV prevention program that provides a range of health education, life skills, social protection, and social and behaviour change interventions.

METHODS

Nonparametric recursive partitioning technique - classification and regression tree (CART) - to identify the best predictors (DREAMS interventions) for achieving the desired HIV-related outcomes (consistent condom use and no transactional sex or sexual violence).

RESULTS

Among adolescent girls, schooling support reduced the likelihood of engaging in transactional sex, whereas schooling support and exposure to parenting program reduced the likelihood experiencing sexual violence. Likelihood of consistent condom use increased among adolescent girls with exposure to preexposure prophylaxis (PrEP), schooling support, and the violence prevention programming. Among young women, multiple pathways reduced the likelihood of engaging in transactional sex: exposure to the male sexual partner program; exposure to the youth fund program; exposure to the violence prevention program; or exposure/engagement with schooling support, parenting programming, and the youth fund program. For young women, consistent condom use increased with schooling support and male partner engagement. Additionally, engagement in violence prevention program and male partner engagement increased the likelihood of not experiencing sexual violence among young women.

CONCLUSION

Exposure to a combination of DREAMS interventions predicted outcomes that can reduce HIV risk among AGYW, though the pathways differed by outcome and age group.

Role of maternal and child health services on the uptake of contraceptive use in India: A reproductive calendar approach

BACKGROUND

According to the latest round of National Family Health Survey-4 (NFHS (2015-16)) maternal and child health care (MCH) services improved drastically compared to NFHS-3. Previous studies have established that the uptake of MCH services increases the likelihood of early adoption of contraceptives among women. So, our study aims to examine if the early initiation of contraceptive has proportionately improved with the recent increase in MCH services.

METHODS

This study used the reproductive calendar of NFHS-4, 2015-16, to evaluate contraceptive initiation within 12 months after the last birth among 1,36,962 currently married women in India. A complementary log-log regression model was created to examine the link between the time of initiation of contraception and MCH care at the national level.

RESULTS

It was found that only a quarter of women within 12 months from last birth have adopted the modern contraceptive method. Among those majority of the females adopted sterilization mostly at the time of birth. The multivariable model identified, that the period of initiation of contraceptive depends on the gender composition of children and access to MCH services. It was found that the odds of early initiation of contraceptive use was higher when a women have only son (AOR = 1.15,95% CI- 1.22, 1.18) compared to women with only daughter. Also, it was found that women who have availed MCH services were more likely to adopt contraceptives earlier.

CONCLUSION

The number of women availing MCH services has increased in India, but it did not result in a proportional increase in initiation of contraception after childbirth. Facilitating family planning services alongside MCH services will be beneficial in low-resource settings. It is a golden opportunity to educate and encourage women for early adoption of contraceptive.

Temporal shifts in HIV-related risk factors among cohorts of adolescent girls and young women enrolled in DREAMS programming: evidence from Kenya, Malawi and Zambia

OBJECTIVES

To assess temporal shifts in HIV risk factors among adolescent girls (AG, aged 15-19 years) and young women (YW, aged 20-24 years) in Kenya, Malawi and Zambia.

DESIGN

Prospective cohorts with two time points (Kenya: 2016/2017, 2018; Malawi: 2017, 2018; Zambia: 2016/2017, 2018) SETTING: Community-based programming.

PARTICIPANTS

1247 AG (Kenya: 389, Malawi: 371, Zambia: 487) and 1628 YW (Kenya: 347, Malawi: 883, Zambia: 398) INTERVENTION: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral approach to reduce AGYW's HIV vulnerability by delivering a package of tailored, multilayered activities and services.Primary and secondary outcome measures: HIV testing, sexually transmitted infection (STI) symptom experience, number of sexual partners, condom use (consistently, at last sex), transactional sex, experience of physical violence (from intimate partners) and sexual violence (from intimate partners and strangers/non-partners).

RESULTS

Changes in HIV-related risk behaviours among DREAMS participants varied by age group and country. Among AG, HIV testing increased (Kenya and Zambia) and sexual violence from partners (in Kenya and Malawi) and non-partners (in Malawi) decreased. Among YW, HIV testing increased and STI experience decreased in Malawi; consistent condom use decreased in Kenya; transactional sex increased in Kenya and Zambia; and physical violence (in Malawi) and sexual violence from partners (in Kenya and Malawi) and non-partners (all three countries) decreased over time.

CONCLUSIONS

Improvements in HIV testing and reductions in experiences of sexual violence were coupled with variable shifts in HIV-related risk behaviours among DREAMS participants in Kenya, Malawi and Zambia. Additional consideration of AGYW's risk circumstances during key life transitions may be needed to address the risk heterogeneity among AG and YW across different contexts.

Spatial heterogeneity in discontinuation of modern spacing method in districts of India

Background

Despite six decades of official family planning programme, the use of modern contraceptive method remained low in India. The discontinuation of modern spacing method (DMSM) has also increased from 42.3% in 2005−06 to 43.6% during 2015–16. Discontinuation rate is higher for Injectable (51%), followed by condom (47%), pill (42%) and lowest in IUD (26%).

Methods

Data from NFHS-4 (2015–16) comprising of 601,509 households, 699,686 women and a sample of 119,548 episode of modern spacing method was used for the analysis. Multiple decrement life table has used to estimate 12-month discontinuation rate of modern spacing methods (DMSM). Moran’s I statistics, Bivariate LISA cluster map has used to understand the spatial correlates and clustering the DMSM. OLS model and impact analysis has used to assess the significant associated covariates with discontinuation.

Result

The 12-month DMSM in India is 43.5%; largely due to desire for becoming pregnant and method failure. The high discontinuation rate was observed in most of the southern (62%) and central (46%) regions of India. DMSM has significantly and spatially associated with neighbouring districts of India (Moran’s I = 0.47, p-value = 0.00). The prevalence of modern spacing method is negatively associated with discontinuation in the neighbouring districts of India. The unmet need (β = 0.84, 95% CI 0.55–1.14), desire of children (β = 0.26, 95% CI − 0.05–0.57) and female sterilization (β = 0.54, 95% CI 0.14–0.95) were three main contributing factor to DMSM.

Conclusion

Districts of high DMSM need programmatic intervention. More attention for counselling to client, health worker outreach to user and better quality care services will stimulate non-user of contraception.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01185-w.

Contraceptive discontinuation is major issue of family planning of India. Without getting proper knowledge of modern spacing method, women facing serious health related issues so that they tend to discontinue their family planning method. We examine the spatial heterogeneity of discontinuation of modern spacing method in 640 district of India. Using secondary data of NFHS-4 (2015–16), we calculated 12-month discontinuation rate of any method and any modern spacing method by reason of discontinuation, also we presented discontinuation pattern by regions of India. To measure the spill over effect and associated factor of discontinuation of modern spacing method, we used OLS model and estimated Impact result. The findings of our study conveys that desire to become pregnant is the leading cause of discontinuation for both any method and any modern spacing method (12.43%), followed by other fertility related reasons and methods relates reason’s (4.40%). Method failure, side effect of method and method related reason together accounts 12% of contraceptive discontinuation in India. Very low use of modern spacing method of districts should be given more attention for policy maker and planner to increase the use of modern spacing method. The districts of high discontinuation of modern spacing method need programmatic intervention. More attention for counselling to client, health worker outreach to user and better quality care services will stimulate non-user of contraception.

Vulnerability of agriculture to climate change increases the risk of child malnutrition: Evidence from a large-scale observational study in India

INTRODUCTION

The impact of climate change on agriculture and food security has been examined quite thoroughly by researchers globally as well as in India. While existing studies provide evidence on how climate variability affects the food security and nutrition, research examining the extent of effect vulnerability of agriculture to climate change can have on nutrition in India are scarce. This study examined a) the association between the degree of vulnerability in agriculture to climate change and child nutrition at the micro-level b) spatial effect of climate vulnerability on child nutrition, and c) the geographical hotspots of both vulnerability in agriculture to climate change and child malnutrition.

METHODS

The study used an index on vulnerability of agriculture to climate change and linked it to child malnutrition indicators (stunting, wasting, underweight and anaemia) from the National Family Health Survey 4 (2015-16). Mixed-effect and spatial autoregressive models were fitted to assess the direction and strength of the relationship between vulnerability and child malnutrition at macro and micro level. Spatial analyses examined the within-district and across-district spill-over effects of climate change vulnerability on child malnutrition.

RESULTS

Both mixed-effect and spatial autoregressive models found that the degree of vulnerability was positively associated with malnutrition among children. Children residing in districts with a very high degree of vulnerability were more like to have malnutrition than those residing in districts with very low vulnerability. The analyses found that the odds of a child suffering from stunting increased by 32%, wasting by 42%, underweight by 45%, and anaemia by 63% if the child belonged to a district categorised as very highly vulnerable when compared to those categorised as very low. The spatial analysis also suggested a high level of clustering in the spatial distribution of vulnerability and malnutrition. Hotspots of child malnutrition and degree of vulnerability were mostly found to be clustered around western-central part of India.

CONCLUSION

Study highlights the consequences that vulnerability of agriculture to climate change can have on child nutrition. Strategies should be developed to mitigate the effect of climate change on areas where there is a clustering of vulnerability and child malnutrition.

Effect of exposure to PM10 on child health: evidence based on a large-scale survey from 184 cities in India

Introduction

Air pollution is increasingly becoming a serious global public health concern. Prior studies examining the effect of air pollution on health have ignored the role of households’ hygienic practices and socioeconomic condition, which are key determinants of the health status of a country like India. This study examines the effects of air pollution, measured in levels of particulate matters of size below 10 µg/m³ (PM₁₀), on child-health outcomes after adjusting for hygiene practices.

Methods

Health data from the National Family Health Survey-4 (NFHS-4) and PM₁₀ levels provided by the Central Pollution Control Board were matched for 184 Indian towns/cities. Child health outcomes included neonatal mortality, post-neonatal mortality, premature births, children with symptoms of acute respiratory infections (ARI) and low birth weight. Multilevel mixed-effects models were used to estimate the risk associated with exposure to PM₁₀.

Result

Analyses based on 23 954 births found that every 10-unit increase in PM₁₀ level, increased the risk of neonatal mortality by 6% (adjusted RR (95% CI): 1.02 (1.02 to 1.09)), and the odds of symptoms of ARI among children by 7% (adjusted OR (95% CI): 1.07 (1.03 to 1.12)), and premature births by 8% (adjusted OR (95% CI): 1.08 (1.03 to 1.12)). There was no statistically significant difference in the effect of PM₁₀ on child health regardless of household’s hygienic practices. Effects of PM₁₀ on child health outcomes remained similar for cities whether or not they were part of the National Clean Air Program (NCAP).

Conclusion

Exposure to PM₁₀, regardless of hygienic practices, increases the risk of adverse child health outcomes. Study findings suggest that the focus of mitigating the effects of air pollution should be beyond the towns/cities identified under NCAP. Given the increasing industrialisation and urbanisation, a systemic, coherent approach is required to address the issue of air pollution in India.

Migration and family planning in the state with highest total fertility rate in India

BACKGROUND

This study examined the relationship between male out-migration and family planning (FP) behaviour of women in rural Bihar.

METHODS

Data was collected from 937 currently married women aged 15-34 years from two districts of Bihar, namely Nawada and Gopalganj. Respondents were selected through a multi-stage systematic sampling and were recruited from both low and high male out-migration blocks. Differences in FP outcomes-use of modern contraceptive methods, intention to use contraceptives in next 12 months and access to FP services-were assessed by volume of migration, husband's migration status, frequency of return, and duration of husband's stay at home during visits.

RESULTS

Women with migrant husbands were about 50% less likely to use modern contraceptive methods. Further, the odds of using modern contraceptives was about half among women with migrant husbands if they resided in high out-migration areas (HMA) than low out-migration areas (LMA) (15% vs 29%, AOR: 0·50, p = 0·017). A higher proportion of women with migrant husbands, specifically from HMA, reported greater intention of using contraceptives in next 12 months than their counterparts (37% vs 23%, AOR: 1·83, p = 0·015). Similarly, access to FP services was negatively associated with the volume of male out-migration, specifically for women with migrant husbands.

CONCLUSIONS

The migratory environment as well as the migration of husbands affect contraceptive use and access to FP services among women. Given that a significant proportion of married males leave their home states for work, it is imperative that FP programs in migration affected areas plan and implement migration-centric FP implementation strategies.

Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India

Introduction

Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex through consistent use of condoms sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying relationship between strengthening of COs, vulnerability reduction, and sustaining of consistent condom use behavior among FSWs.

Methods

We used a longitudinal study design to assess the change in outcomes. A three-stage sampling design was used to select FSWs for the study. Panel data of 2085 FSWs selected from 38 COs across five states of India was used to examine the change in various outcomes from 2015 (Survey Round 1) to 2017 (Survey Round 2). The CO level program pillar measuring institutional development assessed performance of COs in six domains critical for any organization’s functionality and sustainability: governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization. Overall, 32 indicators from all these domains were used to compute the CO strength score. A score was computed by taking mean of average dimension scores. The overall score was divided into two groups based on the median cutoff; COs which scored below the median were considered to have low CO strength, while COs which scored above or equal to median were considered to have high CO strength. Multivariable regression modeling techniques were used to examine the effect of program pillars on outcome measures.

Results

Analyses showed a significant improvement in the strength of the COs over time; percentage of COs having high strength improved from 50% in 2015 to 87% in Round 2. The improvement in CO’s strength increased financial security (Adjusted Odds Ratio [AOR]: 2.18, p<0.01), social welfare security (AOR: 1.71, p<0.01), and socio-legal security (AOR: 2.20, p<0.01) among FSWs. Further, improvement in financial security led to significant increase in consistent condom use with client among FSWs (AOR: 1.69, p<0.01) who were members of COs having high strength. Sustained consistent condom use was positively associated with young age (<30 years), ability to negotiate with clients for condom use, membership in self-help groups, high self-efficacy, self-confidence, and client solicitation in streets and brothels.

Conclusions

Improving financial security and strengthening FSW led CO can improve sustained and consistent condom use. In addition, the program should focus on enhancing ability of FSWs to negotiate with clients for condom use, promote membership in self-help groups and target FSWs who are 30 years or older, and soliciting from homes to sustain consistent condom use across all FSWs.

HIV vulnerability among adolescent girls and young women: a multi-country latent class analysis approach

OBJECTIVES

To stem the HIV epidemic among adolescent girls and young women (AGYW, 15-24 years), prevention programs need to reach AGYW who are most at risk. We examine whether individual- and household-level factors could be used to define HIV vulnerability for AGYW.

METHODS

We surveyed out-of-school AGYW in urban and peri-urban Kenya (N = 1014), in urban Zambia (N = 846), and in rural Malawi (N = 1654) from October 2016 to 2017. LCA identified classes based on respondent characteristics, attitudes and knowledge, and household characteristics. Multilevel regressions examined associations between class membership and HIV-related health outcomes.

RESULTS

We identified two latent classes-high and low HIV vulnerability profiles-among AGYW in each country; 32% of the sample in Kenya, 53% in Malawi, and 51% in Zambia belonged to the high vulnerability group. As compared to AGYW with a low-vulnerability profile, AGYW with a high-vulnerability profile had significantly higher odds of HIV-related outcomes (e.g., very early sexual debut, transactional sex, sexual violence from partners).

CONCLUSIONS

Out-of-school AGYW had differential vulnerability to HIV. Interventions should focus on reaching AGYW in the high HIV vulnerability profiles.

Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey

Introduction

Community-led organizations (COs) have been an integral part of HIV prevention programs to address the socio-economic and structural vulnerabilities faced by female sex workers (FSWs). The current study examines whether strengthening of community-led organizations and community collectivization have been instrumental in reducing the financial vulnerability and empowering FSWs in terms of their self-efficacy, confidence, and individual agency in India.

Data and methods

This study used a panel data of 2085 FSWs selected from 38 COs across five states of India. Two rounds of data (Round 1 in 2015 and Round 2 in 2017) were collected among FSWs. Data were collected both at CO and individual level. CO level data was used to assess the CO strength. Individual level data was used to measure financial security, community collectivization, and individual empowerment.

Results

There was a significant improvement in CO strength and community collectivization from Round 1 to Round 2. High CO strength has led to improved financial security among FSWs (R2: 85% vs. R1: 51%, AOR: 2.5; 95% CI: 1.5–4.1) from Round 1 to Round 2. High collective efficacy and community ownership have improved the financial security of FSWs during the inter-survey period. Further, the improvement in financial security in the inter-survey period led to increased or sustained individual empowerment (in terms of self-confidence, self-efficacy, and individual agency) among FSWs.

Conclusions

Institutional strengthening and community mobilization programs are key to address the structural issues and the decrease of financial vulnerability among FSWs. In addition, enhanced financial security is very important to sustain or improve the individual empowerment of FSWs. Further attention is needed to sustain the existing community advocacy and engagement systems to address the vulnerabilities faced by marginalized populations and build their empowerment.

Community Organization Membership, Financial Security, and Social Protection among Female Sex Workers in India

The purpose of this study is to examine the female sex workers’ (FSWs) community organization (CO) membership, their financial and social protection security, and the relationship between these factors among FSWs in India. Data from 4098 FSWs collected under the Avahan-III baseline evaluation survey—2015 in 5 high HIV prevalence states (Maharashtra, Tamil Nadu, Karnataka, Telangana, and Andhra Pradesh) in India were used here. More than three-fifths (77%) were registered CO members, of whom 79% had been CO members for more than 1 year. The likelihood of having high financial security (19% versus 10%; adjusted odds ratio [AOR]: 1.7; 95% confidence interval [CI]: 1.3-2.1) and social protection security (13% versus 6%; AOR: 1.6; 95% CI: 1.2-2.0) was 2 times higher among FSWs who were CO members compared to those who were not. The study offers important insights into furthering CO membership to address financial and social vulnerability as a path to a sustainable reduction of HIV risk.

Measuring vulnerability among female sex workers in India using a multidimensional framework

Measuring vulnerability and identifying determinants of vulnerability are key to designing interventions for marginalized groups like sex workers. The current study introduces a new approach of measuring vulnerability among female sex workers (FSWs) by adopting a multidimensional poverty measurement framework. A multidimensional vulnerability index was created from four dimensions and 16 indicators using a dual cut-off approach. The study found that 55% of FSWs were multidimensionally vulnerable with 48% of intensity in vulnerability. The overall value of multidimensional vulnerability index was 0.265. FSWs in Maharashtra were most vulnerable (82%). Lack of financial security contributed mostly to FSWs’ vulnerability. Further, compared to less vulnerable FSWs, multidimensionally vulnerable ones were more to engage in behaviors that put them at risk such as inconsistent use of condoms with clients, alcohol consumption, engaging in anal sex with clients and experiencing sexually transmitted infections. Findings suggest that structural, social and financial vulnerabilities of FSWs need to be addressed concurrently.

Building the evidence base on the HIV programme in India: an integrated approach to document programmatic learnings

Background

The Knowledge Network project was launched in 2010 to build evidence on the HIV epidemic by using the data generated by HIV programme implementing organisations in India. This paper describes the implementation of the programme and the strategies adopted to enhance the capacity of individuals to document and publish HIV prevention programme learnings. Further, it discusses the outcomes of the initiative.

Methods

A multipronged approach was adopted, where a group of experts were brought together to collaborate with programme implementing organisations, review available data, develop research questions and guide peer-reviewed publications. Further, scientific writing courses were conducted to support individuals from HIV programme implementing organisations as well as educational and government organisations (mentees) to build the documentation capacity of individuals leading programme implementation and current and future researchers. The impact and quality of evidence generated was measured by examining the number of papers published, the number of citations, and the number of papers with at least 10 citations. Additionally, course participants’ responses to open-ended questions in the anonymous course evaluation questionnaires are presented as verbatim quotes.

Results

Overall, 99 papers on HIV programmatic learnings from India were finalised under the programme, of which 95 have been published. In all, 67 papers were co-authored by mentees. Most papers were published in high-impact factor (1 or more) journals and 72% were cited at least once in the literature. The main themes documented include key populations’ HIV risk, HIV risk of general population groups, HIV/STI service delivery models and community mobilisation interventions.

Conclusion

The study demonstrates that an integrated approach, involving partnership, capacity-building and mentorship, can maximise the use of available data and build the evidence base on HIV programmatic learnings. The capacity-building model adopted in the programme can be used to build scientific writing and documentation capacity in other public health programmes that are implemented at scale.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0291-3) contains supplementary material, which is available to authorised users.

Food and nutrition security in the Hindu Kush Himalayan region

The status of food and nutrition security and its underlying factors in the Hindu-Kush Himalayan (HKH) region is investigated. In this region, one third to a half of children (<5 years of age) suffer from stunting, with the incidence of wasting and under-weight also being very high. The prevalence of stunting, wasting and under-weight in children is particularly high in some mountain areas such as Meghalaya state in India, the western mountains and far-western hills of Nepal, Balochistan province in Pakistan, eastern Afghanistan, and Chin state in Myanmar. Food habits in the HKH region are changing. This has led to a deterioration in traditional mountain food systems with a decline in agrobiodiversity. Factors such as high poverty and low dietary energy intakes, a lack of hygienic environments, inadequate nutritional knowledge, and climate change and environmental degradation are also influencing food and nutrition security in the HKH region. To achieve sustainable food and nutrition security in the mountains, this study suggests a multi-sectoral integrated approach with consideration of nutritional aspects in all development processes dealing with economic, social, agricultural and public health issues. © 2017 Society of Chemical Industry.

Multidimensional poverty and catastrophic health spending in the mountainous regions of Myanmar, Nepal and India

BACKGROUND

Economic burden to households due to out-of-pocket expenditure (OOPE) is large in many Asian countries. Though studies suggest increasing household poverty due to high OOPE in developing countries, studies on association of multidimensional poverty and household health spending is limited. This paper tests the hypothesis that the multidimensionally poor are more likely to incur catastrophic health spending cutting across countries.

DATA AND METHODS

Data from the Poverty and Vulnerability Assessment (PVA) Survey carried out by the International Center for Integrated Mountain Development (ICIMOD) has been used in the analyses. The PVA survey was a comprehensive household survey that covered the mountainous regions of India, Nepal and Myanmar. A total of 2647 households from India, 2310 households in Nepal and 4290 households in Myanmar covered under the PVA survey. Poverty is measured in a multidimensional framework by including the dimensions of education, income and energy, water and sanitation using the Alkire and Foster method. Health shock is measured using the frequency of illness, family sickness and death of any family member in a reference period of one year. Catastrophic health expenditure is defined as 40% above the household's capacity to pay.

RESULTS

Results suggest that about three-fifths of the population in Myanmar, two-fifths of the population in Nepal and one-third of the population in India are multidimensionally poor. About 47% of the multidimensionally poor in India had incurred catastrophic health spending compared to 35% of the multidimensionally non-poor and the pattern was similar in both Nepal and Myanmar. The odds of incurring catastrophic health spending was 56% more among the multidimensionally poor than among the multidimensionally non-poor [95% CI: 1.35-1.76]. While health shocks to households are consistently significant predictors of catastrophic health spending cutting across country of residence, the educational attainment of the head of the household is not significant.

CONCLUSION

The multidimensionally poor in the poorer regions are more likely to face health shocks and are less likely to afford professional health services. Increasing government spending on health and increasing households' access to health insurance can reduce catastrophic health spending and multidimensional poverty.

Degree and correlates of sexual mixing in female sex workers in Karnataka, India

Background The degree of sexual mixing plays an important role in understanding disparities in sexually transmissible infections and HIV across social groups. This study examines the degree of sexual age mixing, and explores its individual and partnership level correlates among female sex workers (FSWs) in Karnataka, India.

METHODS

Data were drawn from special behavioural surveys conducted in 2006-07 among 577 FSWs in two districts of Karnataka: Belgaum and Bangalore. Sexual mixing in age was assessed as the difference in age between FSWs and their sexual partners, and the degree of assortativeness in sexual mixing was assessed using Newman's assortativity coefficient.

RESULTS

A total of 577 FSWs were interviewed; 418 of whom reported two or more partnerships, resulting in 942 partnerships. In about half (52%) of these partnerships, the age difference between the FSW and her sexual partner was 5 years or more. The degree of assortativity in age mixing was 0.098, indicating minimally assortative mixing. The disassortativeness in age mixing was positively associated with young age and no formal education, and negatively with duration in sex work. Partnerships which were of a commercial nature were more likely to be disassortative than noncommercial partnerships.

CONCLUSION

The minimally assortative age mixing indicates sexually transmissible infections can transfer from members of one age group to another. Efforts are required to limit the transmission of infection from one group to other by promoting safer sexual behaviour.

Exposure to pornographic videos and its effect on HIV-related sexual risk behaviours among male migrant workers in southern India

Objective

Research on pornography and its association with HIV-related sexual behaviours is limited in India. This study aims to examine the prevalence and correlates of viewing pornographic videos and examine its associations with HIV-related sexual risk behaviours among male migrant workers in India.

Methods

Data were drawn from a cross-sectional survey conducted in 2007–08 across 21 districts in four states of India. Respondents included 11,219 male migrants aged 18 years or older, who had migrated to at least two places in the past two years for work. Bivariate and multivariate methods were used to examine the association between viewing pornography and HIV-related sexual risk behaviours.

Results

Two-fifths (40%) of the migrants had viewed pornographic videos in one month prior to the survey. Migrants aged 25–29 years, literate, unmarried and away from native village for more than five years were more likely to view pornography than their counterparts. Migrants who viewed pornographic videos were more likely to engage in paid (Adjusted odds ratio [AOR]: 4.2, 95% confidence interval [CI]: 3.7–4.8) and unpaid sex (AOR: 4.2, 95% CI: 3.7–4.7), report inconsistent condom use in paid sex (AOR: 2.3, 95% CI: 1.7–3.0) and experience STI-like symptoms (AOR: 1.7, 95% CI: 1.5–1.8) than their counterparts.

Conclusions

The findings regarding migrants' exposure to pornography and its linkage with high HIV risk behaviour suggest that the HIV prevention programmes for migrants need to be more innovative to communicate on the negative-effects of viewing pornography. More importantly, programmes need to find alternative ways to engage migrants in infotainment activities during their leisure time in an effort to reduce their exposure to pornographic videos as well as risky sexual behaviours.

Non-disclosure of violence among female sex workers: evidence from a large scale cross-sectional survey in India

OBJECTIVE

One of the indicators critical to the success of violence reduction programmes among female sex workers (FSWs) is the pattern of disclosure of violence. This study examines the rate of non-disclosure of violence among FSWs in India by perpetrators of violence and programme exposure.

METHODS

Data were drawn from a cross-sectional study conducted among FSWs in 2009 across four states of India: Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu. The analytical sample included 1341 FSWs who experienced physical violence in past six months. Multilevel logistic regression stratified by state was conducted to examine predictors of non-disclosure.

RESULTS

About 54% of FSWs did not disclose their experience of violence to anyone with considerable variations in the pattern of disclosure across states. Another 36% of FSWs shared the experience with NGO worker/peer. Compared to violence perpetrated by paying partners/stranger, that by non-paying partner were twice more likely to report non-disclosure (53% vs. 68%, Adjusted Odds Ratio [AOR]: 1.8, 95% Confidence Interval [CI]: 1.3-2.4). Similarly, FSWs who were not registered with an NGO/sex worker collective were 40% more likely to report non-disclosure of violence against those registered (58% vs. 53%, AOR: 1.4, 95% CI: 1.1-1.9).

CONCLUSIONS

Non-disclosure of physical violence is quite high among FSWs which can be a barrier to the success of violence reduction efforts. Immediate efforts are required to understand the reasons behind non-disclosure based on which interventions can be developed. Community collectivisation and designing gender-based interventions with the involvement of non-paying partners should be the way forward.

The effect of mobility on sexual risk behaviour and HIV infection: a cross-sectional study of men who have sex with men in southern India

Objectives

Mobility is an important factor contributing to the spread of HIV among key population at risk for HIV; however, research linking this relationship among men who have sex men (MSM) is scarce in India. This study examines the association between mobility and sexual risk behaviour and HIV infection among MSM in southern India.

Methods

Data are drawn from a cross-sectional biobehavioural survey of 1608 self-identified MSM from four districts of Andhra Pradesh in India, recruited through a probability-based sampling in 2009–2010. Logistic regression models were used to estimate odds ratios and 95% CIs for sexual risk behaviours (unprotected sex with any male partner) and HIV infection based on the mobility status (travelled and had sex in the past year) after adjusting for sociodemographics and risk behaviours.

Results

Of the 1608 MSM, one-fourth (26%) were mobile. Of these, three-fourths had travelled across districts but within the state (56%), and one-fifth (20%) across states. As compared to non-mobile MSM, a higher proportion of MSM who were mobile across districts (adjusted (OR=1.42, 95% CI 1.04 to 1.95) or states (adjusted OR=3.20, 95% CI 1.65 to 6.17) reported having unprotected sex with any male sexual partner. Further, mobility across districts (adjusted OR=1.43, 95% CI 1.01 to 2.03) or states (adjusted OR=2.45, 95% CI 1.46 to 4.10) was significantly associated with HIV infection.

Conclusions

Mobile MSM have a higher likelihood of contracting HIV. Interventions extending the ways to reach out to MSM with greater mobility may augment ongoing efforts to reduce the spread of HIV/AIDS in India.

Non-paying partnerships and its association with HIV risk behavior, program exposure and service utilization among female sex workers in India

Background

In India, HIV prevention programs have focused on female sex workers’ (FSWs’) sexual practices vis-à-vis commercial partners leading to important gains in HIV prevention. However, it has become apparent that further progress is contingent on a better understanding of FSWs’ sexual risks in the context of their relationships with non-paying partners. In this paper, we explored the association between FSWs’ non-paying partner status, including cohabitation and HIV risk behaviors, program exposure and utilization of program services.

Methods

We used data from the cross-sectional Integrated Behavioral and Biological Assessment (IBBA) survey (2009–2010) conducted among 8,107 FSWs in three high priority states of India- Maharashtra, Andhra Pradesh and Tamil Nadu. Multiple logistic regression was used to examine the association between non-paying partner and cohabitation status of FSWs with HIV risk behaviors, program exposure and utilization of program services.

Results

FSWs reporting a non-paying partner were more likely to be exposed to and utilize HIV prevention resources than those who did not have a non-paying partner. Analyses revealed that FSWs reporting a non-cohabiting non-paying partner were more likely to be exposed to HIV prevention programs (adjusted OR: 1.7, 95% CI: 1.3 – 2.1), attend meetings (adjusted OR: 1.5, 95% CI: 1.2 – 1.8), and visit a sexually transmitted infections clinic at least twice in the last six months (adjusted OR: 1.6, 95% CI: 1.3 – 1.9) as compared to those reporting no non-paying partner. That said, FSWs with a non-paying partner rarely used condoms consistently and were more vulnerable to HIV infection because of being street-based (p < 0.001) and in debt (p < 0.001).

Conclusion

FSWs with cohabiting partners were more likely to be exposed to HIV prevention program and utilize services, suggesting that this program was successful in reaching vulnerable groups. However, this subgroup was unlikely to use condoms consistently with their non-paying partners and was more vulnerable, being street based and in debt. The next generation of HIV prevention interventions in India should focus on addressing relationship factors like risk communication and condom negotiation, including specific vulnerabilities like indebtedness and street based solicitation among women in sex work.

Effect of public-private partnership in treatment of sexually transmitted infections among female sex workers in Andhra Pradesh, India

BACKGROUND & OBJECTIVES

Providing sexually transmitted infection (STI) services to female sex workers (FSWs) in rural and resource constrained settings is a challenge. This paper describes an approach to address this challenge through a partnership with government health facilities, and examines the effect of this partnership on the utilization of STI services by FSWs in Andhra Pradesh, India.

METHODS

Partnerships were formed with 46 government clinics located in rural areas for providing STI treatment to FSWs in 2007. Government health facilities were supported by local and State level non-government organizations (NGOs) through provision of medicines, training of medical staff, outreach in the communities, and other coordination activities. Data from programme monitoring and behaviour tracking survey were used to examine the accessibility and acceptability in utilization of STI services from partnership clinics.

RESULTS

The number of FSWs accessing services at the partnership clinics increased from 1627 in 2007 to over 15,000 in 2010. The average number of annual visits by FSWs to these clinics in 2010 was 3.4. In opinion surveys, the majority of FSWs accessing services at the partnership clinics expressed confidence that they would continue to receive effective services from the government facilities even if the programme terminates. The overall attitude of FSWs to visit government clinics was more positive among FSWs from partnership clinic areas compared to those from non-partnership clinic areas.

INTERPRETATION & CONCLUSIONS

The partnership mechanism between the NGO-supported HIV prevention programme and government clinic facilities appeared to be a promising opportunity to provide timely and accessible STI services for FSWs living in rural and remote areas.

Adherence to Antiretroviral Therapy and Its Effect on Survival of HIV-Infected Individuals in Jharkhand, India

Introduction

Research in India has extensively examined the factors associated with non-adherence to antiretroviral therapy (ART) with limited focus on examining the relationship between adherence to ART regimen and survival status of HIV infected patients. This study examines the effect of optimal adherence to ART on survival status of HIV infected patients attending ART centers in Jharkhand, India.

Materials and Methods

Data from a cohort of 239 HIV infected individuals who were initiated ART in 2007 were compiled from medical records retrospectively for 36 months. Socio-demographic characteristics, CD4 T cell count, presence of opportunistic infections at the time of ART initiation and ART regimen intake and survival status was collected periodically. Optimal adherence was assessed using pill count methods; patients who took <95% of the specified regimens were identified as non-adherent. Cox-proportional hazard model was used to determine the relative hazards of mortality.

Results

More than three-fourths of the patients were male, on an average 34 year old and median CD4 T cell count was 118 cells/cmm at the time of ART registration. About 57% of the patients registered for ART were found to be adherent to ART. A total of 104 patients died in 358.5 patient-years of observation resulting in a mortality rate of 29 per 100 patient-years (95% confidence interval (CI): 23.9–35.2) and median survival time of 6.5 months (CI: 2.7–10.9). The mortality rate was higher among patients who were non-adherent to ART (64.5, CI: 50.5–82.4) than who were adherent (15.4, CI: 11.3–21.0). The risk of mortality was fourfold higher among individuals who were non-adherent to ART than who were adherent (Adjusted hazard ratio: 3.9, CI: 2.6–6.0).

Conclusion

Adherence to ART is associated with a higher chance of survival of HIV infected patients, ascertaining the need for interventions to improve the ART adherence and early initiation of ART.

Factors associated with risky sexual practices among female sex workers in Karnataka, India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.

Anal sex and associated HIV-related sexual risk factors among female sex workers in Andhra Pradesh, India

BACKGROUND

This study aims to understand the correlates of anal sex practices among female sex workers (FSWs) and examine the association of anal sex with HIV-related sexual risk factors in Andhra Pradesh, India.

METHODS

A cross-sectional behavioural survey was conducted in 2011 among 795 FSWs aged 18 years or older. Probability-based cluster sampling was used to select respondents from sex work hotspots.

RESULTS

One-quarter (23%) of FSWs had practiced anal sex in the last year. The odds of practicing anal sex were higher among FSWs aged 35 years or more than in those aged less than 25 years (adjusted odds ratio (AOR): 2.05, P<0.05), in those formerly married compared to those currently married (AOR: 1.88, P<0.01), in those having an income only from sex work compared to those having additional sources of income (AOR: 1.54, P<0.05), those reporting heavy alcohol consumption compared to those who did not (AOR: 2.80, P<0.01) and those who experienced violence compared to those who had not (AOR: 2.80, P<0.01). FSWs practicing anal sex were more likely to experience sexually transmissible infection (STI) related symptoms than those practicing only vaginal sex. There was no association between anal sex practice and condom use.

CONCLUSIONS

Anal sex is associated with STI symptoms, a factor for HIV risk. HIV intervention programmes need to educate FSWs about the risks associated with anal sex.

Evaluating the McDonald's business model for HIV prevention among truckers to improve program coverage and service utilization in India, 2004-2010

Background

This study describes the experiences and results of a large-scale human immunodeficiency virus (HIV) prevention intervention for long-distance truck drivers operating on the national highways of India.

Methods

The intervention for long-distance truckers started in 2004 across 34 trans-shipment locations. However, due to poor coverage and utilization of services by truckers in the initial 18-month period, the intervention was redesigned to focus on only 17 trans-shipment locations. The redesigned intervention model was based on the McDonald’s business franchise model where the focus is on optimal placement of services, supported with branding and standardization of services offered, and a surround sound communication approach. Program output indicators were assessed using program monitoring data over 7 years (2004–2010) and two rounds of cross-sectional behavioral surveys conducted in January 2008 (n = 1402) and July 2009 (n = 1407).

Results

The number of truckers contacted per month per site increased from 374 in 2004 to 4327 in 2010. Analysis of survey data showed a seven-fold increase in clinic visits in the past 12 months from 2008 to 2009 (21% versus 63%, P < 0.001). A significant increase was also observed in the percentage of truckers who watched street plays (10% to 56%, P < 0.001), and participated in health exhibitions (6% to 35%, P < 0.001). Furthermore, an increase from round 1 to round 2 was observed in the percentage who received condoms (13% to 22%, P < 0.001), and attended one-one counseling (15% to 21%, P < 0.01). Treatment-seeking from program clinics for symptoms related to sexually transmitted infections increased six-fold during this period (16% versus 50%, P < 0.001).

Conclusion

Adoption of a business model for HIV prevention helped to increase program coverage and service utilization among long-distance truckers. Implementing HIV prevention programs in a highly mobile population such as truckers, in a limited number of high-impact locations, supported by branding of services, could help in saturating coverage and optimum utilization of available resources.

Male migrants' non-spousal sexual partnerships in the place of origin: an in-depth investigation in two rural settings of India

Male migrants in India are at disproportionately high risk for HIV, not only because of their sexual behaviours in destination areas but also due to their risk behaviours in their place of origin. While studies have documented male migrants' risky behaviours in the home setting, few have attempted to understand the underlying socio-cultural context in which they engage in such behaviours. This paper examines the patterns and context of male migrants' non-spousal sexual partnerships in two high-out-migration districts of India. Data, drawn from a cross-sectional behavioural mixed-methods study conducted in 2008, included a structured survey with 1272 migrants, followed by in-depth interviews with 33 male migrants. Results suggest that sexual activity was common in the place of origin: around 50% of migrants had sex with a non-spousal female partner and two-fifths had initiated sex in this setting. Migrants' non-spousal sexual behaviours in the home village were influenced by the prevailing socio-cultural context, including migrants' enhanced socio-economic status, attitudes to non-spousal sex and accessibility of sexual partners. Male migrants' non-spousal sexual partnerships in source areas are influenced by socio-cultural factors, which must be considered when designing HIV programmes in India and elsewhere.

Prevalence and correlates of non-disclosure of HIV serostatus to sex partners among HIV-infected female sex workers and HIV-infected male clients of female sex workers in India

This study examines non-disclosure of HIV serostatus to sex partners among HIV-infected adults involved with transactional sex in Mumbai, India. Surveys were conducted with HIV-infected female sex workers (n = 211) and infected male clients (n = 205) regarding HIV knowledge, awareness of sex partners' HIV serostatus, alcohol use, transactional sex involvement post-HIV diagnosis and non-disclosure of HIV serostatus. Gender-stratified multiple logistic regression models were used for analysis. Non-disclosure of one's serostatus to all sex partners was reported by almost three-fifths of females and two-fifths of males. Predictors of non-disclosure included lack of correct knowledge about HIV and no knowledge of sex partners' HIV serostatus. Among females, recent alcohol consumption also predicted non-disclosure. Among males, 10 + paid sexual partners in the year following HIV diagnosis predicted non-disclosure. Secondary HIV prevention efforts in India require greater focus on HIV disclosure communication and integrated alcohol and sexual risk reduction.

Understanding the association between injecting and sexual risk behaviors of injecting drug users in Manipur and Nagaland, India

Background

In India, as in rest of the world, HIV prevention programs have focused on HIV transmission through unsafe injecting practices with less attention on sexual risk behaviors among injecting drug users (IDUs). This study examines the sexual risk taking behaviors of IDUs associated with their pattern of drug use in India.

Methods

Data were obtained from the behavioral tracking survey conducted in 2009 among 1712 IDUs in two districts each of Manipur and Nagaland states in Northeastern part of India. Sexual risk behaviors among IDUs were assessed in terms of multiple sex partners, sex with a paid female partner in the last 12 months and inconsistent condom use with any female partner.

Results

More than one-fourth (27%) in Manipur and almost one in two (47%) IDUs reported having had sex with two or more female partners in the past 12 months. In Manipur where heroin is commonly used, the odds of having multiple sex partners were higher among non-heroin users than heroin users (42% vs. 23%, Adjusted Odds Ratio (AOR): 1.7, 95% Confidence Interval (CI): 1.1-2.6) and who shared needles/syringes in the last one month than who did not share (46% vs. 26%, AOR: 2.2, CI: 1.2-4.0). In Nagaland, where Spasmoproxyvon (SP, a synthetic opioid analgesic that contains dextropropoxyphene, dicyclomine hydrochloride and paracetamol) is most common, regular injectors as compared to occasional injectors were more likely to report multiple sex partners (67% vs. 42%, AOR: 2.7, CI: 1.8-4.1) and sex with paid partners (13% vs. 3%, AOR: 6.0, CI: 3.0-12.1). Sharing of needles/syringes was positively associated with multiple sex partners (51% vs. 44%, AOR: 1.6, CI: 1.2-2.2), and inconsistent condom use (93% vs. 80%, AOR: 3.0, CI: 1.8-5.1).

Conclusions

IDUs with unsafe injecting practices also engage in risky sexual practices magnifying the risk of HIV infection. There is a need to focus on prevention of sexual transmission among high-risk IDUs, particularly in areas where Spasmoproxyvon is commonly used.

Relationship between mobility, violence and HIV/STI among female sex workers in Andhra Pradesh, India

BACKGROUND

Violence and mobility have been identified as critical factors contributing to the spread of HIV worldwide. This study aimed to assess the independent and combined associations of mobility and violence with sexual risk behaviors and HIV, STI prevalence among female sex workers (FSWs) in India.

METHODS

Data were drawn from a cross-sectional, bio-behavioral survey conducted among 2042 FSWs across five districts of southern India in 2005-06. Regression models were used to estimate odds ratios and 95% confidence intervals (CIs) for sexual risk behaviors and HIV infection based on experience of violence and mobility after adjusting for socio-demographic and sex work related characteristics.

RESULTS

One-fifth of FSWs (19%) reported experiencing violence; 68% reported travelling outside their current place of residence at least once in the past year and practicing sex work during their visit. Mobile FSWs were more likely to report violence compared to their counterparts (23% vs. 10%, p < 0.001). Approximately 1 in 5 tested positive for HIV. In adjusted models, FSWs reporting both mobility and violence as compared to their counterparts were more likely to be infected with HIV (Adjusted odds ratio (adjusted OR): 2.07, 95% CI: 1.42-3.03) and to report unprotected sex with occasional (adjusted OR: 2.86, 95% CI: 1.76-4.65) and regular clients (adjusted OR: 2.07, 95% CI: 1.40-3.06).

CONCLUSIONS

The findings indicate that mobility and violence were independently associated with HIV infection. Notably, the combined effect of mobility and violence posed greater HIV risk than their independent effect. These results point to the need for the provision of an enabling environment and safe spaces for FSWs who are mobile, to augment existing efforts to reduce the spread of HIV/AIDS.

The association between adolescent entry into the trucking industry and risk of HIV among long-distance truck drivers in India

This study examines the relationship between entry into the trucking industry during adolescence and both sexually transmitted infections (STIs) and infection by the human immunodeficiency virus (HIV) among long-distance truck drivers in India. Data were sourced from a cross-sectional survey (sample size: 2066) undertaken in 2007 among long-distance truck drivers. The survey spread across major transshipment locations covering the bulk of India’s transport volume along four routes. Participants were interviewed about sexual behaviors and were tested for HIV and STIs. The present authors constructed two synthetic cohorts based on the participants’ duration of employment in the trucking industry: (1) low (duration ≤ 6 years) and (2) high experience (duration ≥ 7 years). Based on age at entry into the trucking industry, participants were termed as either adolescent (age at entry < 18 complete years) or adult entrants (age at entry ≥ 18 complete years). In the low-experience cohort, the adolescent entrants were more likely than the adult entrants to have sex with paid female partners (42.6% versus 27.2%, respectively; adjusted odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.3–2.9) and to practice inconsistent condom use with such partners (69.1% versus 26.8%, respectively; adjusted OR: 5.3; 95% CI: 2.4–11.6). However, no significant differences were found in STI and HIV prevalence between the adolescent and the adult entrants in this cohort. In the high-experience cohort, the adolescent entrants were about two times more likely than the adult entrants to practice inconsistent condom use with paid female partners (38.5% versus 26.7%, respectively; adjusted OR: 1.7; 95% CI: 1.1–2.8) and to test positive for HIV (7.4% versus 4.0%, respectively; adjusted OR: 1.9; 95% CI: 1.2–3.1) and syphilis (5.7% versus 3.5%, respectively; adjusted OR: 1.8; 95% CI: 1.1–3.1). These results suggest the need for focused behavioral change programs in HIV prevention interventions for adolescent truckers in India and elsewhere.

Male migration and risky sexual behavior in rural India: is the place of origin critical for HIV prevention programs?

Background

Recent studies of male migrants in India indicate that those who are infected with HIV are spreading the epidemic from high risk populations in high prevalence areas to populations in low prevalence areas. In this context, migrant men are believed to initiate and have risky sexual behaviors in places of destination and not in places of origin. The paucity of information on men's risky sexual behaviors in places of origin limits the decision to initiate HIV prevention interventions among populations in high out-migration areas in India.

Methods

A cross-sectional behavioral survey was conducted among non-migrants, returned migrants (with a history of migration), and active (current) migrants in rural areas across two districts with high levels of male out-migration: Prakasam district in Andhra Pradesh and Azamgarh district in Uttar Pradesh. Surveys assessed participant demographics, migration status, migration history, and sexual behavior along the migration routes, place of initiation of sex. District-stratified regression models were used to understand the associations between migration and risky sexual behaviors (number of partners, condom use at last sex) and descriptive analyses of migrants' place of sexual initiation and continuation along migration routes.

Results

The average age at migration of our study sample was 19 years. Adjusted regression analyses revealed that active migrants were more likely to engage in sex with sex workers in the past 12 months (Prakasam: 15 percent vs. 8 percent; adjusted odds ratio (aOR)=2.1, 95% CI 1.2-3.4; Azamgarh: 19 percent vs.7 percent; aOR=4.0, 95% CI 2.4-6.6) as well as have multiple (3+) sex partners (Prakasam: 18 percent vs. 9 percent; aOR=2.0, 95% CI 1.3-3.2; Azamgarh: 28 percent vs. 21 percent; aOR=1.9, 95% CI 1.2-3.0) than non-migrants. Contrary to popular belief, a high proportion of active and returned migrants (almost 75 percent of those who had sex) initiated sex at the place of origin before migrating, which is equivalent to the proportion of non-migrants who engaged in sex with sex workers as well as with casual unpaid partners. Moreover, non-migrants were more likely than migrants to engage in unprotected sex.

Conclusion

Findings of this study document that returned migrants and active migrants have higher sexual risk behaviors than the non-migrants. Most migrants initiate non-marital sex in the place of origin and many continue these behaviors in places of destination. Migrants’ destination area behaviors are linked to sex with sex workers and they continue to practice such behaviors in the place of origin as well. Unprotected sex in places of destination with high HIV prevalence settings poses a risk of transmission from high risk population groups to migrants, and in turn to their married and other sexual partners in places of origin. These findings suggest the need for controlling the spread of HIV among both men and women resulting from unsafe sex in places of origin that have high vulnerability due to the frequent migratory nature of populations.

Relationship between reported prior condom use and current self-perceived risk of acquiring HIV among mobile female sex workers in southern India

Background

With the evolution of Health Belief Model, risk perception has been identified as one of several core components of public health interventions. While female sex workers (FSWs) in India continue to be at most risk of acquiring and transmitting HIV, little is known about their perception towards risk of acquiring HIV and how this perception depends upon their history of consistent condom use behavior with different type of partners. The objective of this study is to fill this gap in the literature by examining this relationship among mobile FSWs in southern India.

Methods

We analyzed data for 5,413 mobile FSWs from a cross-sectional behavioral survey conducted in 22 districts from four states in southern India. This survey assessed participants’ demographics, condom use in sex with different types of partners, continuation of sex while experiencing STI symptoms, alcohol use before having sex, and self-perceived risk of acquiring HIV. Descriptive analyses and multilevel logistic regression models were used to examine the associations between risky sexual behaviors and self-perceived risk of acquiring HIV; and to understand the geographical differences in HIV risk perception.

Results

Of the total mobile FSWs, only two-fifths (40%) perceived themselves to be at high risk of acquiring HIV; more so in the state of Andhra Pradesh (56%) and less in Maharashtra (17%). FSWs seem to assess their current risk of acquiring HIV primarily on the basis of their past condom use behavior with occasional clients and less on the basis of their past condom use behaviors with regular clients and non-paying partners. Prior inconsistent condom use with occasional clients was independently associated with current perception of high HIV risk (adjusted odds ratio [aOR)] = 2.1, 95% confidence interval [CI]: 1.7-2.6). In contrast, prior inconsistent condom use with non-paying partners was associated with current perception of low HIV risk (aOR= 0.7, 95% CI: 0.5-0.9). The congruence between HIV risk perception and condom use with occasional clients was high: only 12% of FSWs reported inconsistent condom use with occasional clients but perceived themselves to be at low risk of acquiring HIV.

Conclusion

The association between high risk perception of acquiring HIV and inconsistent condom use, especially with regular clients and non-paying partners, has not been completely internalized by this high risk group of mobile FSWs in India. Motivational efforts to prevent HIV should emphasize the importance of accurately assessing an individual’s risk of acquiring HIV based on condom use behavior with all types of partners: occasional and regular clients as well as non-paying partners; and encourage behavior change based on an accurate self-assessment of HIV risk.

THE OXIDATION, IGNITION AND DETONATION OF FUEL VAPORS AND GASES: V. THE HYDROGEN ENGINE AND THE NUCLEAR THEORY OF IGNITION

It should not be possible, according to the nuclear theory of ignition, stated in Part IV, to obtain ignition in the body of a gaseous combustible mixture by any method of heating if it remain truly homogeneous while the temperature is raised. Such mixtures cease to be homogeneous when heated by sudden compression to the temperatures required for ignition because of the formation of finely divided carbon by pyrolysis of lubricating oil or of hydrocarbon vapor. The finely divided carbon provides nuclear centers of ignition in the gaseous mixture. Ignition due to finely divided carbon produced by pyrolysis of the lubricant is demonstrated by experiments with hydrogen as the fuel for a C.F.R. engine. The usual pre-ignition and severe knocking were obtained when the engine in normal condition was run on hydrogen, and it was impossible, as previously found by others, to use any but weak mixtures even at low compression ratios. When however the combustion space was decarbonized and thereafter maintained reasonably clear of fluffy carbon, hydrogen could be used as the sole fuel at any compression ratio up to the limit of 10:1 possible with the engine, and at any mixture strength ranging from very weak to very rich, while power output varied accordingly. Conversely pre-ignition and combustion knock reappeared when carbon dust was admitted with the combustible mixture.