Articles tagged as "India"

Advocacy, sensitisation, and capacity building are key to integrating services

Development and pilot testing of HIV screening program integration within public/primary health centers providing antenatal care services in Maharashtra, India.

Bindoria SV, Devkar R, Gupta I, Ranebennur V, Saggurti N, Ramesh S, Deshmukh D, Gaikwad S. BMC Res Notes. 2014 Mar 26;7:177. doi: 10.1186/1756-0500-7-177.

Background: The objectives of this paper are: (1) to study the feasibility and relative benefits of integrating the prevention of parent-to-child transmission (PPTCT) component of the National AIDS Control Program with the maternal and child health component of the National Rural Health Mission (NRHM) by offering HIV screening at the primary healthcare level; and (2) to estimate the incremental cost-effectiveness ratio to understand whether the costs are commensurate with the benefits.

Methods: The intervention included advocacy with political, administrative/health heads, and capacity building of health staff in Satara district, Maharashtra, India. The intervention also conducted biannual outreach activities at primary health centers (PHCs)/sub-centers (SCs); initiated facility-based integrated counseling and testing centers (FICTCs) at all round-the-clock PHCs; made the existing FICTCs functional and trained PHC nurses in HIV screening. All "functional" FICTCs were equipped to screen for HIV and trained staff provided counseling and conducted HIV testing as per the national protocol. Data were collected pre- and post- integration on the number of pregnant women screened for HIV, the number of functional FICTCs and intervention costs. Trend analyses on various outcome measures were conducted. Further, the incremental cost-effectiveness ratio per pregnant woman screened was calculated.

Results: An additional 27% of HIV-infected women were detected during the intervention period as the annual HIV screening increased from pre- to post-intervention (55% to 79%, p < 0.001) among antenatal care (ANC) attendees under the NRHM. A greater increase in HIV screening was observed in PHCs/SCs. The proportions of functional FICTCs increased from 47% to 97% (p < 0.001). Additionally, 93% of HIV-infected pregnant women were linked to anti-retroviral therapy centers; 92% of mother-baby pairs received Nevirapine; and 89% of exposed babies were enrolled for early infant diagnosis. The incremental cost-effectiveness ratio was estimated at INR 44 (less than 1 US$) per pregnant woman tested.

Conclusions: Integrating HIV screening with the broader Rural Health Mission is a promising opportunity to scale up the PPTCT program. However, advocacy, sensitization, capacity building and the judicious utilization of available resources are key to widening the reach of the PPTCT program in India and elsewhere.

Abstract   Full-text [free] access 

Editor’s notes: This article evaluates the incremental unit cost of integrating rapid HIV testing into existing maternal and child health (MCH) and primary health care services. This approach is interesting in that it can be described as political as well as clinical.  These approaches included substantial advocacy with district political and administrative health heads, sensitisation and mobilization of health workers, and supply chain support to ensure that existing counselling and testing facilities were “functional” - equipped to provide the service.

The programme also included a number of activities intended to generate demand for HIV testing and counselling in antenatal care. These included integration of HIV screening with regular village health and nutrition days, and utilisation of community health workers (ASHAs) to mobilise people for testing. 

This article provides much-needed evidence on the cost-effectiveness of integrating HIV counselling and testing into primary and antenatal health care services in India. It also encourages us to think about integration more broadly as a health systems activity, rather than simply a clinical programme. It highlights the importance of demand creation and mobilization of political will through advocacy, sensitisation and capacity building as part of the integration process.

Asia
India
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Physical as well as sexual partner violence is associated with increased HIV risk

Intimate partner violence and HIV infection among women: a systematic review and meta-analysis

Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. 4 J Int AIDS Soc. 2014 Feb 13;17:18845. doi: 10.7448/IAS.17.1.18845. eCollection 2014.

Introduction: To assess evidence of an association between intimate partner violence (IPV) and HIV infection among women.

Methods: Medline/PubMed, Embase, Web of Science, EBSCO, Ovid, Cochrane HIV/AIDS Group's Specialized Register and Cochrane Central Register of Controlled Trials were searched up to 20 May 2013 to identify studies that examined the association between IPV and HIV infection in women. We included studies on women aged ≥15 years, in any form of sexually intimate relationship with a male partner.

Results: Twenty-eight studies [(19 cross-sectional, 5 cohorts and 4 case-control studies) involving 331 468 individuals in 16 countries - the US (eight studies), South Africa (four studies), East Africa (10 studies), India (three studies), Brazil (one study) and multiple low-income countries (two studies)] were included. Results were pooled using RevMan 5.0. To moderate effect estimates, we analyzed all data using the random effects model, irrespective of heterogeneity level. Pooled results of cohort studies indicated that physical IPV [pooled RR (95% CI): 1.22 (1.01, 1.46)] and any type of IPV [pooled RR (95% CI): 1.28 (1.00, 1.64)] were significantly associated with HIV infection among women. Results of cross-sectional studies demonstrated significant associations of physical IPV with HIV infection among women [pooled OR (95% CI): 1.44 (1.10, 1.87)]. Similarly, results of cross-sectional studies indicated that combination of physical and sexual IPV [pooled OR (95% CI): 2.00 (1.24, 3.22) and any type of IPV [pooled OR (95% CI): 1.41 (1.16, 1.73)] were significantly associated with HIV infection among women.

Conclusions: Available evidence suggests a moderate statistically significant association between IPV and HIV infection among women. To further elucidate the strength of the association between IPV and HIV infection among women, there is a need for high-quality follow-up studies conducted in different geographical regions of the world, and among individuals of diverse racial/cultural backgrounds and varying levels of HIV risks.

Abstract Full-text [free] access

Editor’s notes: Globally, an estimated 30% of partnered women will experience physical and/or sexual violence. As well as being a violation of human rights, there is growing evidence about the different ways in which violence and the fear of violence may limit women’s ability to prevent themselves from acquiring infection, or access services. This paper presents a systematic review and meta-analysis of current evidence on whether exposures to violence by an intimate partner increase women’s HIV risk. Commonly, debates on this issue focus on forced sex. The findings suggest that the issue is more complex – with exposures to physical violence also being associated with increased HIV risk. Exposures to both physical and sexual violence by partners, which is an indicator of more severe partner violence, found stronger effect estimates. The pathways underlying the documented associations may be multiple: as well as forced sex, women may have difficulties negotiating condom use or accessing services. Other studies have suggested that there may also be other characteristics of the relationship.  These are that men who are violent are also more likely to have other risk behaviours such as problematic alcohol use or multiple sexual partners. These result in them being more likely to be HIV positive than non-violent men. The findings suggest that violence prevention activities may reduce HIV risk. They also highlight the need to ensure that HIV services are sensitive to, and able to support, women who have experienced or fear violence.

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CD4 counts at antiretroviral therapy start rising globally, but could do better!

Immunodeficiency at the start of combination antiretroviral therapy in low-,  middle-, and high-income countries.

The IeDEA and ART Cohort Collaborations. J Acquir Immune Defic Syndr 2014 Jan 1;65(1):e8-e16. doi: 10.1097/QAI.0b013e3182a39979.

Objective: To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

Methods: Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

Results: In total, 379 865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/µL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/µL (76% increase), 88 to 135 cells/µL (53%), and 209 to 274 cells/µL (31%). In 2009, compared with LIC, median counts were 13 cells/µL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/µL (-62 to +18) lower in UMIC, and 112 cells/µL (+75 to +149) higher in HIC. They were 23 cells/µL (95% CI: +18 to +28 cells/µL) higher in women than men. Median counts were 88 cells/µL (95% CI: +35 to +141 cells/µL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

Conclusions: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/µL in LIC and MIC and below 300 cells/µL in HIC. Earlier start of cART will require substantial efforts and resources globally.

Abstract access 

Editor’s notes: In this multi-cohort analysis spanning six continents, median CD4 counts at initiation of combination antiretroviral therapy were substantially higher in high-income compared to low- or middle-income countries. Median CD4 counts at initiation increased between 2002 and 2009 in most countries studied, but these increases were greater in low- and middle-income than high-income countries and were greater among men than women. Baseline CD4 counts in low- and middle-income countries were higher among countries with national antiretroviral therapy coverage of 80% or above. Nevertheless, despite the massive scale-up of antiretroviral therapy in low-income countries since 2002, the increases in median CD4 count at the start of antiretroviral therapy have been modest. Substantial efforts and resources are needed to achieve earlier implementation of antiretroviral therapy globally.

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Linking cervical cancer prevention into infrastructure for HIV services in sub-Saharan Africa

Infrastructure requirements for human papillomavirus vaccination and cervical cancer screening in sub-Saharan Africa.

Sankaranarayanan R, Anorlu R, Sangwa-Lugoma G, Denny LA. Vaccine. 2013 Dec 29;31 Suppl 5:F47-52. doi: 10.1016/j.vaccine.2012.06.066.

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Global Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3-5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9-13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript.

Abstract access 

Editor’s notes: Infection with human papillomavirus (HPV) can lead to cervical cancer. HIV-positive women are more likely to acquire and have persistent HPV, so the high burden of HIV in sub-Saharan Africa (SSA) contributes to the burden of cervical cancer. This review article discusses the options for the prevention of cervical cancer in SSA. While this article is primarily focused on cervical cancer, it highlights the potential linkages of prevention activities with HIV/AIDS services with an emphasis on infrastructure to improve access to these services for women in SSA. The options for cervical cancer prevention in SSA include HPV vaccination, visual inspection tests, HPV DNA tests and cytology screening. These options and the infrastructure required for each are described in detail, and some of the barriers to delivery are highlighted. Treatment options are also described, including cryotherapy following visual inspection. 

Africa, Asia
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An integrated investment approach for women’s and children’s health

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, Mason E, Friedman HS, Bhutta ZA, Lawn JE, Sweeny K, Tulloch J, Hansen P, Chopra M, Gupta A, Vogel JP, Ostergren M, Rasmussen B, Levin C, Boyle C, Kuruvilla S, Koblinsky M, Walker N, de Francisco A, Novcic N, Presern C, Jamison D, Bustreo F; on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Lancet. 2013 Nov 18. doi: S0140-6736(13)62231-X. pii: 10.1016/S0140-6736(13)62231-X. [Epub ahead of print]

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Abstract access 

Editor’s notes: Over the past 20 years there have been substantial gains in maternal and child health (MCH). However, much still needs to be done – assuming a continuation of current rates of progress, there would nevertheless be shortfalls in the achievement of MDG 4 and 5 targets. Especially in sub-Saharan Africa, HIV is an important underlying cause of maternal and child ill health. This paper models the costs and benefits of an accelerated action on MCH, including for HIV, the prevention of mother to child HIV transmission; first line treatment for pregnant women; cotrimoxazole for children, and the provision of paediatric antiretroviral therapy (ART). These HIV services are complemented by health systems strengthening; increased family planning provision; and packages for malaria, immunisation, and child health. The paper is interesting for many reasons, including both the breadth of its intervention focus, and the detailed modelling of the likely health, social and economic benefits of such investments.

Although the direct HIV related benefits are not described in detail in the main paper, it is likely that these result both from increased contraceptive use (prong 2 for preventing vertical HIV transmission), as well as ART and cotrimoxazole provision. It also illustrates the potential value of developing a cross-disease investment approach, as a means to ensure that services effectively respond to the breadth of women’s and children’s health needs. This more ‘joined up’, integrated perspective on strategies for health investment can support core investments in health systems strengthening. It can also potentially achieve important cross-disease synergies, e.g., ensuring that a child who has not acquired HIV at birth does not then die from malaria. 

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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Intrauterine infections, but not obstetric complications, more common among pregnant women with HIV

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis. 

Calvert C, Ronsmans C. PLoS One. 2013 Oct 4;8(10):e74848. doi:10.1371/journal.pone.0074848.

Background: Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings: Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00-5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42-13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions: The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Women with HIV are thought to have a higher risk of adverse outcomes during pregnancy. This review is valuable in summarizing available data on this topic. Many of the included studies predated the wide availability of antiretroviral therapy. There was a clear association between HIV infection and intrauterine infections, but not with the other obstetric complications, e.g., obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia, examined in the review. Considering individual conditions analysed, HIV infection was associated with antepartum haemorrhage, (but not postpartum haemorrhage). It was also found to be associated with pregnancy-induced hypertension (but not pre-eclampsia or eclampsia), and uterine rupture or prolonged labour (but not other complications of dystocia). The authors note that the studies were generally of low quality, and there were too few studies to examine the effect of antiretroviral therapy on these complications.  

Given the excess of intrauterine infections in women with HIV, the authors suggest that these might be preventable with prophylactic antibiotics. Overall, where causes of maternal mortality are documented, pregnant women with HIV are more likely to die of non-pregnancy related infections, than of obstetric complications. Specifically, non-pregnancy related infections are tuberculosis, pneumonia or meningitis. Pregnant women living with HIV need access to antenatal services and a skilled attendant at delivery. But, the top priority with respect to reducing maternal mortality is effective antiretroviral therapy.

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Modelling finds early treatment of HIV discordant couples is cost-effective in India and South Africa

Cost-effectiveness of HIV Treatment as Prevention in Serodiscordant Couples.

Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, Paltiel AD, Nakamura YM, Godbole SV, Panchia R, Sanne I, Weinstein MC, Losina E, Mayer KH, Chen YQ,Wang L, McCauley M, Gamble T, Seage GR 3rd, Cohen MS, Freedberg KA. N Engl J Med. 2013 Oct 31;369(18):1715-25. doi: 10.1056/NEJMsa1214720.

Background: The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons.

Methods: For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART.

Results: In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modelled assumptions in the two countries.

Conclusions:  In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings.

Abstract access

Editor’s notes: The HPTN 052 found that antiretroviral therapy (ART) can prevent onward HIV transmission. With this finding, countries in the North and South are faced with optimizing treatment protocols, for the direct clinical benefit of ART, and its impact on national HIV epidemics.  Walensky et al. draw on data from this clinical trial in India and South Africa to model the short (5 year) and long (cohort lifetime) term cost-effectiveness. The main study models cost-effectiveness with trial based parameters i.e., cd4+ count at presentation, virological suppression and failure, loss to follow up and transmission rates. They also estimate cost-effectiveness in routine care setting and worst case scenario to consider the robustness of findings.  In contrast to many model projections which find ART for prevention more cost effective over longer time frames, Walensky’s projections show very immediate (5 year) reductions in transmission and treatment costs attributable to preventing opportunistic infections.  In South Africa this results in short term cost-saving; as the cost of treating these are relatively lower in India, this is highly cost effective, albeit not cost saving. In the longer term their model shows that many of these transmissions are delayed rather than avoided altogether: in South Africa the 5 year reduction in transmission is 69% versus 13% over the cohort lifetime.  Evaluated against per capita GDP in each country, treatment as prevention is shown to be cost-effective in both settings.  These results are sensitive to retention in care and effective virological suppression, though would not change policy recommendations. However it does highlight critical role of both the health system and patients in reaping the optimal prevention benefits of treatment. 

Africa, Asia
India, South Africa
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Changing dynamics of female sex work in India has implications for HIV prevention

Demographic changes and trends in risk behaviours, HIV and other sexually transmitted infections among female sex workers in Bangalore, India involved in a focused HIV preventive intervention.

Jayaraman GC, Kumar S, Isac S, Javalkar P, Gowda PR, Raghunathan N, Gowda CS, Bhattacharjee P, Moses S, Blanchard JF. Sex Transm Infect. 2013 Sep 17. doi: 10.1136/sextrans-2013-051203. [Epub ahead of print]

The primary objectives of this study were to assess the changing demographic characteristics of female sex workers (FSWs) in the urban Bangalore district, India, and trends in programme coverage, HIV/sexually transmitted infection prevalence rates and condom use. Cross-sectional, integrated behavioural and biological assessments of FSWs were conducted in 2006, 2009 and 2011. Univariate and multivariate analyses were used to describe trends over time. The results indicate the mean age of initiation into sex work has increased (26.9 years in 2006 vs 27.6 years in 2011, p<0.01), a higher proportion of FSWs reported being in 'stable' relationships in 2011 (70.2% vs 43.2% in 2006, p<0.01) and having conducted sex work outside the district in the past 6 months (10.0% in 2006 vs 16.0% in 2011 p=0.01). There was an increase in the proportion of FSWs using cellphones to solicit clients (4.4% in 2006 vs 57.5% in 2011, p<0.01) and their homes for sex work (61.4% in 2006 vs 77.8% in 2011, p<0.01). Reactive syphilis prevalence declined (12.6% in 2006 to 4% in 2011, p=0.02), as did high-titre syphilis prevalence (9.5% in 2006 to 2.5% in 2011, p=0.01). HIV prevalence declined but not significantly (12.7% in 2006 and 9.3% in 2011, p=0.39). Condom use remained above 90% increasing significantly among repeat (paying) clients (66.6% in 2006 to 93.6% in 2011, p<0.01). However, condom use remained low with non-paying partners when compared with occasional paying partners (17.6% vs 97.2% in 2011, p<0.01). Given the changing dynamics in the FSW population at multiple levels, there is a need to develop and customise strategies to meet local needs.

Keywords: commercial sex, epidemiology (general), HIV, programme science, syphilis

Abstract access

Editor’s notes: The “Pragati” HIV intervention programme for female sex workers (FSWs) has been running in Bangalore since 2005. Anonymous, unlinked cross-sectional surveys among random samples of FSWs have been conducted in 2006, 2009 and 2011, providing detailed data on the female sex worker population over this time period. The female sex worker population changed substantially, with an increasing proportion of female sex workers reporting being married, increasing solicitation by cellphone, increasing use of the female sex worker’s home for sex work and a decreasing proportion of female sex workers reporting that more than half their clients are “new”. HIV prevalence and syphilis decreased between 2006 and 2011; although the decrease in HIV prevalence was not statistically significant. Given the lack of a control group, it is difficult to directly attribute these changes to the programme, particularly given secular changes during this time (e.g. increasing use of cellphones). Nevertheless the substantial changes in behaviour among this population of female sex workers suggests that interventions that may have been appropriate in 2006 may no longer be appropriate in 2011, demonstrating a clear need for ongoing research and intervention adaptation.

Asia
India
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Hundreds of thousands of HIV infections averted through the Avahan initiative in South India

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

Pickles M, Boily M-C, Vickerman P, Lowndes CM, Moses S, Blanchard JF, Deering KN, Bradley J, Ramesh BM, Washington R, Adhikary R, Mainkar M, Paranjape RS, Alary M. Lancet Global Health. 2013 Sep 30;  doi:10.1016/S2214-109X(13)70083-4

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

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

Findings: In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32 700 HIV infections (95% credibility interval 17 900—61 600) were averted over the first 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62 800 (32 000—118 000) averted infections, and extrapolation suggested that 202 000 (98 300—407 000) infections were averted across all 69 Avahan districts in South India, increasing to 606 000 (290 000—1 193 000) over 10 years. Over the first 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted.

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

Abstract access 

Editor’s notes: The Avahan initiative was established in 2003, aiming to scale-up targeted HIV prevention strategies in 4 states in South India, focusing on the high-risk groups who were driving the HIV epidemic. This paper has a number of important features.  What was striking is that Avahan had a large intervention effect which increased over time and has averted hundreds of thousands of infections. The study also provides an example of how rigorous mathematical modelling can assess the effectiveness of a large-scale intervention when a cluster randomized trial is not conducted for logistical or ethical reasons. It is also notable that the intervention used behavioural interventions and STI treatment focused on core groups, rather than antiretroviral therapy. The modelling indicates that the reduction in HIV incidence was due to these behavioural interventions which resulted in increased condom use.

Asia
India
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‘Public’ and ‘hidden’ transcripts of the Global Fund in India

Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India.

Kapilashrami A, McPake B. Health Policy Plan. 2013 Sep;28(6):626-35. doi: 10.1093/heapol/czs102. Epub 2012 Nov 11.

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

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Editor’s notes: The paper presents results of a study on the implementation of the Global Fund fourth round HIV/AIDS grant in five states of India. It draws on Scott’s (1992) distinction between ‘dominant public transcripts’ –  official and documented statements describing principles, structures and activities - and ‘hidden transcripts’ meaning the unofficial practices and realities that are rarely acknowledged in official documents. While such a distinction is not new in the social sciences, for instance public and private accounts of experiences of health and illness are often contrasted, this framing provides a useful way to distinguish official rhetoric from interviewees’ discourses and observation of day-to-day practices of decision making and implementation. The study took an ethnographic approach between 2007 and 2009 to articulate these ‘hidden transcripts’ consisting of observations of meetings, document review and 70 ‘in-depth’ stakeholder interviews.

The paper reports on several aspects of the Indian experience that reinforce findings from previous studies of the effects of Global Fund HIV/AIDS programmes in other countries. These include limited involvement of local civil society organisations in grant application processes. Instead the application process was dominated by government, bilateral and multilateral agencies and large national/international civil society organisations. Country Coordination Mechanism (CCM) activities were confined to applying for grants rather than overseeing programme implementation. Demanding reporting requirements strained an already weak health system, created competition between implementers and impacted negatively on the continuity of interventions. The paper concludes that while the Global Fund claims to be a financial mechanism for country-driven programmes, its structures, rules and conditions create a highly regulating environment for programme implementation. 

Asia
India
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