The costs of scaling up HIV prevention for high risk groups: lessons learned from the Avahan Programme in India.

OBJECTIVE: The study objective is to measure, analyse costs of scaling up HIV prevention for high-risk groups in India, in order to assist the design of future HIV prevention programmes in South Asia and beyond. DESIGN: Prospective costing study. METHODS: This study is one of the most comprehensive studies of the costs of HIV prevention for high-risk groups to date in both its scope and size. HIV prevention included outreach, sexually transmitted infections (STI) services, condom provision, expertise enhancement, community mobilisation and enabling environment activities. Economic costs were collected from 138 non-government organisations (NGOs) in 64 districts, four state level lead implementing partners (SLPs), and the national programme level (Bill and Melinda Gates Foundation (BMGF)) office over four years using a top down costing approach, presented in US$2011. RESULTS: Mean total unit costs (2004-08) per person reached at least once a year and per monthly contact were US$ 235(56-1864) and US$82(12-969) respectively. 35$ 477 per person reached in 2004 to US$145 per person reached in 2008). At the service level also unit costs decreased slightly over time from US$ 68 to US$ 64 per person reached. CONCLUSIONS: Scaling up HIV prevention for high risk groups requires significant investment in expertise enhancement and programme administration. However, unit costs decreased with programme expansion in spite of an increase in the scope of activities

Outputs and cost of HIV prevention programmes for truck drivers in Andhra Pradesh, India

<p>Abstract</p> <p>Background</p> <p>HIV prevention programmes for truck drivers form part of the HIV control efforts, but systematic data on the outputs and cost of providing such services in India are not readily available for further planning and use of resources.</p> <p>Methods</p> <p>Detailed cost and output data were collected from written records and interviews for 2005–2006 fiscal year using standardized methods at six sampled HIV prevention programmes for truck drivers in the Indian state of Andhra Pradesh. The total economic cost for these programmes was computed and the relation of unit cost of services per truck driver with programme scale was assessed using regression analysis.</p> <p>Results</p> <p>A total of 120,436 truck drivers were provided services by the six programmes of which 55.9% were long distance truck drivers. The annual economic cost of providing services to a truck driver varied between programmes from US$1.52 to 4.56 (mean US$ 2.49). There was an inverse relation between unit economic cost of serving a truck driver and scale of the programme (R²= 0.63; p = 0.061). The variation between programmes in the average number of contacts made by the programme staff with truck drivers was 1.3 times versus 5.8 times for contacts by peer educators. Only 1.7% of the truck drivers were referred by the programmes for counseling and HIV testing.</p> <p>Conclusion</p> <p>These data provide information for further planning of HIV prevention programmes for truck drivers and estimating the resources needed for such programmes. The findings suggest the need to strengthen the role of peer educators and increase referral of truck drivers for HIV testing.</p

Severity of Visual Field Loss at First Presentation to Glaucoma Clinics in England and Tanzania

Purpose: To compare severity of visual field (VF) loss at first presentation in glaucoma clinics in England and Tanzania. Methods: Large archives of VF records from automated perimetry were used to retrospectively examine vision loss at first presentation in glaucoma clinics in Tanzania (N = 1,502) and England (N = 9,264). Mean deviation (MD) of the worse eye at the first hospital visit was used as an estimate of detectable VF loss severity. Results: In Tanzania, 44.7% {CI95%: 42.2, 47.2} of patients presented with severe VF loss (< −20 dB), versus 4.6% {4.1, 5.0} in England. If we consider late presentation to also include cases of advanced loss (-12.01 dB to -20 dB), then the proportion of patients presenting late was 58.1% {55.6, 60.6} and 14.0% {13.3, 14.7}, respectively. The proportion of late presentations was greater in Tanzania at all ages, but the difference was particularly pronounced among working-age adults, with 50.3% {46.9, 53.7} of 18–65-year-olds presenting with advanced or severe VF loss, versus 10.2% {9.3, 11.3} in England. In both countries, men were more likely to present late than women. Conclusions: Late presentation of glaucoma is a problem in England, and an even greater challenge in Tanzania. Possible solutions are discussed, including increased community eye-care, and a more proactive approach to case finding through the use of disruptive new technologies, such as low-cost, portable diagnostic aids

A population-based study of human immunodeficiency virus in south India reveals major differences from sentinel surveillance-based estimates

BACKGROUND: The human immunodeficiency virus (HIV) burden among adults in India is estimated officially by direct extrapolation of annual sentinel surveillance data from public-sector antenatal and sexually transmitted infection (STI) clinics and some high-risk groups. The validity of these extrapolations has not been systematically examined with a large sample population-based study. METHODS: We sampled 13838 people, 15–49 years old, from 66 rural and urban clusters using a stratified random method to represent adults in Guntur district in the south Indian state of Andhra Pradesh. We interviewed the sampled participants and obtained dried blood spots from them, and tested blood for HIV antibody, antigen and nucleic acid. We calculated the number of people with HIV in Guntur district based on these data, compared it with the estimate using the sentinel surveillance data and method, and analysed health services use data to understand the differences. RESULTS: In total, 12617 people (91.2% of the sampled group) gave a blood sample. Adjusted HIV prevalence was 1.72% (95% confidence interval 1.35–2.09%); men 1.74% (1.27–2.21%), women 1.70% (1.36–2.04%); rural 1.64% (1.10–2.18%), urban 1.89% (1.39–2.39%). HIV prevalence was 2.58% and 1.20% in people in the lower and upper halves of a standard of living index (SLI). Of women who had become pregnant during the past 2 years, 21.1% had used antenatal care in large public-sector hospitals participating in sentinel surveillance. There was an over-representation of the lowest SLI quartile (44.7%) in this group, and 3.61% HIV prevalence versus 1.08% in the remaining pregnant women. HIV prevalence was higher in that group even when women were matched for the same SLI half (lower half 4.39%, upper 2.63%) than in the latter (lower 1.06%, upper 1.05%), due to referral of HIV-positive/suspected women by private practitioners to public hospitals. The sentinel surveillance method (HIV prevalence: antenatal clinic 3%, STI clinic 22.8%, female sex workers 12.8%) led to an estimate of 112635 (4.38%) people with HIV, 15–49 years old, in Guntur district, which was 2.5 times the 45942 (1.79%) estimate based on our population-based study. CONCLUSION: The official method in India leads to a gross overestimation of the HIV burden in this district due to addition of substantial extra HIV estimates from STI clinics, the common practice of referral of HIV-positive/suspected people to public hospitals, and a preferential use of public hospitals by people in lower socioeconomic strata. India may be overestimating its HIV burden with the currently used official estimation method

Acute Modulation of Toll-Like Receptors by Insulin

OBJECTIVE—Low-dose insulin infusion has been shown to exert a prompt and powerful anti-inflammatory effect. Toll-like receptors (TLRs) are major determinants of the inflammatory response to viral and bacterial pathogens. We have now hypothesized that low-dose insulin infusion in obese type 2 diabetic patients suppresses TLR expression

Is the HIV burden in India being overestimated?

BACKGROUND: The HIV burden estimate for India has a very wide plausibility range. A recent population-based study in a south Indian district demonstrated that the official method used in India to estimate HIV burden in the population, which directly extrapolates annual sentinel surveillance data from large public sector antenatal and sexually transmitted infection (STI) clinics, led to a 2–3 times higher estimate than that based on population-based data. METHODS: We assessed the generalisability of the reasons found in the Guntur study for overestimation of HIV by the official sentinel surveillance based method: addition of substantial unnecessary HIV estimates from STI clinics, the common practice of referral of HIV positive/suspect patients by private practitioners to public hospitals, and a preferential use of public hospitals by lower socioeconomic strata. We derived conservative correction factors for the sentinel surveillance data and titrated these to the four major HIV states in India (Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu), and examined the impact on the overall HIV estimate for India. RESULTS: HIV data from STI clinics are not used elsewhere in the world as a component of HIV burden estimation in generalised epidemics, and the Guntur study verified that this was unnecessary. The referral of HIV positive/suspect patients from the private to the public sector is a widespread phenomenon in India, which is likely causing an upward distortion in HIV estimates from sentinel surveillance in other parts of India as well. Analysis of data from the nationwide Reproductive and Child Health Survey revealed that lower socioeconomic strata were over-represented among women seeking antenatal care at public hospitals in all major south Indian states, similar to the trend seen in the Guntur study. Application of conservative correction factors derived from the Guntur study reduced the 2005 official sentinel surveillance based HIV estimate of 3.7 million 15–49 years old persons in the four major states to 1.5–2.0 million, which would drop the official total estimate of 5.2 million 15–49 years old persons with HIV in India to 3–3.5 million. CONCLUSION: Plausible and cautious extrapolation of the trends seen in a recent large and rigorous population-based study of HIV in a south Indian district suggests that India is likely grossly overestimating its HIV burden with the current official sentinel surveillance based method. This method needs revision

Awareness regarding eye donation among stakeholders in Srikakulam district in South India

Background There is a huge need for the availability of transplantable donor corneas worldwide to reduce the burden of corneal blindness due to corneal opacity. Voluntary eye donation depends on the awareness levels of various stakeholders in the community. This study aimed to assess the awareness level regarding eye donation among various stakeholders in Srikakulam district in the state of Andhra Pradesh, India. Methods 355 subjects were selected from the district using multi stage random sampling. A pre tested semi structured questionnaire was used to collect information regarding each individual’s awareness, knowledge, and perception regarding eye donation. Each response was scored individually and a total score was calculated. Univariate and multivariate regression analysis was used to determine the factors associated with willingness towards eye donation and increased awareness levels. Results Of the 355 subjects interviewed, 192 (54%) were male and 163 (46%) were female. The mean age of the stakeholders was 35.9 years (SD ±16.1) and all the study subjects were literate. Ninety-three percent of subjects were aware of the concept of eye donation. Knowledge levels were similar among the teaching community and persons engaged in social service, but lower among students (p < 0.05). Among the stakeholders, there was considerable ambiguity regarding whether persons currently wearing spectacles or suffering from a chronic illnesses could donate their eyes. Older age group (p < 0.001), female gender (p < 0.001) and education (p < 0.001) were associated with increased knowledge levels. 82% of the subjects were willing to donate their eyes and this was unaffected by gender or geographical location (rural vs urban). Conclusions Awareness levels and willingness to donate eyes are high among the stakeholders in Srikakulam district in India. The services of stakeholders could be utilized, in conjunction with other community based eye donation counselors, to promote awareness regarding eye donation among the general population

Crash characteristics and patterns of injury among hospitalized motorised two-wheeled vehicle users in urban India

<p>Abstract</p> <p>Background</p> <p>Traffic crashes and consequent injuries represent a growing public health concern in India, particularly in light of increasing motorization. Motorised two-wheeled vehicles (MTV) constitute a large portion of the vehicle fleet in India. We report the crash characteristics and injury patterns among a cohort of MTV riders and pillions presenting to hospital post-crash.</p> <p>Methods</p> <p>Consecutive MTV riders and pillions, whether alive or dead, injured in a road traffic crash presenting to the emergency departments of two government hospitals and three branches of a private hospital in urban Hyderabad, India, were recruited to this study.</p> <p>Results</p> <p>378 MTV users were enrolled to the study of whom 333 (88.1%) were male, 252 (66.7%) were riders and median age was 31.3 years. A total of 223 (59%) MTV users were injured in multi-vehicle crashes while one-third had a frontal impact. The majority (77%) were assessed as having a Glasgow coma score (GCS) of 13–15, 12% a GCS of 9–12 and 11% a GCS of 3–8. No difference was seen in the severity distribution of injuries based on GCS among riders and pillions. Open wounds and superficial injuries to the head (69.3%) and upper extremity (27%) and lower extremity (24%) were the most common injuries. 43 (11%) sustained an intracranial injury, including 12 (28%) with associated fracture of the bones of the head. There were few differences in types of injuries sustained by riders and pillions though riders had a significantly lower risk of crush injuries of the lower extremity than pillions (relative risk, RR 0.25, 95% CI 0.08–0.81) and female pillions were at a significantly lower risk of sustaining fractures of the lower extremity than male pillions (RR 0.30, 95% CI 0.09 – 0.94). Overall, 42 (11%) MTV users died, of which 42.8% died before reaching the hospital. Only 74 (19.6%) MTV users had worn a helmet correctly and failure to wear a helmet was associated with a five times greater risk of intracranial injury (RR 4.99, 95% CI 1.23–20.1). Of the 19 pre-hospital deaths, 16 (84%) had not worn a helmet.</p> <p>Conclusion</p> <p>Head injuries accounted for the major proportion of injuries sustained in MTV users. Non-helmet use was associated with increased risk of serious head injuries. The data presented on the nature and severity of injuries sustained by MTV users can assist with planning to deal with these consequences as well as prevention of these injuries given the high use of MTV in India.</p