Barriers to Anti-Retroviral Therapy among Men who have sex with men in West Bengal, India

OBJECTIVESTo explore the challenges and barriers to the continuum of HIV care and services of Men who have sex with men (MSM) living with HIV through qualitative inquiries and to measure adherence to Anti-Retroviral Therapy (ART), and barriers that hinder ART access.METHODOLOGYThe study was conducted in Kolkata, India. During the qualitative phase, we conducted one Focus Group Discussion (FGD) with a MSM community-based organization (CBO) and 6 in-depth interviews (IDI) with MSM assigned to ART. In the quantitative phase, we recruited 104 seropositive MSM, who had been assigned to ART. We conducted a baseline Audio Computer-Assisted Self-Interview (ACASI) with the participants. A follow-up ACASI was conducted after 3months. We employed the Aids Clinical Trial Group questionnaire and Homosexuality Stigma Scale for collection of relevant information. RESULTSThe FGD and IDIs with seropositive MSM’s, identified several barriers they have to overcome in order to access free HIV care services in India. Social discrimination and barriers to HIV testing as well as of ART adherence. Poor health system responsiveness emerged as a major theme. The baseline ACASI revealed that 36% (95%Cl: 26%, 45%) of the MSM’s were depressed. Depression was significantly associated with increased internalized stigma. An increase by 5units in the stigma scale was associated with an increment of 1unit on the depression scale (adjβ:0.2, 95%Cl: 0.1, 0.3). Self-reported adherence to ART reveals MSM’s were similarly adherent 67% (95%Cl: 57%, 77%) as the general adult population. Among those who missed ART pills (n=41), 44% of the MSM’s just had forgot to take their medications. Fearing stigma, 24% did not want it to be know he takes ART medications and thus skipped medications. Linear multivariate analysis revealed that depression among MSM’s lowered adherence score (adjβ: -3.2, 95%Cl: -4.9, -1.5). Alcoholics had a significantly lower score of adherence as compared to non-alcoholics (adjβ: -14.6, 95%Cl: -25.0, -4.2), after controlling for other variables. Being less confident to be able to take medications at baseline significantly decreased the adherence score by 26 units when compared to those who were confident at baseline. (adjβ: -27.1, 95%Cl: -39.2, -14.9), after controlling for other variables.CONCLUSIONOur study findings will help fill some of the existing knowledge gaps regarding mental health status of MSM’s living with HIV in India and barriers of ART adherence among these socially marginalized population. We expect the findings to inform design and implementation of suitable and effective intervention strategies targeted to improve the quality of life of HIV infected MSM living in India

Progressive Paraparesis due to Extramedullary Haematopoiesis in Thalassaemia Intermedia Treated Successfully with Radiotherapy: A Case Report

Extramedullary Haematopoiesis (EMH), a rare complication of Thalassaemia Intermedia (TI), can present with pressure symptoms including Spinal Cord Compression (SCC) and can be treated using surgery, radiotherapy, hypertransfusion, or hydroxyurea. Hereby, the authors present a case report of a 20-year-old male young thalassaemic patient presented with progressive paraparesis. Neurological examination suggested SCC, and Magnetic Resonance Imaging (MRI) of the spine revealed paravertebral masses due to EMH. The patient was treated with radiotherapy to a dose of 30 Gy over three weeks. There was immediate, near-complete resolution of symptoms, and the patient could walk without assistance. He has been doing well since 1.5 years of treatment. So, in cases of TI, one should think of EMH as a differential diagnosis for paraparesis. Early clinicoradiological diagnosis of EMH-induced SCC is necessary and possible, as there is a high chance of complete remission of symptoms with radiotherapy, which is a non invasive and effective treatment option

Predictors of rational management of diarrhea in an endemic setting: observation from India.

Decades after the establishment of clear guidelines for management, mostly due to irrational approach, diarrhea is still a major concern in the developing world, including India. The scenario is even worse in urban slums owing to poor health-seeking and socio-environmental vulnerability. Determining the distribution of rational diarrhea management by practitioners and identification of its important predictors seemed urgent to minimize the potential for antibiotic resistance, diarrhea-related mortality and morbidity in these areas.Between May 2011 and January 2012, 264 consenting, randomly selected qualified and non-qualified practitioners (including pharmacists) were interviewed in the slums of Kolkata, a populous city in eastern India, regarding their characteristics, diarrhea-related knowledge (overall and in six separate domains: signs/symptoms, occurrence/spread, management, prevention/control, cholera and ORS), prescribed antibiotics, intravenous fluid (IVF) and laboratory investigations. Rationality was established based on standard textbooks.Among participants, 53.03% had no medical qualifications, 6.06% were attached to Governmental hospitals, 19.32% had best knowledge regarding diarrhea. While treating diarrhea, 7.20%, 17.80% and 20.08% respectively advised antibiotics, IVF and laboratory tests rationally. Logistic regression revealed that qualified and Governmental-sector practitioners managed diarrhea more rationally. Having best diarrhea-related knowledge regarding signs/symptoms (OR=5.49, p value=0.020), occurrence/spread (OR=3.26, p value=0.035) and overall (OR=6.82, p value=0.006) were associated with rational antibiotic prescription. Rational IVF administration was associated with best knowledge regarding diarrheal signs/symptoms (OR=3.00, p value=0.017), occurrence/spread (OR=3.57, p value=0.004), prevention/control (OR=4.89, p value=0.037), ORS (OR=2.55, p value=0.029) and overall (OR=4.57, p value<0.001). Best overall (OR=2.68, p value=0.020) and cholera-related knowledge (OR=2.34, p value=0.019) were associated with rational laboratory testing strategy.Diarrheal management practices were unsatisfactory in urban slums where practitioners' knowledge was a strong predictor for rational management. Interventions targeting non-qualified, independent practitioners to improve their diarrhea-related knowledge seemed to be required urgently to ensure efficient management of diarrhea in these endemic settings

Association of physician’s characteristics and knowledge regarding diarrhea with rationality of fluid management and laboratory testing practices while treating diarrhea cases (N^a = 264).

<p>Association of physician’s characteristics and knowledge regarding diarrhea with rationality of fluid management and laboratory testing practices while treating diarrhea cases (N<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0123479#t003fn001" target="_blank">^a</a> = 264).</p

Association of physician’s characteristics and knowledge regarding diarrhea with rationality of antibiotic use for diarrheal management (N^a = 264).

<p>Association of physician’s characteristics and knowledge regarding diarrhea with rationality of antibiotic use for diarrheal management (N<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0123479#t002fn002" target="_blank">^a</a> = 264).</p

Distribution of the characteristics and diarrheal management practices among participating physicians (N = 264^a).

<p>Distribution of the characteristics and diarrheal management practices among participating physicians (N = 264<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0123479#t001fn001" target="_blank">^a</a>).</p

Clinical, epidemiological, and spatial characteristics of <it>Vibrio parahaemolyticus</it> diarrhea and cholera in the urban slums of Kolkata, India

<p>Abstract</p> <p>Background</p> <p>There is not much information on the differences in clinical, epidemiological and spatial characteristics of diarrhea due to <it>V. cholerae</it> and <it>V. parahaemolyticus</it> from non-coastal areas. We investigated the differences in clinical, epidemiological and spatial characteristics of the two <it>Vibrio</it> species in the urban slums of Kolkata, India.</p> <p>Methods</p> <p>The data of a cluster randomized cholera vaccine trial were used. We restricted the analysis to clusters assigned to placebo. Survival analysis of the time to the first episode was used to analyze risk factors for <it>V. parahaemolyticus</it> diarrhea or cholera. A spatial scan test was used to identify high risk areas for cholera and for <it>V. parahaemolyticus</it> diarrhea.</p> <p>Results</p> <p>In total, 54,519 people from the placebo clusters were assembled. The incidence of cholera (1.30/1000/year) was significantly higher than that of <it>V. parahaemolyticus</it> diarrhea (0.63/1000/year). Cholera incidence was inversely related to age, whereas the risk of <it>V. parahaemolyticus</it> diarrhea was age-independent. The seasonality of diarrhea due to the two <it>Vibrio</it> species was similar. Cholera was distinguished by a higher frequency of severe dehydration, and <it>V. parahaemolyticus</it> diarrhea was by abdominal pain. Hindus and those who live in household not using boiled or treated water were more likely to have <it>V. parahaemolyticus</it> diarrhea. Young age, low socioeconomic status, and living closer to a project healthcare facility were associated with an increased risk for cholera. The high risk area for cholera differed from the high risk area for <it>V. parahaemolyticus</it> diarrhea.</p> <p>Conclusion</p> <p>We report coexistence of the two vibrios in the slums of Kolkata. The two etiologies of diarrhea had a similar seasonality but had distinguishing clinical features. The risk factors and the high risk areas for the two diseases differ from one another suggesting different modes of transmission of these two pathogens.</p