HIV risk behaviours among injecting drug users in Northeast India following scale-up of a targeted HIV prevention programme

BACKGROUND: In the Northeast Indian states of Manipur and Nagaland there has been an ongoing HIV epidemic among injecting drug users (IDUs) since the mid-1990s. Project ORCHID is an Avahan-funded HIV prevention project that has been working in selected districts of Manipur and Nagaland since 2004. It supports local partner non-government organisations (NGOs) to deliver a range of harm reduction interventions, and currently reaches approximately 14,500 IDUs across the two states. To assess changes in HIV risk behaviours two Behavioural Tracking Surveys (BTS) were undertaken among IDUs in 2007 and 2009. METHODS: The BTS used respondent driven sampling (RDS) to recruit adult male IDUs (18 years of age and above) from Ukhrul and Chandel districts in Manipur, and Kiphire and Zunheboto districts in Nagaland. This paper reports on analysis of socio-demographics, drug use and injecting practices, sexual behaviour and condom use, knowledge of HIV, and exposure to interventions. Descriptive data were analysed using RDSAT, and odds ratios were calculated in SPSS. RESULTS: The proportion of IDUs reporting NOT sharing needles / syringes at last injection increased substantially in Ukhrul (59.6% to 91.2%) and Zunheboto (45.5% to 73.8%), remained high in Chandel (97.0% to 98.9%), and remained largely unchanged in Kiphire (63.3% to 68.8%). The use of condoms with regular partners was low in all districts at both time points. In Ukhrul, Kiphire and Zunheboto the proportion of IDUs using condoms during sexual intercourse with a casual partner increased substantially to approximately 70-85%, whilst in Chandel the increase was only marginal (57.4% to 63.6%). Exposure to NGO HIV prevention interventions was significantly associated (p<0.05) with lower odds of sharing needles during the previous month (Nagaland, OR=0.63; Manipur, OR 0.35). CONCLUSION: Despite district-level differences, the results from this BTS study indicate that exposure to HIV prevention services, predominately delivered in this region by NGOs, is associated with a reduced likelihood of engaging in HIV risk behaviours. IDUs using HIV prevention services are more likely to engage in safe injecting and sexual practices, and effort is required to sustain / increase opportunities for IDUs to access these services. These outcomes are a noteworthy achievement in a very challenging context

Opioid substitution therapy in manipur and nagaland, north-east india: operational research in action

<p>Abstract</p> <p>Background</p> <p>There is good evidence for the effectiveness of opioid substitution therapy (OST) for injecting drug users (IDUs) in middle and high-income countries but little evidence regarding the provision of OST by non-government organisations (NGOs) in resource-poor settings. This paper reports on outcomes of an NGO-based OST program providing sub-lingual buprenorphine to opiate dependent IDUs in two north-east Indian states (Manipur and Nagaland), a region where conflict, under-development and injecting of heroin and Spasmoproxyvon (SP) are ongoing problems. The objectives of the study were: 1) to calculate OST treatment retention, 2) to assess the impact on HIV risk behaviours and quality of life, and 3) to identify client characteristics associated with cessation of treatment due to relapse.</p> <p>Methods</p> <p>This study involves analysis of data that were routinely and prospectively collected from all clients enrolled in an OST program in Manipur and Nagaland between May 2006 and December 2007 (n = 2569, 1853 in Manipur and 716 in Nagaland) using standardised questionnaires, and is best classified as operational research. The data were recorded at intake into the program, after three months, and at cessation. Outcome measures included HIV risk behaviours and quality of life indicators. Predictors of relapse were modelled using binary logistic regression.</p> <p>Results</p> <p>Of all clients enrolled in OST during the month of May 2006 (n = 713), 72.8% remained on treatment after three months, and 63.3% after six months. Statistically significant (p = 0.05) improvements were observed in relation to needle sharing, unsafe sex, incidents of detention, and a range of quality of life measures. Greater spending on drugs at intake (OR 1.20), frequently missing doses (OR 8.82), and having heroin rather than SP as the most problematic drug (OR 1.95) were factors that increased the likelihood of relapse, and longer duration in treatment (OR 0.76) and regular family involvement in treatment (OR 0.20) reduced the likelihood of relapse.</p> <p>Conclusion</p> <p>The findings from this operational research indicate that the provision of OST by NGOs in the severely constrained context of Manipur and Nagaland achieved outcomes that are internationally comparable, and highlights strategies for strengthening similar programs in this and other resource-poor settings.</p

Community beliefs about treatments and outcomes of mental disorders: A mental health literacy survey in a rural area of Maharashtra, India

Objectives: Mental health remains a neglected issue in most developing countries, especially in rural areas where access to effective mental health services is limited. The integration of mental health into primary health care is being promoted as a strategy to address this problem. Consequently, there is an urgent need to enhance mental health awareness among communities, and to provide mental health training for primary healthcare staff. In order to do this effectively, it is important to understand and take account of local views on mental health and illness. As such, a mental health literacy (MHL) assessment was undertaken in a poor, rural area of Maharashtra, India to inform the development of a mental health training programme. Study design: A cross-sectional MHL survey was undertaken in late 2007. Methods: Data were collected from 240 systematically sampled community members and 60 purposively sampled village health workers (VHWs) using an interviewer-administered questionnaire. Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis), and were asked to name the problems, and to identify the treatments and people that were most likely to be helpful (or otherwise), and the likely outcomes for people with such problems. Results: Most participants recognized that the people in the vignettes were experiencing a mental health problem. 'Depression' was the most common label for the problems experienced in the depression vignette, and 'a mind/brain problem' was the most common label in the case of the psychosis vignette. Socio-economic interventions provided by family, friends and neighbours were considered to be most helpful. Local VHWs and doctors were also viewed as potentially helpful, but psychiatrists less so. Approximately half of the sample thought that dealing with the problem alone would be helpful. Special diets, tonics, appetite stimulants and sleeping pills were also strongly endorsed, but awareness of psychiatric medications was negligible. Conclusion: The findings from this study highlight the need to enhance MHL in this community. Additionally, there is a need to build the capacity of the primary healthcare staff, including the VHWs, so that they are equipped to provide an effective local response for people experiencing mental health problems

Attitudes to people with mental disorders: a mental health literacy survey in a rural area of Maharashtra, India

Introduction: People with mental disorders experience discrimination as a consequence of stigmatising attitudes that are largely socio-culturally constructed. Thus, there is a need to understand local contexts in order to develop effective programs to change such attitudes. We undertook a mental health literacy survey in rural Maharashtra, India, prior to developing a mental health training program for village health workers (VHWs) in a primary health care setting. Methods: A cross-sectional mental health literacy survey was undertaken in late 2007, which involved interviewer-administration of a questionnaire to 240 systematically sampled community members, and 60 purposively sampled VHWs. Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis), and were asked about attitudes towards, and desired social distance from, the people in the vignettes (the latter being a proxy measure for stigma). Linear regression modelling was undertaken to identify predictors of social distance. Results: Although the community was relatively accepting of people with mental disorders, false beliefs and negative attitudes were still evident. Desired social distance was consistently greater for the person depicted in the psychosis vignette compared to the depression vignette. For both vignettes, the main predictor of greater social distance was perceiving the person as dangerous, and the predictors of reduced social distance were being a VHW, and seeing the problem as a sign of personal weakness. For depression, believing the cause to be family tensions also reduced social distance. For psychosis, labelling the disorder as a mind/brain problem, and believing the cause to be lack of control over life or genetic factors increased social distance. The vast majority did not agree that the problems experienced in the vignettes were 'a real medical illness'. Conclusion: Promoting bio-medical explanations for mental disorders in this setting may exacerbate discriminatory attitudes. Provision of contextually relevant mental health training for the VHWs so that they are able to communicate, model and shape more positive attitudes is the next step

My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India

<p>Abstract</p> <p>Background</p> <p>The north-east Indian states of Manipur and Nagaland are two of the six high HIV prevalence states in the country, and the main route of HIV transmission is injecting drug use. Understanding the pathways to injecting drug use can facilitate early intervention with HIV prevention programs. While several studies of initiation into injecting drug use have been conducted in developed countries, little is known about the situation in developing country settings. The aim of this study was to increase understanding of the contextual factors associated with initiation into injecting drug use in north-east India, and the influence of these factors on subsequent initiation of others.</p> <p>Method</p> <p>In mid 2006 a cross-sectional survey among 200 injecting drug users (IDUs) was undertaken in partnership with local NGOs that provide HIV prevention and care services and advocacy for IDUs in Imphal, Manipur and Dimapur, Nagaland. The questionnaire elicited detailed information about the circumstances of the first injection and the contexts of participants' lives. Demographic information, self-reported HIV status, and details about initiation of others were also recorded.</p> <p>Results</p> <p>Initiation into injecting drug use occurred at 20 years of age. The drugs most commonly injected were Spasmo-proxyvon (65.5%) and heroin (30.5%). In 53.5% cases, a needle belonging to someone else was used. Two-thirds (66.7%) had used the drug previously, and 91.0% had known other IDUs prior to initiation (mean = 7.5 others). The first injection was usually administered by another person (94.5%), mostly a friend (84.1%). Initiation is a social event; 98% had others present (mean = 2.7 others). Almost 70% of participants had initiated at least one other (mean = 5 others). Initiation of others was independently associated with being male and unemployed; having IDU friends and using alcohol around the time of initiation; and having been taught to inject and not paid for the drug at the time of initiation.</p> <p>Conclusion</p> <p>Targeting harm reduction messages to (non-injecting) drug users and capitalising on existing IDU social networks to promote safe injecting and deter initiation of others are possible strategies for reducing the impact of injecting drug use and the HIV epidemic in north-east India.</p

A mental health training program for community health workers in India: impact on knowledge and attitudes

<p>Abstract</p> <p>Background</p> <p>Unmet needs for mental health treatment in low income countries are pervasive. If mental health is to be effectively integrated into primary health care in low income countries like India then grass-roots workers need to acquire relevant knowledge and skills to be able to recognise, refer and support people experiencing mental disorders in their own communities. This study aims to provide a mental health training intervention to community health workers in Bangalore Rural District, Karnataka, India, and to evaluate the impact of this training on mental health literacy.</p> <p>Methods</p> <p>A pre-test post-test study design was undertaken with assessment of mental health literacy at three time points; baseline, completion of the training, and three month follow-up. Mental health literacy was assessed using the interviewer-administered Mental Health Literacy Survey. The training intervention was a four day course based on a facilitator's manual developed specifically for community health workers in India.</p> <p>Results</p> <p>70 community health workers from Doddaballapur, Bangalore Rural District were recuited for the study. The training course improved participants' ability to recognize a mental disorder in a vignette, and reduced participants' faith in unhelpful and potentially harmful pharmacological interventions. There was evidence of a minor reduction in stigmatizing attitudes, and it was unclear if the training resulted in a change in participants' faith in recovery following treatment.</p> <p>Conclusion</p> <p>The findings from this study indicate that the training course demonstrated potential to be an effective way to improve some aspects of mental health literacy, and highlights strategies for strengthening the training course.</p

Social inclusion and exclusion of people with mental illness in Timor-Leste: a qualitative investigation with multiple stakeholders.

BACKGROUND: Social inclusion is a human right for all people, including people with mental illness. It is also an important part of recovery from mental illness. In Timor-Leste, no research has investigated the social experiences of people with mental illness and their families. To fill this knowledge gap and inform ongoing mental health system strengthening, we investigated the experiences of social inclusion and exclusion of people with mental illness and their families in Timor-Leste. METHODS: Eighty-five participants from the following stakeholder groups across multiple locations in Timor-Leste were interviewed: (1) people with mental illness and their families; (2) mental health and social service providers; (3) government decision makers; (4) civil society members; and (5) other community members. Framework analysis was used to analyse interview transcripts. RESULTS: People with mental illness in Timor-Leste were found to face widespread, multi-faceted sociocultural, economic and political exclusion. People with mental illness were stigmatised as a consequence of beliefs that they were dangerous and lacked capacity, and experienced instances of bullying, physical and sexual violence, and confinement. Several barriers to formal employment, educational, social protection and legal systems were identified. Experiences of social inclusion for people with mental illness were also described at family and community levels. People with mental illness were included through family and community structures that promoted unity and acceptance. They also had opportunities to participate in activities surrounding family life and livelihoods that contributed to intergenerational well-being. Some, but not all, Timorese people with mental illness benefited from disability-inclusive programming and policies, including the disability pension, training programs and peer support. CONCLUSIONS: These findings highlight the need to combat social exclusion of people with mental illness and their families by harnessing local Timorese sociocultural strengths. Such an approach could centre around people with mental illness and their families to: increase population mental health awareness; bolster rights-based and culturally-grounded mental health services; and promote inclusive and accessible services and systems across sectors

A participatory intervention to improve the mental health of widows of injecting drug users in north-east India as a strategy for HIV prevention

BACKGROUND: Manipur and Nagaland, in the north-east of India, are classified as high prevalence states for HIV, and intravenous drug use is an important route of transmission. Most injecting drug users (IDUs) are men, an estimated 40% are married, and death rates have been high in the last five years, consequently the number of widows of IDUs has increased. Many of these widows and their children are HIV-infected and experience poor health, discrimination, and impoverishment; all factors likely to be compromising their mental health. People with poor mental health are more likely to engage in HIV risk behaviours. Mental health can be promoted by public health actions with vulnerable population groups. METHODS: We designed an intervention study to assess the feasibility and impact of a participatory action process to promote the mental health and well-being of widows of IDUs in Manipur and Nagaland, as a strategy for reducing the risk of engagement in HIV risk behaviours. This paper describes the background and rationale for the study, the intervention, and the study methods in detail. RESULTS: Pending analysis. CONCLUSION: This intervention study will make a significant contribution to the emerging evidence that supports associations between mental health and HIV. The concept of promoting mental health among women who are vulnerable to HIV infection or already infected as a strategy for HIV prevention in a development setting is breaking new ground

Some peace of mind: assessing a pilot intervention to promote mental health among widows of injecting drug users in north-east India

<p>Abstract</p> <p>Background</p> <p>HIV prevalence in north-east India is high and injecting drug use (IDU) is common. Due to HIV-related deaths there are increasing numbers of IDU widows, many of whom are HIV infected, and experiencing poor health, social isolation, discrimination and poverty, all factors likely to be compromising their mental health. There is increasing recognition of the links between HIV and mental health.</p> <p>Methods</p> <p>The aim of this study was to pilot a peer-facilitated, participatory action group (PAG) process and assess the impact of the intervention on the mental health of participants. The intervention consisted of 10 PAG meetings involving 74 IDU widows. Changes in quality of life (WHOQOL-BREF), mental health (GHQ12) and somatic symptoms were assessed. The value of the intervention from the perspective of the participants was captured using a qualitative evaluation method (Most Significant Change).</p> <p>Results</p> <p>Participants' quality of life, mental health and experience of somatic symptoms improved significantly over the course of the intervention, and the women told stories reflecting a range of 'significant changes'.</p> <p>Conclusion</p> <p>This pilot intervention study demonstrated that a participatory approach to mental health promotion can have a positive impact on the lives of vulnerable women, and the potential to contribute to HIV prevention. Further investigation is warranted.</p

Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis.

Multiple sclerosis is a common disease of the central nervous system in which the interplay between inflammatory and neurodegenerative processes typically results in intermittent neurological disturbance followed by progressive accumulation of disability. Epidemiological studies have shown that genetic factors are primarily responsible for the substantially increased frequency of the disease seen in the relatives of affected individuals, and systematic attempts to identify linkage in multiplex families have confirmed that variation within the major histocompatibility complex (MHC) exerts the greatest individual effect on risk. Modestly powered genome-wide association studies (GWAS) have enabled more than 20 additional risk loci to be identified and have shown that multiple variants exerting modest individual effects have a key role in disease susceptibility. Most of the genetic architecture underlying susceptibility to the disease remains to be defined and is anticipated to require the analysis of sample sizes that are beyond the numbers currently available to individual research groups. In a collaborative GWAS involving 9,772 cases of European descent collected by 23 research groups working in 15 different countries, we have replicated almost all of the previously suggested associations and identified at least a further 29 novel susceptibility loci. Within the MHC we have refined the identity of the HLA-DRB1 risk alleles and confirmed that variation in the HLA-A gene underlies the independent protective effect attributable to the class I region. Immunologically relevant genes are significantly overrepresented among those mapping close to the identified loci and particularly implicate T-helper-cell differentiation in the pathogenesis of multiple sclerosis