Knowing your HIV/AIDS epidemic and tailoring an effective response: how did India do it?

Tremendous global efforts have been made to collect data on the HIV/AIDS epidemic. Yet, significant challenges remain for generating and analysing evidence to allocate resources efficiently and implement an effective AIDS response. India offers important lessons and a model for intelligent and integrated use of data on HIV/AIDS for an evidence-based response. Over the past 15 years, the number of data sources has expanded and the geographical unit of data generation, analysis and use for planning has shifted from the national to the state, district and now subdistrict level. The authors describe and critically analyse the evolution of data sets in India and how they have been utilised to better understand the epidemic, advance policy, and plan and implement an increasingly effective, well-targeted and decentralised national response to HIV and AIDS. The authors argue that India is an example of how ‘know your epidemic, know your response’ message can effectively be implemented at scale and presents important lessons to help other countries design their evidence generation systems

High Rates of All-cause and Gastroenteritis-related Hospitalization Morbidity and Mortality among HIV-exposed Indian Infants

<p>Abstract</p> <p>Background</p> <p>HIV-infected and HIV-exposed, uninfected infants experience a high burden of infectious morbidity and mortality. Hospitalization is an important metric for morbidity and is associated with high mortality, yet, little is known about rates and causes of hospitalization among these infants in the first 12 months of life.</p> <p>Methods</p> <p>Using data from a prevention of mother-to-child transmission (PMTCT) trial (India SWEN), where HIV-exposed breastfed infants were given extended nevirapine, we measured 12-month infant all-cause and cause-specific hospitalization rates and hospitalization risk factors.</p> <p>Results</p> <p>Among 737 HIV-exposed Indian infants, 93 (13%) were HIV-infected, 15 (16%) were on HAART, and 260 (35%) were hospitalized 381 times by 12 months of life. Fifty-six percent of the hospitalizations were attributed to infections; gastroenteritis was most common accounting for 31% of infectious hospitalizations. Gastrointestinal-related hospitalizations steadily increased over time, peaking around 9 months. The 12-month all-cause hospitalization, gastroenteritis-related hospitalization, and in-hospital mortality rates were 906/1000 PY, 229/1000 PY, and 35/1000 PY respectively among HIV-infected infants and 497/1000 PY, 107/1000 PY, and 3/1000 PY respectively among HIV-exposed, uninfected infants. Advanced maternal age, infant HIV infection, gestational age, and male sex were associated with higher all-cause hospitalization risk while shorter duration of breastfeeding and abrupt weaning were associated with gastroenteritis-related hospitalization.</p> <p>Conclusions</p> <p>HIV-exposed Indian infants experience high rates of all-cause and infectious hospitalization (particularly gastroenteritis) and in-hospital mortality. HIV-infected infants are nearly 2-fold more likely to experience hospitalization and 10-fold more likely to die compared to HIV-exposed, uninfected infants. The combination of scaling up HIV PMTCT programs and implementing proven health measures against infections could significantly reduce hospitalization morbidity and mortality among HIV-exposed Indian infants.</p

Use of Technology in Segregating Occupational risks of Migrant and linking them with Services: Experiences from National AIDS Control Program for Migrants

Background: The migrant intervention in India was initiated during the National AIDS Control Program (NACP) Phase-2 (2002-2007). Even by the end of NACP Phase-3 (2010-11); the service uptake among migrants remained very low (14% referred for HIV testing, of which only 37% were tested). USAID PHFI-PIPPSE project in collaboration with the National AIDS Control Organization (NACO) developed a unique system called Migrant Service Delivery System (MSDS) to capture migrants profile with respect to their risk profile and to provide tailor made services to them.Description: MSDS is a web-based system, designed and implemented to increase service uptake among migrants through evidence based planning. 110 destination migrants Targeted Intervention (TI) from 11 states were selected for study with varied target populations in terms of occupations; to understand occupation related risk behaviors amongst the migrants. Occupation wise registration data of high risk vulnerable migrants were analyzed through MSDS for the period April 2014-June 2016. Analysis was made on specific indicators amongst these occupational groups to understand the risk behavior and their vulnerability to HIV and STI.Lessons Learned: Out of total migrants workers enrolled in MSDS HIV rate is found to be highest amongst Auto-Rickshaw (18.66%) followed by daily wage laborers (14.46%), loom workers (10.73%), industrial workers (10.04%) and construction workers (7.93%). With 45.14% positivity, industrial workers are found to be most vulnerable to Sexually Transmitted Infections (STIs) amongst all occupational categories followed by loom workers (16.28%), skilled worker (Furniture, Jeweler)(7.14%), daily wage laborers (5.45%) .Conclusion/Next Steps: MSDS is an effective tool to assess migrants’ risk and their vulnerability to HIV for designing evidence informed program. This system calls for a replication across all destination TIs by NACO for differential strategies for different occupation groups to ensure better yield through scientific planning of intervention among high risk and high vulnerable migrants.

The potential demand for and strategic use of an HIV-1 vaccine in Southern India

Even a modestly effective HIV-1 vaccine would be highly useful in India and could avoid millions of deaths. How should such a vaccine be introduced? Based on evidence of adoption of other vaccines in India, current levels of spending on them and coverage of prevention programs targeting both high- and low-risk groups, Seshadri, Subramaniyam, and Jha assess the potential demand for and strategic use of an HIV-1 vaccine in the four southern Indian states of Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu. The authors also discuss potential strategies for delivery of the vaccine, prioritization for vaccination, and the political economyof such a vaccine in India. Assuming a vaccine cost of $10 a dose and including estimated delivery costs, the total cost of vaccinating 21.6 million adolescents 11-14 years of age and 1 percent of adults would be Rs. 12.25 billion (US$ 245 million). To maintain the vaccination rate in the 11-14 year old cohort, an additional 6.77 million in that age range would have to be vaccinated each year, at a vaccine cost of Rs. 3.39 billion (US$ 67.5 million). An HIV-1 vaccine will greatly reduce HIV/AIDS in India, but it will not be a panacea. There will be a continued need for effective prevention programs to guard against behavior reversals or an imperfect vaccine. Key inputs for prevention, immunization, and treatment programs such as identification of various groups that could be immunized (vulnerable groups or general populations), strengthened surveillance, capacity building, operations research, and evaluation at local levels will continue to require intensive support.Health Monitoring&Evaluation,Public Health Promotion,HIV AIDS,Disease Control&Prevention,Early Child and Children's Health,Health Monitoring&Evaluation,Adolescent Health,HIV AIDS,Primary Education,Early Child and Children's Health

Patterns of voluntary and replacement blood donors in a tertiary care center: a retrospective study

Background: Blood donor base is the foundation of any blood transfusion system. In India any able-bodied individual between the age of 18 and 60 years can donate blood. Blood donors are of two types: voluntary donors and replacement donors. Blood donation should be done by low risk population otherwise there is high risk of transfusion transmissible infections like HIV, hepatitis B, hepatitis C and malaria. The present study was conceived to see the patterns of blood donation among voluntary and replacement blood donors in tertiary care centre.Methods: In this study 50 (27 male and 23 female) adult skulls were investigated to determine the type of asterion, its distance from important bony landmarks and also the nearby venous sinuses were measured.Results: Of the total 340078, 298421(87.75%) collections were voluntary and 41657(12.25%) were replacement collections. A total of 2810 camps were held to gather blood through voluntary donors. Number of blood camps held show an increasing pattern as we progress in time. Also, the trends in voluntary blood donations increased over the period and more donors donated blood whereas replacement donors decreased over the period and eventually vanished in time.Conclusions: For a safe blood service in our country, where comprehensive laboratory tests are neither possible nor pragmatic, it is best to switch over to 100% voluntary donations, as it is now established that only voluntary non-remunerated regular donation is the safest. Thus, one of our key strategies to enhance blood safety is to focus on motivating non-remunerated blood donors and phasing out even replacement donors

HIV Transmission Potential Among Local and Migrant Factory Workers in Kolkata, India

Migrant workers in India play a key role in the spread of HIV. Kolkata is a common destination for workers, who may acquire infection and transmit it to their wives and/or other sexual partners. We investigated sexual relations and condom use by factory workers. Migrant and local factory workers were randomly selected from five wards of Kolkata. Information was collected about demographic and socio-economic characteristics, sexual relationships, condom usage, and perceptions and intent to use condoms. Condom use was very low in both groups of workers, particularly among migrants. Many married workers visited female sex workers but never used condoms. Few intended to use condoms, and if they did, it did not always translate into actual usage. There is great potential for transmission of HIV/sexually transmitted infections by these workers. Carefully designed intervention and education programs in the context of low literacy and cultural norms are urgently needed

HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes

Objective To determine the rates of death and infection from HIV in India

Opioid substitution treatment with sublingual buprenorphine in Manipur and Nagaland in Northeast India: what has been established needs to be continued and expanded

Manipur and Nagaland in northeast India report an antenatal HIV prevalence of > 1% and the current HIV prevalence among injecting drug users is 24% and 4.5% respectively. Through support from DFID's Challenge Fund, Emmanuel Hospital Association (EHA) established thirteen drop-in-centres across the two states to deliver opioid substitution treatment with sublingual buprenorphine for 1200 injecting drug users. Within a short span of time the treatment has been found to be attractive to the clients and currently 1248 injecting opioid users are receiving opioid substitution treatment. The project is acceptable to the drug users, the families, the communities, religious as well as the militant groups. The treatment centres operate all days of the week, have trained staff members, utilize standardized protocols and ensure a strict supervised delivery system to prevent illicit diversion of buprenorphine. The drug users receiving the substitution treatment are referred to HIV voluntary counselling and testing. As this treatment has the potential to change HIV related risk behaviours, what has been established in the two states needs to be continued and expanded with the support from the Government of India

Ten years’ trend of HIV seroprevalence among Indian pregnant women attending antenatal clinic at tertiary hospital in Dhule, Maharashtra, India

Background: In India, HIV epidemic is in fourth decade and has the heterogeneity. The trend indicated HIV infection spreads from high risk behavior groups to general population. Maternal to foetal HIV transmission rate is found to vary from 20 to 25% in absence of any interventions. Newly infected persons contribute to the total number of persons living with HIV, they will progress to disease and death over the time and are a potential source of further infection. Maternal HIV status directly affects the perinatal transmission and hence the paediatric HIV cases. This transmission of HIV from mother to child can be prevented by appropriate measures. So this study is intended to identify ten years’ trends in HIV seroprevalence among antenatal population at a tertiary hospital in Dhule, Maharashtra, India.Methods: Retrospective study of ICTC evaluation of pregnant women attending antenatal clinic at obstetrics and gynaecology department of Shri Bhausaheb Hire Government Medical College in Dhule, Maharashtra, India. Blood samples were collected after informed consent and pre-test counseling. The samples were tested for HIV antibodies as per WHO and NACO guidelines. The data of ten years period from January 2004 to December 2013 was evaluated to identify the trends of HIV seroprevalence among pregnant women attending antenatal clinic.Results: 309 pregnant women were HIV positive out of 70453 tested from 84608 ANC women during the study period. The overall prevalence for the 10 years was 0.44%. HIV prevalence had reduced from 0.89% in 2004 to 0.17% in 2013. Maximum HIV positive women i.e. 63.2% were 18 to 23 years old, primigravida (53.8%) and from rural area (58.5%). Mother to foetal transmission was noted 10 babies were detected to be HIV positive while 223 were HIV negative. 10 HIV positive mothers decided for MTP, while in 36 neonatal death was noted.Conclusions: Declining HIV seroprevalence rate is noted among pregnant women attending the antenatal clinics from 2004 to 2013. The effective implementation of prevention of parent to child transmission of HIV/AIDS (PPTCT) programmed is helping in control of the spread of HIV

Studying prevention of parent to child transmission services, interventions, coverage and utilization

Background: Human immunodeficiency virus (HIV) infection is increasing at an alarming rate globally. Apart from heterosexual route, mother to-child transmission is the next most important route of HIV transmission accounting for over 90% of infections in children. The present retrospective study is undertaken to evaluate the effectiveness of implementation of PPTCT programmed in GMERS Medical College, Sola, Ahmedabad, Gujarat, India.Methods: At ICTCs, registered ANCs are counseled and tested for HIV. HIV+ve ANCs are linked to services and followed-up for institutional delivery. Antiretroviral prophylaxis with nevirapine was given to seropositive mother-baby pairs during delivery and children testing. HIV+ve ANCs since 2014 to 2016 subsequently delivered till December 2018 and their exposed children followed up till 18 months for confirmation of their seropositivity status in PPTCT were study at GMERS medical college, sola, Ahmedabad, Gujarat, India.Results: 13595 ANCs registered, 100% were counseled pre-test, and 99.5% of them tested, 79.5% were counseled post-test.  CD4 testing was carried out in all HIV+ve ANCs. 55 ANCs were detected HIV+ve inclusive of 37 new registered, 16 re-pregnancy and 2 unregistered cases. 55 pregnancy outcomes reported institutionally total 85.9% delivered at institute out of them 26.5% were caesarian sections and 62.4% delivered vaginally. Out of 48 live births, 47 sdNVP-MB-Pair were given. 48 children were traced till 18 months, 82.5% of live births were alive, and 68.75% of live births were tested. 1 was found HIV+ve with history of adherence to all prescribed PPTCT guidelines.Conclusions: PMTCT services - counseling and testing should be provided to all ANCs. EDD-based tracking, institutional deliveries, postnatal counseling to be encouraged along with complete MB pair coverage, capacity building of concerned staff regarding delivery of HIV+ve ANCs and exposed children tracking