Rapid assessment of facilitators and barriers related to the acceptance, challenges and community perception of daily regimen for treating tuberculosis in India

Introduction: The Revised National Tuberculosis Control Program (RNTCP) is the largest tuberculosis (TB) control program in the world based on Directly Observed Treatment Short-Course (DOTS) strategy. Globally, most countries have been using a daily regimen and in India a shift towards a daily regimen for TB treatment has already begun. The daily strategy is known to improve program coverage along with compliance. Such strategic shifts have both management and operational implications. We undertook a rapid assessment to understand the facilitators and barriers in adopting the daily regimen for TB treatment in three Indian states. Methods: In-depth interviews were planned across six districts of three purposively selected states of Maharashtra, Bihar and Sikkim, among health system personnel at various levels to identify their perspectives on adoption of a daily regimen for TB. These districts were sampled on the basis of TB notification rates. Thematic analysis of the qualitative data was undertaken. Results: 62 respondents were interviewed from these 6 districts. During the analysis, it was observed that an easily accessible, patient-centred and personalized outreach is an enabling factor for adherence to treatment. Lack of transportation facilities, out-of-pocket expenses and loss of wages for accessing DOTS at institutions are major identified barriers for treatment adherence at individual level. At program level, lack of trained service providers, poor administration of treatment protocols and inadequate supervision by health care providers and program managers are key factors that influence program outcomes. Conclusion: A major observation that emerged from the interviews is that the key to achieve a relapse-free cure is ensuring that a patient receives all doses of the prescribed treatment regimen. However, switching to a daily regimen makes adherence difficult and thus new strategies are needed for its implementation at patient and health provider levels. Most stakeholders appreciate the reasons for switching to a daily regimen. The stakeholders recognised the efforts of the Ministry of Health & Family Welfare (MoHFW) in spearheading the program. Strategies like the 99 DOTS call-centre approach may also further ensure treatment adherence

HIV Infection, Genital Symptoms and Sexual Risk Behavior among Indian Truck Drivers from a Large Transportation Company in South India

Background: Sentinel surveillance conducted in the high Human Immuno-deficiency Virus (HIV) prevalent state of Andhra Pradesh includes sub-populations thought to be at high-risk for HIV, but has not included truck drivers. Novel HIV prevention programs targeting this population increasingly adopt public - private partnership models. There have been no targeted studies of HIV prevalence and risk behavior among truck drivers belonging to the private sector in India. Methods: A sample of 189 truck drivers, aged between 15 and 56, were recruited from Gati Limited′s large trucking depot in Hyderabad, India. A quantitative survey instrument was conducted along with blood collection for HIV 1/2 testing. Multivariate regression models were utilized to determine predictors of HIV infection and risk behavior. Results: 2.1% of subjects were infected with HIV. Older age was protective against self-reported genital symptoms (OR = 0.77; P = 0.03), but these were more likely among those truck drivers with greater income (OR = 1.05; P = 0.02), and those who spent more time away from home (OR = 25.7; P = 0.001). Men with higher incomes also reported significantly more sex partners (OLS coefficient = 0.016 more partners / 100 rupees in monthly income, P = 0.04), as did men who spent a great deal of time away from home (OLS coefficient = 1.30, P = 0.002). Drivers were more likely to report condom use with regular partners if they had ever visited a female sex worker (OR = 6.26; P = 0.002), but married drivers exhibited decreased use of condoms with regular partners (OR = 0.14, P = 0.008). Men who had higher levels of knowledge regarding HIV and HIV preventative practices were also more likely to use condoms with regular partners (OR = 1.22, P = 0.03). Conclusion: Time away from home, urban residence, income, and marital status were the strongest correlates of genital symptoms for Sexually Transmitted Infections (STI) and risk behaviors, although none were consistent predictors of all outcomes. Low HIV prevalence might be explained by a cohort that was mostly married, and at home. Novel HIV prevention interventions may be most cost effective when focusing upon young, single, and long-haul truck drivers

A Digital Network Approach to Infer Sex Behavior in Emerging HIV Epidemics

Purpose: Improve the ability to infer sex behaviors more accurately using network data.Methods: A hybrid network analytic approach was utilized to integrate: (1) the plurality of reports from others tied to individual(s) of interest; and (2) structural features of the network generated from those ties. Network data was generated from digitally extracted cell-phone contact lists of a purposeful sample of 241 high-risk men in India. These data were integrated with interview responses to describe the corresponding individuals in the contact lists and the ties between them. HIV serostatus was collected for each respondent and served as an internal validation of the model’s predictions of sex behavior.Results: We found that network-based model predictions of sex behavior and self-reported sex behavior had limited correlation (54% agreement). Additionally, when respondent sex behaviors were re-classified to network model predictions from self-reported data, there was a 30.7% decrease in HIV seroprevalence among groups of men with lower risk behavior, which is consistent with HIV transmission biology.Conclusion: Combining the relative completeness and objectivity of digital network data with the substantive details of classical interview and HIV biomarker data permitted new analyses and insights into the accuracy of self-reported sex behavior.</p

Percentage of MSM sex behavior agreement with self-report in social compared to sex networks.

<p>More agreement between self-report and model predictions is evident in the social network (upper surface) than the sex network (lower surface); however agreement between self-report and model predictions increases across thresholds as closeness (κ) between sex network members increases. (τ) serves as a metric comparing proportions of model predictions for insertive and receptive sex positions. (κ) serves as a measure of closeness indicated by score from 1.0 (least close) to 3.0 (closest).</p

Network redundancy curve of study respondents used to determine adequate sample size for network model (n = 241).

<p>Curve fit from data on index of respondents and week of respondent interviews versus network size to exponential model. The data were fit to a scaled/shifted exponential cumulative distribution function f(x) = 99.2–95.9e∧(−4.9x) where x represents the index of the respondent and f(x) represents network size. Data approach horizontal asymptote at approximately 240 respondents.</p

HIV seroprevalence of MSM according to network predictions (dark line) of sex roles and self-report of sex role (red).

<p>The network predictions (black line) reveal higher HIV seroprevalence among receptive MSM and lower HIV seroprevalence among insertive MSM as compared to self-reported sex positions (dotted red line). These higher and lower HIV seroprevalence rates designated by network predictions match the direction in which biologic HIV transmission differences would confer HIV seroprevalence among receptive (black line is higher) and insertive (black line is lower) MSM.</p

Self-reported insertive only and receptive only sex behavior classified as versatile according to the network model.

<p>Versatile sex means engaging in both insertive and receptive anal sex. Respondents self-reporting insertive sex only were more likely to be classified as versatile by the network model. (τ) serves as a metric comparing proportions of insertive and receptive model predictions.</p

Sample recruitment schema of study respondents (n = 241), Southern India 2010.

<p>Non-respondents were eligible participants who did not present for informed consent at a nearby field office following field recruitment. Name interpreters are a series of questions asked about contact list members of respondents. In this case respondents identified contact list members as MSM or not MSM.</p

Subscriber Identity Module (SIM) card reader.

<p>The SIM card reader <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101416#pone.0101416-Adafruit1" target="_blank">[22]</a>, was assembled using a kit from Adafruit Industries (New York, NY). The card reader is operated by means of pySIM <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0101416#pone.0101416-pySIM1" target="_blank">[23]</a>, a free open-source SIM card-reading software package.</p