Suchergebnisse

BackgroundHIV/AIDS in India disproportionately affects women, not by their own risks, but by those of their partners, generally their spouses. We address two marginalized populations at elevated risk of acquiring HIV: women who are married to men who also have sex with men (MSM) and wives of injection drug users (IDUs).MethodsWe used a combination of focus groups (qualitative) and structured surveys (quantitative) to identify the risks that high‐risk men pose to their low‐risk wives and/or sexual partners. Married MSM were identified using respondent‐driven recruitment in Tamil Nadu, India, and were interviewed by trainer assessors. A sample of wives of injection drug users in Chennai were recruited from men enrolled in a cohort study of the epidemiology of drug use among IDUs in Chennai, and completed a face‐to‐face survey. Focus groups were held with all groups of study participants, and the outcomes transcribed and analyzed for major themes on family, HIV and issues related to stigma, discrimination and disclosure.ResultsUsing mixed‐methods research, married MSM are shown to not disclose their sexual practices to their wives, whether due to internalized homophobia, fear of stigma and discrimination, personal embarrassment or changing sexual mores. Married MSM in India largely follow the prevailing norm of marriage to the opposite sex and having a child to satisfy social pressures. Male IDUs cannot hide their drug use as easily as married MSM, but they also avoid disclosure. The majority of their wives learn of their drug‐using behaviour only after they are married, making them generally helpless to protect themselves. Fear of poverty and negative influences on children were the major impacts associated with continuing drug use.ConclusionsWe propose a research and prevention agenda to address the HIV risks encountered by families of high‐risk men in the Indian and other low‐ and middle‐income country contexts.

AbstractIntroductionThere are limited data on young people who inject drugs (PWID) from low‐ and middle‐income countries where injection drug use remains a key driver of new HIV infections. India has a diverse injection drug use epidemic and estimates suggest that at least half of PWID are ≤30 years of age. We compared injection and sexual risk behaviours and HIV incidence between younger and older PWID and characterized uptake of HIV testing and harm reduction services to inform targeted HIV prevention efforts.MethodsWe analysed cross‐sectional data from 14,381 PWID recruited from cities in the Northeast and North/Central regions of India in 2013 using respondent driven sampling (RDS). We compared "emerging‐adult" (18 to 24 years, 26% of sample) and "young‐adult" PWID (25 to 30 years, 30% of sample) to older PWID (>30 years, 44% of sample) using logistic regression to evaluate factors associated with three recent risk behaviours: needle‐sharing, multiple sexual partners and unprotected sex. We estimated age‐stratified cross‐sectional HIV incidence using a validated multi‐assay algorithm.ResultsCompared to older adults, emerging‐adults in the Northeastern states were significantly more likely to share needles (males adjusted odds ratio [aOR] 1.82; females aOR 2.29, p < 0.01), have multiple sexual partners (males aOR 1.56; females aOR 3.75, p < 0.01), and engage in unprotected sex (males aOR 2.29, p < 0.01). In the North/Central states, young‐adult males were significantly more likely to needle‐share (aOR 1.23, p < 0.05) while emerging‐adult males were significantly more likely to have multiple sexual partners (aOR 1.74, p < 0.05). In both regions, emerging‐adults had the lowest HIV testing. Participation in harm reduction services was low across all age groups. Annual HIV incidence was higher in emerging‐ and young‐adult PWID in the North/Central region: emerging‐adults: 4.3% (95% confidence interval [CI] 3.0, 5.6); young‐adults: 4.9% (95% CI 3.7, 6.2); older adults: 2.1% (95% CI 1.4, 2.8).ConclusionsHigher HIV incidence and engagement in risky behaviours among younger PWID compared to older PWID, coupled with low utilization of harm reduction services highlight the importance of targeting this population in HIV programming. Age‐specific interventions focused on addressing the needs of young PWID are urgently needed to curb the HIV epidemic in this vulnerable population.

AbstractIntroductionThe COVID‐19 pandemic has threatened to diminish gains in HIV epidemic control and impacts are likely most profound among key populations in resource‐limited settings. We aimed to understand the pandemic's impact on HIV‐related service utilization among men who have sex with men (MSM) and people who inject drugs (PWID) across India.MethodsBeginning in 2013, we established integrated care centres (ICCs) which provide HIV preventive and treatment services to MSM and PWID across 15 Indian sites. We examined utilization patterns for an 18‐month period covering 2 months preceding the pandemic (January–February 2020) and over the first and second COVID‐19 waves in India (March 2020–June 2021). We assessed: (1) unique clients accessing any ICC service, (2) ICC services provided, (3) unique clients tested for HIV and (4) HIV diagnoses and test positivity. Among an established cohort of PWID/MSM living with HIV (PLHIV), we administered a survey on the pandemic's impact on HIV care and treatment (June–August 2020).ResultsOverall, 13,854 unique clients visited an ICC from January 2020 to June 2021. In January/February 2020, the average monthly number of clients was 3761. Compared to pre‐pandemic levels, the number of clients receiving services declined sharply in March 2020, dropping to 25% of pre‐pandemic levels in April/May 2020 (first wave), followed by a slow rebound until April/May 2021 (second wave), when there was a 57% decline. HIV testing followed a similar trajectory. HIV test positivity changed over time, declining in the first wave and reaching its nadir around July 2020 at ∼50% of pre‐pandemic levels. Positivity then increased steadily, eventually becoming higher than pre‐pandemic periods. The second wave was associated with a decline in positivity for MSM but was relatively unchanged for PWID. Among 1650 PLHIV surveyed, 52% of PWID and 45% of MSM reported the pandemic impacted their ability to see an HIV provider. MSM had barriers accessing sexually transmitted infection testing and partner HIV testing.ConclusionsThe COVID‐19 pandemic led to significant decreases in HIV‐related service utilization among key populations in India. This presents an opportunity for increased transmission and patients presenting with advanced disease among groups already disproportionately impacted by HIV.

AbstractIntroductionGlobally, there have been significant declines in HIV incidence over the past two decades, but this decline is slowing, and in some settings, declines have stalled or are growing—particularly where epidemics are concentrated in key populations (KPs). Understanding temporal changes in HIV incidence among KP is critical yet, due to logistical constraints, there are few sources of longitudinal incidence data, particularly among KP.MethodsWe present HIV incidence rates from June 2014 to December 2022 among cisgender men who have sex with men (MSM) and people who inject drugs (PWID) attending community‐based integrated care centres (ICCs) in 15 Indian cities. ICCs, established between 2014 and 2017, provide HIV testing and other services to MSM (eight sites) or PWID (eight sites). Client HIV testing data were included in the analysis if they had ≥2 tests and were not positive on the first test. We calculated incidence rates per 100 person‐years (PY), stratified by KP, city/site and year. Poisson regression explored associations of incidence with time, age, gender (PWID only) and ICC use.ResultsFrom June 2014 to December 2022, 13,501 clients (5722 MSM, 7779 PWID) had ≥2 HIV tests over a median of 1.8 years. There were a total of 1093 incident HIV acquisitions. Overall incidence rates for MSM and PWID were 1.9/100 PY (95% CI: 1.7−2.2) and 4.1 (3.9−4.4), respectively. Among MSM sites, incidence ranged from 0.4 to 3.5 and in PWID sites from 0.6 to 17.9. From adjusted models, incidence increased by 17% annually among MSM. Among PWID, incidence increased by 11% annually up until 2020 and then decreased by 29% after 2020; when excluding the outlier of New Delhi, incidence was stable among PWID. MSM and PWID 21−25 years old had the highest risk of HIV and among PWID, those more consistently engaged in medication for opioid use disorder were at the lowest risk.ConclusionsWhile there was substantial geographic variability, MSM and PWID engaged in a free community‐based clinic experienced persistently high HIV incidence (>2/100 PY). KP in low‐ and middle‐income countries should be a focus when considering novel strategies such as long‐acting pre‐exposure prophylaxis to curtail incidence.

AbstractIntroductionInjection drug networks may influence their network members' health‐seeking behaviours. Using data from a sociometric injecting partner network of people who inject drugs (PWID) in New Delhi, India, we assessed the role of injecting partner (alter) behaviours on individual engagement in HIV prevention services.MethodsWe enumerated injecting partner linkages among 2512 PWID using coupon referrals and biometric data from November 2017 to March 2020. Participants completed interviewer‐administered questionnaires and provided information on injection behaviours, injecting partners, HIV/hepatitis C (HCV) testing and service engagement. Multilevel multiple‐membership models (MMMM) evaluated individual PWID HIV testing, medication for opioid use disorder (MOUD) and syringe service engagement as a function of alter attributes, accounting for membership across multiple ego‐networks. Logistic regression models assessed parallel associations among socially proximal injecting peers, defined as PWID ≤3 path length from ego.ResultsMedian age was 26 years; 99% were male. PWID had median 2 injecting partners and 8 socially proximal peers; 14% reported HIV testing, 33% accessed MOUD and 13% used syringe services 6 months prior. In MMMM analyses, PWID with ≥1 versus 0 injecting partners who received HIV testing were significantly more likely to report HIV testing (adjusted odds ratio [aOR]: 2.27, 95% confidence interval [CI]: 1.68–3.16), MOUD (aOR: 1.99, 95% CI: 1.60–2.53) and syringe service use (aOR: 1.66, 95% CI: 1.21–2.39). We observed similar findings for individual MOUD and syringe service use. Having ≥1 versus 0 HIV‐positive partners was associated with decreased HIV testing and MOUD but increased syringe service use (aOR: 1.54, 95% CI: 1.09–2.17). PWID with ≥1 versus 0 socially proximal peers who used non‐sterile injection equipment reported increased HIV testing (aOR: 1.39, 95% CI: 1.01–1.92), MOUD (aOR: 1.40, 95% CI: 1.10–1.77) and syringe service use (aOR: 1.82, 95% CI: 1.23–2.68).ConclusionsWe found differential associative relationships between individual HIV prevention service engagement and the health or risk behaviours of direct and indirect alters. Characterizing network exposure beyond direct injecting partnerships provided important context on possible mechanisms of behavioural influence. Findings could be leveraged to design peer‐based interventions that promote network diffusion of health‐seeking behaviours.

AbstractIntroductionThere are limited data on the impact of COVID‐19‐associated disruptions and novel HIV service delivery strategies among key populations (KPs) in low‐ and middle‐income countries. In March 2020, in response to COVID‐19, the Government of India revised HIV service delivery policies to include community antiretroviral therapy (ART) distribution and multi‐month dispensing (MMD) of ART for all people living with HIV (PLHIV).MethodsTo assess the acceptability of these adaptations and impact of the pandemic among KPs, we conducted focus groups in November–December 2020 with purposively sampled men who have sex with men (MSM), female sex workers (FSWs) and transgender women (TGW) in Telangana and Maharashtra. Seven discussions were conducted. Topics included HIV service access, risk behaviours, economic security and feedback to ensure service continuity. Inductive coding identified themes across topics.ResultsForty‐four individuals aged 20–49 years participated in discussions (13 MSM; 16 FSW; and 15 TGW). Twenty‐four participants self‐identified as living with HIV. People not living with HIV reported challenges in accessing HIV antibody testing at hospitals due to travel restrictions and fear of contracting COVID‐19. Participants accessed HIV antibody testing using transportation arranged by community‐based organizations after lockdowns eased. PLHIV reported uninterrupted ART refills and generally consistent adherence; however, there were experiences of delayed CD4 and HIV RNA testing. Participants shared appreciation for MMD as it saved time, money, and reduced exposure to COVID‐19. Participants expressed gratitude for home deliveries which enabled ART access, yet shared concerns about home‐based services causing confidentiality breaches with family/neighbours. Participants voiced preferences for community‐based service provision due to proximity, convenient hours, and welcoming environments compared to public hospitals. Other requests included support for income, employment, nutrient‐rich food and more accessible mental health, HIV, and other health services.ConclusionsCOVID‐19 restrictions had a greater impact on access to HIV antibody, CD4, and RNA testing services compared to ART access. High acceptance of MMD and community‐based services support the continued role of differentiated service delivery models to improve KP access to HIV antibody, CD4, RNA testing services, convenient ART retrieval, and integrated services beyond HIV, which may be critical for survival and wellbeing.

INTRODUCTION: There are limited data on the impact of COVID‐19‐associated disruptions and novel HIV service delivery strategies among key populations (KPs) in low‐ and middle‐income countries. In March 2020, in response to COVID‐19, the Government of India revised HIV service delivery policies to include community antiretroviral therapy (ART) distribution and multi‐month dispensing (MMD) of ART for all people living with HIV (PLHIV). METHODS: To assess the acceptability of these adaptations and impact of the pandemic among KPs, we conducted focus groups in November–December 2020 with purposively sampled men who have sex with men (MSM), female sex workers (FSWs) and transgender women (TGW) in Telangana and Maharashtra. Seven discussions were conducted. Topics included HIV service access, risk behaviours, economic security and feedback to ensure service continuity. Inductive coding identified themes across topics. RESULTS: Forty‐four individuals aged 20–49 years participated in discussions (13 MSM; 16 FSW; and 15 TGW). Twenty‐four participants self‐identified as living with HIV. People not living with HIV reported challenges in accessing HIV antibody testing at hospitals due to travel restrictions and fear of contracting COVID‐19. Participants accessed HIV antibody testing using transportation arranged by community‐based organizations after lockdowns eased. PLHIV reported uninterrupted ART refills and generally consistent adherence; however, there were experiences of delayed CD4 and HIV RNA testing. Participants shared appreciation for MMD as it saved time, money, and reduced exposure to COVID‐19. Participants expressed gratitude for home deliveries which enabled ART access, yet shared concerns about home‐based services causing confidentiality breaches with family/neighbours. Participants voiced preferences for community‐based service provision due to proximity, convenient hours, and welcoming environments compared to public hospitals. Other requests included support for income, employment, nutrient‐rich food and ...

BACKGROUND: We evaluated the effectiveness of integrated care centers (ICCs), which provided single-venue HIV testing, prevention, and treatment services for people who inject drugs (PWID) and men who have sex with men (MSM), in India. METHODS: We conducted baseline respondent-driven sampling (RDS) surveys in 27 sites across India, and selected 22 of these (12 PWID and 10 MSM) for a cluster randomised trial on the basis of high HIV prevalence and logistical considerations. We used stratified (PWID and MSM), restricted randomisation to allocate sites to either the ICC intervention or usual care (11 sites per arm). We implemented ICCs in 11 cities (6 PWID ICCs embedded within opioid agonist treatment centers and 5 MSM PWIDs embedded within locations of government-sponsored health services), with a single ICC per city in all but 1 city. After a 2-year intervention phase, we conducted evaluation RDS surveys of target population members 18 years or older at all sites. The primary outcome was self-reported HIV testing in the prior 12 months (recent testing) in the evaluation survey. We used a biometric identification system to estimate ICC exposure (visited an ICC at least once) among evaluation survey participants at intervention sites. This trial is registered with ClinicalTrials.gov (NCT01686750). FINDINGS: ICCs provided HIV testing for 14,689 unique clients during the intervention phase. In the evaluation phase (August 2016 to May 2017) we surveyed 11,721 PWID and 10,005 MSM participants using RDS. In the primary population-level analysis, recent HIV testing was 31% higher in ICC than usual care sites (adjusted prevalence ratio [aPR] 1·31, 95% confidence interval [CI] 0·95, 1·81, p=0·09). Among survey participants at intervention sites, ICC exposure was lower than expected (median exposure 40% at PWID sites and 24% at MSM sites). In intervention sites, survey participants who visited an ICC were 3·5-fold (95% CI 2·9, 4·1) more likely to report recent HIV testing than participants who had not. Post-hoc analyses ...