A survey of MSM HIV prevention outreach workers in Chennai, India.

The present formative study sought to describe issues relevant to HIV prevention among men who have sex with men (MSM) in South India by surveying 62 MSM outreach workers from three non governmental organizations in Chennai. Although 92% reported having sex with men, only 74% identified as gay and 27% were married. Only half of these men reported having been tested for HIV. More than half of the sample reported that they would rather not know they had HIV until they were sick, and almost half indicated that they would rather end their life than live with the disease. Eighty-five percent of the sample reported having experienced varying levels of harassment from police, and 86% reported varying levels of harassment from others. These data point to several important barriers to HIV prevention among MSM in South India and lay the groundwork for enhancing the use of outreach workers to play a role in HIV prevention in this population.     

Alcohol use and HIV sexual risk among MSM in Chennai, India

Men who have sex with men (MSM) in India are a core risk group for HIV. Heavy alcohol consumption is associated with increased sexual risk-taking behaviours in many cultures, in particular among MSM. However, no studies to date have explored alcohol use and HIV risk among MSM in India. MSM in Chennai, India (n = 210) completed an interviewer-administered behavioural and psychosocial assessment. Bivariate and multivariable logistic regression procedures examined behavioural and demographic associations with weekly alcohol consumption. Twenty-eight percent of the sample (n = 58) reported using alcohol at least weekly to the point of being buzzed/intoxicated, which was associated with older age, being married to a woman, being panthi (masculine appearing, predominantly insertive partners) versus kothi (feminine acting/appearing and predominantly receptive partners), weekly tobacco use, unprotected anal sex and unprotected vaginal sex in the three months prior to study enrollment (all P < 0.05). In a multivariable model, unprotected vaginal sex in the previous three months and being married to a women were unique variables associated with weekly alcohol use (all P < 0.01). Further investigation of alcohol use within the context of sexual risk taking is warranted among Indian MSM. Panthis and MSM who are married to women may be particularly likely to benefit from interventions to decrease alcohol intake and concurrent unsafe sex.     

Reaching out beyond the hills: HIV prevention among injecting drug users in Manipur, India

Outreach interventions using ex-IDUs to inform and educate their peers about HIV/AIDS prevention measures have been found to be effective in the United States and other developed countries. While HIV/AIDS prevention programmes targeting IDUs have also been implemented in a number of developing countries, very little information is available on the process of implementation of these programmes. This paper attempts to document some of this knowledge by describing the implementation process of an outreach intervention targeting IDUs in a small town-Churachandpur-with high injection drug use and high HIV infection rates, in the north-eastern state of Manipur. The paper describes the barriers encountered in implementing the outreach and how these barriers were minimized. In conclusion, the paper makes the case for targeting outreach to the larger community before targeting the IDUs.     

Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai,South India

India's National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.     

A pilot study of the NGO-based relational intervention model for HIV prevention among drug users in China.

The rapid growth of the HIV epidemic in China has raised a number of concerns among health care providers, governmental agencies, and nongovernmental organizations (NGOs). This article (a) briefly discusses the HIV epidemic in China, (b) explains why Chinese NGOs need to join the fight against the epidemic, (c) describes the development of an indigenous culture-based model for use by NGOs to prevent HIV among injection drug users, and (d) discusses a Chinese NGO's experience in piloting the model. Data from the pilot study indicate that the model was successful in increasing knowledge about HIV/AIDS, increasing condom use, and decreasing needle and syringe sharing among a sample of female injection drug users (n = 100). The results of this study could have potential for other NGOs that are interested in adopting and adapting this model for HIV prevention.     

A controlled study of a spirituality-focused intervention for increasing motivation for HIV prevention among drug users.

Spiritual Self-Schema (3-S) therapy is a manual-guided intervention for increasing motivation for HIV prevention that integrates a cognitive model of self within a Buddhist framework suitable for people of all faiths. In this controlled study, 72 methadone-maintained clients received either standard care and 8 weeks of 3-S therapy, or standard care alone. At treatment completion, 3-S clients reported significantly greater increases in spiritual practices, expression of spiritual qualities, and motivation for HIV prevention. They were also less likely to have engaged in HIV risk behavior. Correlational analyses showed that attendance at 3-S therapy sessions was significantly positively related to spiritual practice at treatment completion and to motivation for HIV prevention, and that both attendance at 3-S sessions and motivation for HIV preventive behavior were significantly negatively related to HIV risk behavior. Completion of 3-S therapy predicted posttreatment HIV preventive behavior, controlling for pretreatment behavior, demographics, and addiction severity measures (odds ratio = 8.89; 95% confidence interval = 1.62-48.93).     

Dropout from care among HIV-infected patients enrolled in care at a tertiary HIV care center in Chennai,India

Long-term follow-up of persons infected with HIV infection is essential to optimize clinical outcomes. However, limited data exist on the rates of dropout (DO) from HIV care and factors associated with DO especially from resource-limited settings. We conducted a retrospective analysis of the data available at YRGCARE, a private HIV care provider in south India that has registered over 15,000 HIV-infected persons since its inception in 1993. We included 7995 patients who registered for care between 1 January 2004 and 31 December 2009. A dropout was defined as a person who registered for care during this period and had not been seen in the clinic for >1 year. Logistic regression was used to examine factors associated with DO from clinical care. The median age of the patients registered for care was 34 years; 66% were male and 83% were married. The overall DO rate was 38.1 per 100 person-years – the majority of the DOs occurred within 6 months from registration. In multivariate analyses, patients who were enrolled in clinical studies/projects entitling them to free medications and retention staff (Odds Ratio [OR]: 0.65) or were on antiretroviral therapy (ART; OR: 0.37) or had a CD4 > 350 at the last visit (OR: 0.20) were significantly less likely to DO from clinical care. We observed a high rate of DO from clinical care at this tertiary HIV clinic in Chennai, India. Making ART available free of charge in the private sector and providing incentives/benefits for attending clinic visits as is routinely done in clinical trials might help improve retention.     

Barriers and facilitators to antiretroviral medication adherence among patients with HIV in Chennai, India: a qualitative study

Antiretroviral therapy (ART) for HIV is increasingly being introduced and utilized in diverse areas of the world. However, little research exists on adherence to ART in different cultural settings, particularly in developing countries such as India. This formative qualitative study examined barriers and facilitators of ART adherence among 60 (49 men, 11 women; 33 taking ART, 27 not currently taking ART) patients receiving HIV primary care at YRG CARE, a nongovernmental organization, in Chennai, India. The average participant reported becoming HIV infected through heterosexual transmission, was between 31 and 40 years old, had over ninth class standard education, was married, and generally had access to medical care; however, we obtained some qualitative data from various other risk categories. Trained ethnographers at the study site conducted in-depth interviews in the local language. These interviews were analyzed for content and ethnographic data. Almost all of the participants discussed the cost of ART as a barrier, with many reporting extended drug holidays, turning to family and/or friends, or taking drastic measures (i.e., selling family jewels, property) for financial assistance. Other barriers centered on privacy and stigma issues, such as disclosure of HIV inhibiting pill-taking and social support. Frequently discussed facilitators of adherence included perceived benefits of ART and proper adherence, perceptions about the consequences of nonadherence, and social support, if available. These data highlight the importance of reducing the cost of antiretroviral medications, involving family members in HIV care, and addressing privacy issues and stigma in counseling interventions in this setting.     

The role of community consultants in designing an HIV prevention intervention.

This article describes the significant role of community members during the intervention development phase of a randomized clinical trial of an HIV prevention intervention for African American and Latina women and their main sexual partners. Sixteen women and 13 male partners were engaged as "consultants" in a series of focus group discussions aimed at exploring their reactions and ideas about potential topics and approaches for the intervention. Each individual participated in three focus groups-two single-sex groups and a third that brought women and their male partners together. Focus group data extended our knowledge about the impact of relationship dynamics on safer sex negotiation and allowed us to design an intervention that is contextually specific and pragmatic. Target community members can provide critical input during the intervention development process and should be recognized as viable and meaningful collaborators in all phases of intervention research.     

Correlates of HIV Testing Uptake among Kothi-Identified Men who have Sex with Men in Public Sex Environments in Chennai, India

Kothi-identified men who have sex with men in India are highly marginalized and are at high-risk for HIV. This study examines HIV testing among 132 self-reported HIV-negative and unknown serostatus kothis recruited from public sex environments in Chennai, India. Using logistic regression we identified variables associated with HIV testing uptake (i.e., being tested and knowing the result). Sixty-one percent reported HIV testing uptake. At the bivariate level, married men, those with low HIV transmission knowledge, those who engaged in unprotected anal sex and unprotected receptive anal sex were at lower odds of reporting testing uptake. In multivariate analysis, married men and those with low levels of HIV transmission knowledge were at decreased odds of being tested, as were kothis who experienced forced sex. Culturally competent programs engaging married kothis are needed. Interventions to facilitate HIV prevention education and systemic interventions to combat sexual violence may facilitate HIV testing uptake among kothis.     

Evaluation of an HIV prevention intervention for women living with HIV

ABSTRACT

It is estimated that 23% of the adults and adolescents living with HIV in the United States are female. The Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) funds evidence-based interventions (EBIs) to reduce HIV risk behaviors, including HIV prevention programs for people living with HIV and their partners. While EBIs have been shown to be effective in controlled research environments, there are limited data on intervention implementation in real-world settings. Women Involved in Life Learning from Other Women (WILLOW) is a four-session small-group intervention that targets heterosexual women aged 18–50 who are living with HIV. This evaluation assessed changes in participants’ HIV knowledge, attitudes, beliefs and risk behaviors. A repeated measures design was used to collect participant risk behaviors at baseline, and again at three and six months post-intervention. Changes in attitudes, beliefs, and risk behaviors were assessed using generalized estimating equations. After participation in WILLOW, participants reported increased HIV knowledge, attitudes and beliefs, being more supportive of condom use, and reduced prevalence of HIV risk behaviors. Findings suggest that the WILLOW intervention can be successfully delivered by community-based organizations to reduce HIV risk behaviors among members of this high-risk population.     

A certain fate: spread of HIV among young injecting drug users in Manipur, north-east India

This study aimed to measure risk behaviours and seroprevalence of HIV and hepatitis C virus in IDUs in Manipur, North-East India, and evaluate the impact of the recently established Syringe and Needle Exchange Program (SNEP). Sampling strategy was based on social networks. Peer interviewers administered the study questionnaire and collected blood for anti-HCV and anti-HIV testing. One hundred and ninety-one IDUs (85% male) took part. Average age at first injection was 19 years and average length of time injecting was 3.7 years. The main drug currently injected was heroin (66%). Most (93%) reported having shared injecting equipment and only 42% had used the SNEP. Three-quarters (74.7%) were infected with HIV and almost all (98%) with HCV. Age (p < 0.001) and length of time injecting (p < 0.001) were significantly associated with being HIV-positive. Over two-thirds were sexually active, but only 3% consistently used condoms. Almost three-quarters of IDUs in this study were infected with HIV, most within the first two years of injecting, indicating infection continues to spread at very high rates. Unsafe sexual practices place partners of infected IDUs at risk of infection. The SNEP must increase its coverage to young and new IDUs before they are exposed to blood-borne viruses.     

Effects of a cognitive-behavioral HIV prevention intervention among HIV negative male substance abusers in VA residential treatment.

This investigation compared the effectiveness of a cognitive-behavioral HIV risk reduction intervention with a standard care (SC) comparison condition in modifying HIV risk related knowledge, beliefs, attitudes, and behavior at 6-month and 12-month follow-ups among 149 HIV seronegative males. The two intervention conditions were administered while participants were in inpatient alcohol and other drug abuse treatment. Global drug abuse severity, as well as injection drug abuse, decreased significantly from preintervention to follow-up across conditions. There were significant increases in the proportions reporting sexual activity and increases in levels of unprotected sex acts between baseline and follow-up across conditions. However, no changes in sex risk behavior were found among those who reported sexual activity both prior to and after intervention across conditions. Participants revealed relatively adequate knowledge regarding HIV and HIV risk reduction practices, strong belief in the utility of safer practices and in their ability to enact such practices, and relatively strong commitment to practice safer sex across conditions at baseline assessment. In general, substantial postintervention improvements over baseline levels in these areas were not found. Relatively modest changes in sexual self-efficacy and in safe-sex guidelines were identified in analyses involving the total sample. Exploratory subgroup analysis suggested increases in knowledge and reductions in susceptibility and anxiety among those who reported sexual activity both prior to and after intervention. Among participants reporting initiation of sexual activity after intervention, those receiving SC revealed changes in perceived susceptibility and in condom attitudes. A discussion is presented of challenges associated with providing meaningful HIV risk reduction intervention when baseline levels of sex risk behavior, perceived HIV infection susceptibility, and HIV anxiety are only moderate and when initial levels of sexual self-efficacy and commitment are relatively high.     

High HIV Seropositivity at an Anonymous Testing Site in Chennai, India: Client Profile and Trends over Time

Despite the magnitude of the HIV epidemic in India, few centers exist that provide anonymous HIV testing that is also accompanied by adequate counseling and referral. This study describes the trends in demographic profiles, HIV serostatus, and risk factors among 1,745 male and female clients who accessed an anonymous counseling and testing center in Chennai, India from 1994 to 1998. The prevalence of HIV in this sample was 51%, indicating that the clinic is successful in its outreach to at-risk individuals. The increasing number of clients over time suggests that this clinic has been well-received by the community. Correlates of being HIV-positive included occasional condom use, being married, being referred by an HIV-positive sex partner, working as a truck driver or migrant, or having a spouse in these professions. The success of this clinic serves as a model for similar centers in India, and points to the widespread need for anonymous testing and counseling.