AIDS in India

Pediatric tuberculosis in India: Justice and human rights

Tuberculosis (TB) is the deadliest infectious disease across the world, with the greatest burden occurring in India. Pregnant women and children are especially vulnerable to adverse effects from infection, and they tend to have diminished ability to protect themselves. Malnutrition, HIV, and other causes of immune suppression such as exposure to air pollution make one more prone to serious illness or death from TB infection. Risk factors are influenced by maternal education, access to health care, poverty, nutrition, healthcare stigma, and sanitation, among others. Current literature is heavily clinical, lacking focus on upstream factors, with a skew toward secondary and tertiary prevention strategies (i.e., case finding and treatment), and less emphasis on primary prevention (e.g., wealth equity and environmental regulation). Given concerns with extremely drug resistant TB and because infectious diseases can permeate National borders, public health nurses, and other healthcare professionals must educate themselves and advocate on behalf of vulnerable populations such as children in India. Improved sanitation, air quality monitoring, women's education, and increased access to health care are cost-effective and evidence-based strategies to address pediatric TB in India, a challenge which is grounded in human rights and justice.

Apparel Consumption and Embodied Experiences of Gay Men and Transgender Women in India: Variety and Ambivalence, Fit Issues, LGBT-Fashion Brands, and Affordability

The purpose of this study was to explore Indian LGBT individuals' apparel consumption practices and embodied experiences related to fashion, style, and the body. Specifically, our research questions were these: What are Indian LGBT individuals' experiences like when navigating the fashion system, and how do they experience their own embodiment in what they wear and how they appear? A qualitative, phenomenological approach was used to answer the research questions. Three gay men and seven transgender women responded to a solicitation for participation and completed a semistructured interview. In our data analysis, we established four themes that relate to two larger areas of emphasis: embodiment and the fashion system. Regarding embodiment, participants related many experiences with their bodies, including (a) variety and ambivalence with bodily practices and (b) difficulty with clothing fit. The other themes centered around knowledge and desires related to the fashion system. Within the fashion system, participants expressed (a) fashion brand awareness and a need for LGBT-centered brands and (b) affordability as a barrier to clothing purchase. Overall, the essence of fashioning one's body as a transgender woman or gay man in India is that, while there has been a significant amount of gender oppression in India, these participants were interested in and desired gender-neutral or LGBT-focused brands.

Kaposi's sarcoma-associated herpesvirus related malignancy in India, a rare but emerging member to be considered

Kaposi's sarcoma-associated herpesvirus (KSHV) is associated with viral malignancy, related to HIV-AIDS. With a wide geographical discrimination in its occurrence, Asian countries shows low to moderate prevalence with higher occurrence in some particular areas. India is one of the largest countries in Asia, having various geographical and cultural variations where KSHV has been considered as an unthinkable entity to cause any of its associated disease. India has been reported as a low prevalent zone for KSHV malignancy till date. Also there are no reports so far, describing the occurrence pattern of this malignancy. So this review approaches towards figuring out the tendency of prevalence pattern of this malignancy and associated risk factors found to be present in Indian population. From this study it is revealed that, KSHV related malignancy is a relatively newly reported and emerging disease in India and may exist in hidden pockets throughout India in association with tuberculosis. India shows prevalence in HIV-associated Kaposi's sarcoma in regions where socially discriminated LGBT (lesbian, gay, bisexual, and transgender) groups, unprotected sexual behavior and heterosexuality are the important risk factors for sexually transmitted viral diseases. Anti-retro viral therapy is not sufficient to combat the virus and may act adversely. On a note regarding the clinical representations of Kaposi's sarcoma, oral, mucosal, pleural and abdominal involvements are observed in worst cases and these can be considered as the main manifesting criteria for this malignancy among Indians.

Oral health status and treatment needs among HIV/AIDS patients attending antiretroviral therapy center in Western India: A cross-sectional study

Aims and Objectives:

Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem across the globe. Among 37.9 million people are living with HIV in the world and 21.40 lakh are in India itself. The aim of this study was to assess the oral mucosal, periodontal, and dentition status of HIV/AIDS patients attending ART (antiretroviral therapy) center in Jaipur city, India.

Methods and Materials:

A total of 588 HIV/AIDS subjects at the ART center in Jaipur city were examined. Oral mucosal, periodontal, and dentition status was recorded using a modified WHO Oral Health Assessment form 1997. A pilot study was conducted among 50 patients. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20.0. The statistical tests that were applied for the analysis included Chi-square test, Fisher exact test, and one-way analysis of variance (ANOVA).

Results:

Of 588 study subjects examined, 65.6% were men and 34.4% were women. Candidiasis was the most prevalent oral lesion (32.5%) followed by acute necrotizing gingivitis (26%), hyper melanotic pigmentation (15.8%), and ulcerations (8.7%), respectively. Oral hairy leukoplakia was observed in only 3.9% and not a single case of Kaposi's sarcoma was reported. Buccal mucosa (36.7%) was the most common site of the presence of oral mucosal lesions. The mean decayed, missing, and filled teeth (DMFT) score was 4.03 ± 1.54. Almost all the subjects needed one or other form of dental treatment. Only 12% of the patients had healthy periodontium.

Conclusion:

Candidiasis was the most prevalent oral lesion. Efforts should be made to meet the increased treatment needs in these patients.

HIV/AIDS epidemic in West Bengal: An overview

Background

West Bengal is a low-prevalent state with high vulnerability for HIV. The state bears around 6% of HIV burden of India. With consistent effort on preventive, diagnostic, and curative services under National AIDS Control Program, HIV prevalence is gradually coming down. Our study objective is to determine the trend of HIV positivity among different groups/population attending Integrated Counseling and Testing Centres (ICTCs) over a period of 8 years and identify the group of population needing special attention.

Methods

The study was conducted with available program data year-wise from 2008-2009 to 2014-2015 among different groups of population who attended ICTCs for HIV testing. Year-wise positivity was calculated and trend analysis was performed by linear regression method keeping year as regressor. Similar methodology was applied for different typologies among the high-risk groups (HRGs) and trend analysis was done using linear regression for the study period from 2012-2013 to 2014-2015.

Results

HIV positivity among general male and non-pregnant individuals, HRG population, transgender (TG) population, and pregnant women showed a significant declining trend over the past 8 financial years, but the discordance rate remained almost the same. Regarding HIV positivity trend among different typologies of HRGs, trucker group showed a significant increase in HIV positivity over the past 3 years, whereas HIV positivity among other groups like female sex workers, men having sex with men, injecting drug users, and migrant labors did not undergo significant changes over the past 3 years.

Conclusion

HIV-preventive services among truckers need to be emphasized. HIV screening services among the TG population should be further scaled up through more number of targeted interventions.

Social Determinants of Infectious Diseases in South Asia

South Asian countries have developed infectious disease control programs such as routine immunization, vaccination, and the provision of essential drugs which are operating nationwide in cooperation with many local and foreign NGOs. Most South Asian countries have a relatively low prevalence of HIV/AIDS until now, but issues like poverty, food insecurity, illiteracy, poor sanitation, and social stigma around AIDS are widespread and are creating formidable challenges to prevention of further spread of this epidemic. Besides that, resurgence of tuberculosis along with the emergence of the drug resistant (MDR-TB and XDRTB) strains and the coepidemic of TB and HIV are posing ever-growing threats to the underdeveloped healthcare infrastructure. The countries are undergoing an epidemiological transition where the disease burden is gradually shifting to noncommunicable diseases, but the infectious diseases still account for almost half of the total disease burden. Despite this huge burden of infectious diseases in South Asia, which is second only to Africa, there is yet any study on the social determinants of infectious diseases in a local context. This paper examines various issues surrounding the social determinants of infectious diseases in South Asian countries with a special reference to HIV and tuberculosis. And, by doing so, it attempts to provide a framework for formulating more efficient prevention and intervention strategies for the future.

Adherence to antiretroviral therapy in India: a systematic review and meta-analysis

OBJECTIVE

To assess the adherence to antiretroviral therapy (ART) in the human immunodeficiency virus (HIV)-infected population in India.

DESIGN

Systematic review and meta-analysis.

MATERIALS AND METHODS

The Medline and Cochrane library database were searched. Any prospective or retrospective study enrolling a minimum of 10 subjects with a primary objective of assessing ART adherence in the HIV population in India was included. Data were extracted on adherence definition, adherence estimates, study design, study population characteristics, recall period and assessment method. For metaanalysis, the pooled proportion was calculated as a back-transform of the weighted mean of the transformed proportions (calculated according to the Freeman-Tukey variant of the arcsine square root) using the random effects model.

RESULTS

There were seven cross-sectional studies and one retrospective study enrolling 1666 participants. Publication bias was significant (P = 0.003). Pooled results showed an ART adherence rate of 70% (95% confidence interval: 59-81%, I(2) = 96.3%). Sensitivity analyses based on study design, adherence assessment method and study region did not influence adherence estimates. Fifty percent (4/8) of the studies reported cost of medication as the most common obstacle for ART adherence. Twenty-five percent (2/8) reported lack of access to medication as the reason for non-adherence and 12% (1/8) cited adverse events as the most prevalent reason for non-adherence. The overall methodological quality of the included studies was poor.

CONCLUSION

Pooled results show that overall ART adherence in India is below the required levels to have an optimal treatment effect. The quality of studies is poor and cannot be used to guide policies to improve ART adherence.

Immunologic response among HIV-infected patients enrolled in a graduated cost-recovery programme of antiretroviral therapy delivery in Chennai, India

BACKGROUND & OBJECTIVES

Sustainability of free antiretroviral therapy (ART) roll out programmes in resource-limited settings is challenging given the need for lifelong therapy and lack of effective vaccine. This study was undertaken to compare treatment outcomes among HIV-infected patients enrolled in a graduated cost-recovery programme of ART delivery in Chennai, India.

METHODS

Financial status of patients accessing care at a tertiary care centre, YRGCARE, Chennai, was assessed using an economic survey; patients were distributed into tiers 1- 4 requiring them to pay 0, 50, 75 or 100 per cent of their medication costs, respectively. A total of 1754 participants (ART naοve = 244) were enrolled from February 2005-January 2008 with the following distribution: tier 1=371; tier 2=338; tier 3=693; tier 4=352. Linear regression models with generalized estimating equations were used to examine immunological response among patients across the four tiers.

RESULTS

Median age was 34; 73 per cent were male, and the majority were on nevirapine-based regimens. Median follow up was 11.1 months. The mean increase in CD4 cell count within the 1 st three months of HAART was 50.3 cells/μl per month in tier 1. Compared to those in tier 1, persons in tiers 2, 3 and 4 had comparable increases (49.7, 57.0, and 50.9 cells/μl per month, respectively). Increases in subsequent periods (3-18 and >18 months) were also comparable across tiers. No differential CD4 gains across tiers were observed when the analysis was restricted to patients initiating ART under the GCR programme.

INTERPRETATION & CONCLUSIONS

This ART delivery model was associated with significant CD4 gains with no observable difference by how much patients paid. Importantly, gains were comparable to those in other free rollout programmes. Additional cost-effectiveness analyses and mathematical modelling would be needed to determine whether such a delivery programme is a sustainable alternative to free ART programmes.

Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India

Background

Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.

Methods

We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population (“national population”), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for “cost-effective” was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for “very cost-effective” was <1x the annual per capita GDP ($1,300/YLS).

Results

Compared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.

Conclusions

In India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.

Incidence of multiple Herpesvirus infection in HIV seropositive patients, a big concern for Eastern Indian scenario

BACKGROUND

Human immunodeficiency virus (HIV) infection is associated with an increased risk for human herpes viruses (HHVs) and their related diseases and they frequently cause disease deterioration and therapeutic failures. Methods for limiting the transmission of HHVs require a better understanding of the incidence and infectivity of oral HHVs in HIV-infected patients. This study was designed to determine the seroprevalence of human herpes viruses (CMV, HSV 2, EBV-1, VZV) antibodies and to evaluate their association with age, sex as well as other demographic and behavioral factors.

RESULTS

A study of 200 HIV positive patients from Eastern India attending the Calcutta Medical College Hospital, Kolkata, West Bengal, Apex Clinic, Calcutta Medical College Hospital and ART Center, School of Tropical Medicine, Kolkata, West Bengal was done. Serum samples were screened for antibodies to the respective viruses using the indirect ELISA in triplicates.CytoMegalo virus (CMV), Herpes Simplex virus type 2 (HSV-2), Varicella Zoster virus (VZV), and Epstein Barr virus (EBV-1) were detected in 49%, 47%, 32.5%, and 26% respectively.

CONCLUSION

This study has contributed baseline data and provided insights in viral OI and HIV co-infection in Eastern India. This would undoubtedly serve as a basis for further studies on this topic.

Mortality among injection drug users in Chennai, India (2005-2008)

BACKGROUND

Injection drug users (IDUs) have estimated mortality rates over 10 times higher than the general population; much of this excess mortality is HIV-associated. Few mortality estimates among IDUs from developing countries, including India, exist.

METHODS

IDUs (1158) were recruited in Chennai from April 2005 to May 2006; 293 were HIV positive. Information on deaths and causes was obtained through outreach workers and family/network members. Mortality rates and standardized mortality ratios were calculated; multivariate Poisson regression was used to identify predictors of mortality.

RESULTS

We observed 85 deaths over 1998 person-years (p-y) of follow-up [mortality rate (MR) 4.25 per 100 p-y; 95% confidence interval (CI) = 3.41-5.23]. The overall standardized mortality ratio was 11.1; for HIV-positive IDUs, the standardized mortality ratio was 23.9. Mortality risk among HIV-positive IDUs (MR: 8.88 per 100 p-y) was nearly three times that of negative IDUs (MR: 3.03 per 100 p-y) and increased with declining immune status (CD4 cells > 350: 5.44 per 100 p-y vs. CD4 cells < or = 200: 34.5 per 100 p-y). This association persisted after adjustment for confounders. The leading causes of mortality in both HIV negative and positive IDUs were overdose (n = 22), AIDS (n = 14), tuberculosis (n = 8) and accident/trauma (n = 9).

CONCLUSION

Substantial mortality was observed in this cohort with the highest rates among HIV-positive IDUs with CD4 counts of less than 350 cells/microl. Although, in these 2 years, non-AIDS deaths outnumbered 0002030-related deaths, the relative contribution of 0002030-associated mortality is likely to increase with advancing HIV disease progression. These data reinforce the need for interventions to reduce the harms associated with drug use and increase HAART access among IDUs in Chennai.

Use of an HIV-1 reverse-transcriptase enzyme-activity assay to measure HIV-1 viral load as a potential alternative to nucleic acid-based assay for monitoring antiretroviral therapy in resource-limited settings

An inexpensive and technically less-demanding methodology to quantify HIV-1 viral load would be of great value for resource-limited settings, where the nucleic-acid amplification technique (NAAT) is impractical and/or resource-prohibitive. In this study, an HIV-1 reverse-transcriptase enzyme-activity assay (ExaVir Load assay, version 1) was compared with the gold standard RT-PCR assay, Roche HIV-1 Amplicor Monitor, version 1.5. A total of 121 plasma specimens were used for the evaluation. ExaVir Load had a sensitivity of 97 % and a specificity of 71 % in identifying specimens with <400 copies ml−1 in the Roche RT-PCR assay as being less than the detection limit of the assay (5500 copies ml−1). The mean difference (95 % limits of agreement) between Roche RT-PCR and ExaVir Load was –0.23 (−1.59 to 1.13) log10(copies ml−1) by Bland–Altman analysis. Significant negative correlations were seen between CD4+ T-cell counts and the ExaVir Load assay (r=−0.32, P<0.05), and between CD4+ T-cell counts and the Roche RT-PCR (r=−0.38, P<0.01). The present study with HIV-1 showed a strong correlation between the ExaVir Load assay and the RT-PCR assay. Hence, the ExaVir Load assay could be considered for use in resource-limited settings as an alternative viral-load assay to the standard NAAT-based assay after further evaluation with prospective specimens.

Financial burden of health services for people with HIV/AIDS in India

In resource-limited settings, illness can impose a major financial burden on patients and their families. With the advent and increasing accessibility of antiretroviral therapy, HIV/AIDS has now become a fundamentally chronic treatable disease with far reaching economic and social consequences, and hence it is crucial to also examine the long-term financial impact of HIV healthcare. Beyond the direct costs of medications, monitoring, and medical care, additional costs include the long-term lost earnings of HIV-infected individuals as well as of their household members who also provide care. A clearer understanding of the financial burden of healthcare for HIV-infected Indians can allow policy makers and planners to better allocate limited resources. This article reviews the financial consequences of HIV care and treatment on individuals and their households by examining current treatment options, HIV monitoring, the clinical course of HIV disease, and the roles of the private and public sector in providing HIV care in India. Future studies should more thoroughly examine the financial impact of HIV-related costs incurred by households over time and examine household responses to these costs.