Cellulose sulfate did not prevent HIV infection and may have increased the risk of HIV acquisition. (ClinicalTrials.gov number, NCT00153777; and Current Controlled Trials number, ISRCTN95638385.)

In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state government's prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to accessing PPTCT services in the rural northern Karnataka district of Bagalkot using in depth interviews and focus group discussions with HIV-infected women who had participated in the PPTCT program, male and female family members, and HIV service providers. Participants discussed personal experiences, community perceptions of HIV, and decision-making related to accessing PPTCT services. They described stigma towards HIVinfected individuals from multiple sources: healthcare workers, community members, family and self. Stigma-related behaviors were based on fears of HIV transmission through personal contact and moral judgment. Experience and/or fears of discrimination led pregnant women to avoid using PPTCT interventions. Government, cultural and historical factors are described as the roots of much the stigma-related behavior in this setting. Based on these formative data, PPTCT program planners should consider further research and interventions aimed at diminishing institutional and interpersonal HIV-associated stigma experienced by pregnant women.

Understanding the burden and pattern of mental disorders as well as mapping the existing resources for delivery of mental health services in India, has been a felt need over decades. Recognizing this necessity, the Ministry of Health and Family Welfare, Government of India, commissioned the National Mental Health Survey (NMHS) in the year 2014–15. The NMHS aimed to estimate the prevalence and burden of mental health disorders in India and identify current treatment gaps, existing patterns of health-care seeking, service utilization patterns, along with an understanding of the impact and disability due to these disorders. This paper describes the design, steps and the methodology adopted for phase 1 of the NMHS conducted in India. The NMHS phase 1 covered a representative population of 39,532 from 12 states across 6 regions of India, namely, the states of Punjab and Uttar Pradesh (North); Tamil Nadu and Kerala (South); Jharkhand and West Bengal (East); Rajasthan and Gujarat (West); Madhya Pradesh and Chhattisgarh (Central) and Assam and Manipur (North East). The NMHS of India (2015–16) is a unique representative survey which adopted a uniform and standardized methodology which sought to overcome limitations of previous surveys. It employed a multi-stage, stratified, random cluster sampling technique, with random selection of clusters based on Probability Proportionate to Size. It was expected that the findings from the NMHS 2015–16 would reveal the burden of mental disorders, the magnitude of the treatment gap, existing challenges and prevailing barriers in the mental-health delivery systems in the country at a single point in time. It is hoped that the results of NMHS will provide the evidence to strengthen and implement mental health policies and programs in the near future and provide the rationale to enhance investment in mental health care in India. It is also hoped that the NMHS will provide a framework for conducting similar population based surveys on mental health and other public health problems in low and middle-income countries.

BackgroundGlobally, the routinely used case-based reporting and IgG serosurveys underestimate the actual prevalence of COVID-19. Simultaneous estimation of IgG antibodies and active SARS-CoV-2 markers can provide a more accurate estimation.MethodsA cross-sectional survey of 16416 people covering all risk groups was done between 3-16 September 2020 using the state of Karnataka’s infrastructure of 290 hospitals across all 30 districts. All participants were subjected to simultaneous detection of SARS-CoV-2 IgG using a commercial ELISA kit, SARS-CoV-2 antigen using a rapid antigen detection test (RAT), and reverse transcription-polymerase chain reaction (RT-PCR) for RNA detection. Maximum-likelihood estimation was used for joint estimation of the adjusted IgG, active, and total prevalence, while multinomial regression identified predictors.FindingsThe overall adjusted prevalence of COVID-19 in Karnataka was 27 ·3% (95% CI: 25 ·7-28 ·9), including IgG 16 ·4% (95% CI: 15 ·1 - 17 ·7) and active infection 12 ·7% (95% CI: 11 ·5-13 ·9). The case-to-infection ratio was 1:40, and the infection fatality rate was 0 ·05%. Influenza-like symptoms or contact with a COVID-19 positive patient are good predictors of active infection. The RAT kits had higher sensitivity (68%) in symptomatic participants compared to 47% in asymptomatic.InterpretationThis is the first comprehensive survey providing accurate estimates of the COVID-19 burden anywhere in the world. Further, our findings provide a reasonable approximation of population immunity threshold levels. Using the RAT kits and following the syndromic approach can be useful in screening and monitoring COVID-19. Leveraging existing surveillance platforms, coupled with appropriate methods and sampling framework, renders our model replicable in other settings.

This study compared rates of HIV-related sexual risk behaviours reported in individual face-to-face (FTFI) and group anonymous polling booth (PBS) interviews in India. In PBS, respondents grouped by gender and marital status answered yes/no questions by putting tokens with question numbers in colour-coded containers. Data were subsequently collated for each group as a whole, so responses were not traceable back to individuals. Male and female PBS participants reported substantially higher rates of pre-marital, extra-marital, commercial and anal sex than FTFI participants; e.g. 11 vs. 2% married males reported paying for sex; 6 vs. 1% unmarried males reported homosexual anal sex.

BackgroundIn the context of AVAHAN, the India AIDS Initiative of the Bill & Melinda Gates Foundation, general population surveys (GPS) were carried out between 2006 and 2008 in Belgaum (northern), Bellary (mid-state) and Mysore (southern) districts of Karnataka state, south India. Data from these three surveys were analysed to understand heterogeneity in HIV risk.MethodsOutcome variables were the prevalence of HIV and sexually transmitted infections (STIs). Independent variables included age, district, place of residence, along with socio-demographic, medical and behavioural characteristics. Multivariate logistic regression was undertaken to identify characteristics associated with HIV and differences between districts, incorporating survey statistics to consider weights and cluster effects.ResultsThe participation rate was 79.0% for the interview and 72.5% for providing a blood or urine sample that was tested for HIV. Belgaum had the highest overall HIV (1.43%) and Herpes simplex type-2 (HSV-2) (16.93%) prevalence, and the lowest prevalence of curable STIs. In Belgaum, the HIV epidemic is predominantly rural, and among women. In Bellary, the epidemic is predominantly in urban areas and among men, and HIV prevalence was 1.18%. Mysore had the lowest prevalence of HIV (0.80%) and HSV-2 (10.89%) and the highest prevalence of curable STIs. Higher HIV prevalence among men was associated with increasing age (p<0.001), and with history of STIs (AOR=2.44,95%CI:1.15-5.17). Male circumcision was associated with lower HIV prevalence (AOR=0.33,95%CI:0.13-0.81). Higher HIV prevalence among women was associated with age (AOR25-29years=11.22,95%CI:1.42-88.74, AOR30-34years=13.13,95%CI:1.67-103.19 and AOR35-39years=11.33,95%CI:1.32-96.83), having more than one lifetime sexual partner (AOR=4.61,95%CI:1.26-16.91) and having ever used a condom (AOR=3.32,95%CI:1.38-7.99). Having a dissolved marriage (being widowed/divorced/separated) was the strongest predictor (AOR=10.98,95%CI: 5.35-22.57) of HIV among women. Being a muslim woman was associated with lower HIV prevalence (AOR=0.27,95%CI:0.08-0.87).ConclusionThe HIV epidemic in Karnataka shows considerable heterogeneity, and there appears to be an increasing gradient in HIV prevalence from south to north. The sex work structure in the northern districts may explain the higher prevalence of HIV in northern Karnataka. The higher prevalence of HIV and HSV-2 and lower prevalence of curable STIs in Belgaum suggests a later epidemic phase. Similarly, higher prevalence of curable STIs and lower HIV and HSV-2 prevalence in Mysore suggests an early phase epidemic.

BackgroundHeterogeneity of the HIV epidemic across districts of south India is reflected in HIV positivity among antenatal clinic (ANC) attendees. Along with individual factors, contextual factors also need consideration for effective HIV interventions. Thus, identifying district and individual level factors that influence ANC HIV positivity assumes importance to intervene effectively.MethodsData on HIV sentinel surveillance among the ANC population were obtained from the National AIDS Control Organization (NACO) between years 2004 and 2007. Data from serial cross-sectional studies among female sex workers (FSWs) conducted during this time period in 24 districts were used to generate district level variables corresponding to parameters concerning this high risk population. Other district level data were obtained from various official/governmental agencies. Multilevel logistic regression was used to identify individual and district level factors associated with ANC-HIV positivity.ResultsThe average ANC-HIV prevalence from 2004 to 2007 in the 24 integrated biological and behavioural assessments (IBBA) districts ranged from 0.25 to 3.25%. HIV positivity was significantly higher among ANC women with age≥25 years [adjusted odds ratio (AOR):1.49; 95% confidence interval (95%CI):1.27 to 1.76] compared to those with age<25 years; illiterate (AOR:1.62; 95%CI:1.03 to 2.54) compared to literate; employed in agriculture (AOR:1.34; 95%CI:1.11 to 1.62) or with occupations like driver/helper/industry/factory workers/hotel staff (AOR:1.59; 95%CI:1.26 to 2.01) compared to unemployed. District level HIV prevalence among FSWs (AOR:1.03; 95%CI:1.0 to 1.05) and percentage women marrying under 18 years were significantly associated with ANC-HIV positivity (AOR:1.02; 95%CI:1.00 to 1.04).ConclusionIlliteracy of the woman, higher HIV prevalence among FSWs and early marriage were associated with HIV positivity among pregnant women in southern India. In addition to targeted HIV preventive interventions among FSWs, studying and changing the behavior of FSW clients and addressing structural drivers of the epidemic might indirectly help reduce HIV infection among women in southern India.

Although this analysis is limited by lack of precise comparative data on intervention coverage and intensity, it supports the notion that scaled-up, intensive, targeted HIV preventive interventions among high-risk groups can have a measurable and relatively rapid impact on HIV transmission in the general population, particularly young sexually active populations as represented by ANC attenders. Such focused intervention programmes should be rapidly taken to scale in all HIV epidemics, and especially in concentrated epidemics such as in India.