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Despite the challenges, the integrated biobehavioural assessment was a huge achievement, and was largely successful in providing previously unavailable information about the HIV situation among populations that are critical to the curtailment of HIV spread in India. Lessons from the first round will be used to evolve the second round into an exercise with increased evaluative capability for Avahan.

Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.

We explore the magnitude of and current trends in HIV infection among people who inject drugs and estimate the reach of harm reduction interventions among them in seven high-burden countries of the South-East Asia Region. Our data are drawn from the published and unpublished literature, routine national HIV serological and behavioural surveillance surveys and information from key informants. Six countries (Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh) had significant epidemics of HIV among people who inject drugs. In Thailand, Indonesia, Bangladesh, Myanmar and India, there is no significant decline in the prevalence of HIV epidemics in this population. In Nepal, north-east India, and some cities in Myanmar, there is some evidence of decline in risk behaviours and a concomitant decline in HIV prevalence. This is countered by the rapid emergence of epidemics in new geographical pockets. Available programme data suggest that less than 12 000 of the estimated 800 000 (1.5%) people who inject drugs have access to opioid substitution therapy, and 20-25% were reached by needle-syringe programmes at least once during the past 12 months. A mapping of harm reduction interventions suggests a lack of congruence between the location of established and emerging epidemics and the availability of scaled-up prevention services. Harm reduction interventions in closed settings are almost nonexistent. To achieve significant impact on the HIV epidemics among this population, governments, specifically national AIDS programmes, urgently need to scale up needle-syringe programmes and opioid substitution therapy and make these widely available both in community and closed settings.

Background: Migration, population mobility, and sex work continue to drive sexually transmitted epidemics in India. Yet interventions targeting high incidence networks are rarely implemented at sufficient scale to have impact. India AIDS Initiative (Avahan), funded by the Bill and Melinda Gates Foundation, is scaling up interventions with sex workers (SWs) and other high risk populations in India's six highest HIV prevalence states. Methods: Avahan resources are channelled through state level partners (SLPs) to local level nongovernmental organisations (NGOs) who organise outreach, community mobilisation, and dedicated clinics for SWs. These clinics provide services for sexually transmitted infections (STIs) including Condom Promotion, syndromic case management, regular check-ups, and treatment of asymptomatic infections. SWs take an active role in service delivery. STI capacity building support functions on three levels. A central capacity building team developed guidelines and standards, trains state level STI coordinators, monitors outcomes, and conducts operations research. Standards are documented in an Avahan-wide manual. State level STI coordinators train NGO clinic staff and conduct supervision of clinics based on these standards and related quality monitoring tools. Clinic and outreach staff report on indicators that guide additional capacity building inputs. Results: In 2 years, clinics with community outreach for SWs have been established in 274 settings covering 77 districts. Mapping and size estimation have identified 187 000 SWs. In a subset of four large states covered by six SLPs (183 000 estimated SWs, 65 districts), 128 326 (70%) of the SWs have been contacted through peer outreach and 74 265 (41%) have attended the clinic at least once. A total of 127 630 clinic visits have been reported, an increasing proportion for recommended routine check ups. Supervision and monitoring facilitate standardisation of services across sites. Conclusion: Targeted HIV/STI interventions can be brought to scale and standardised given adequate capacity building support. Intervention coverage, service utilisation, and quality are key parameters that should be monitored and progressively improved with active involvement of SWs themselves.

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In most countries, the burden of HIV among people who inject drugs, men who have sex with men, and sex workers is disproportionately high compared with that in the general population. Meanwhile, coverage rates of effective interventions among those key populations (KPs) are extremely low, despite a strong evidence base about the effectiveness of currently available interventions. In its first decade, President's Emergency Plan for AIDS Relief (PEPFAR) is making progress in responding to HIV/AIDS, its risk factors, and the needs of KPs. Recent surveillance, surveys, and size estimation activities are helping PEPFAR country programs better estimate the HIV disease burden, understand risk behavior trends, and determine coverage and resources required for appropriate scale-up of services for KPs. To expand country planning of programs to further reduce HIV burden and increase coverage among KPs, PEPFAR has developed a strategy consisting of technical documents on the prevention of HIV among people who inject drugs (July 2010) and prevention of HIV among men who have sex with men (May 2011), linked with regional meetings and assistance visits to guide the adoption and scale-up of comprehensive packages of evidence-based prevention services for KPs. The implementation and scaling up of available and targeted interventions adapted for KPs are important steps in gaining better control over the spread and impact of HIV/AIDS among these populations.

The objective was to evaluate the association between antiretroviral therapy and AIDS mortality in New York City (NYC). Design was a population-based case-control study. We randomly selected 150 case patients and 150 control patients whose AIDS diagnosis was made during 1994 to 1996 (male : female, 2 : 1) from among 19,238 persons reported to the NYC Health Department HIV/AIDS Reporting System (HARS). Case patients had died of AIDS-related causes in 1996. Control patients, category matched with case patients on gender, were not known to have died by the end of 1996. Analysis was performed on 279 patients (142 cases and 137 controls). Cases and controls were similar in age, gender, race, HIV transmission category, and health insurance coverage. The median baseline CD4 count was 30 cells/~L for those who died and 103 cells/~L for survivors (p < .0.001). The prescription of HAART (antiretroviral combination that includes at least one protease inhibitor) in 1996 was strongly associated with survival in univariate analysis (OR = 5.1, 95%CI = 2.5-10.2). This association remained in a logistic regression analysis after adjusting for sex, age, race, health insurance status, HIV transmission categories, year of AIDS diagnosis, baseline CD4 count, and other antiretroviral therapy (AOR = 8.6, 95%CI = 3.5-20.7). Prescription of combination therapy other than HAART in 1996 and baseline CD4 count were also associated with survival, but less strongly so. The survival benefit of HAART extends beyond the confines of a few highly selected patients into the "real world," reducing AIDS deaths at the population level. This population-based study sup-