Comparison of prevention of parent-to-child HIV transmission programme & national biennial HIV sentinel surveillance data for tracking HIV epidemic in India

Background & objectives: HIV sentinel surveillance (HSS) among antenatal women in India has been used to track the epidemic for many years. However, reliable tracking at the local level is not possible as ANC sentinel sites are limited in number and cover a smaller sample size at each site. Prevention of parent-to-child-transmission (PPTCT) programme data has a potential advantage due to better geographical coverage, which could provide more precise HIV case estimates; therefore, we compared HSS ANC data with PPTCT programme data for HIV tracking. Methods: Out of the 499 surveillance sites, where HSS and PPTCT programme was being conducted in 2015, 210 sites (140 urban and 70 rural) were selected using a stratified random sampling method. HSS (n=72,981) and PPTCT (n=112,832) data records were linked confidentially. The sociodemographic characteristics of HSS and PPTCT attendees were compared. HIV prevalence from HSS ANC was compared with the PPTCT programme data using Chi-square test. State- and site-level correlation of HIV prevalence was also done. Concordance between HSS and PPTCT HIV positivity was estimated using kappa statistics. Results: The age distribution of HSS and PPTCT attendees was similar (range: 23 to 27 yr); however, HSS ANC participants were better educated, whereas PPTCT recorded a higher proportion of homemakers. The correlation of HIV prevalence between HSS and PPTCT was high (r=0.9) at the State level and moderate at the site level (r=0.7). The HIV positivity agreement between HSS ANC and PPTCT was good (kappa=0.633). A similar prevalence was reported across 26 States, whereas PPTCT had a significantly lower prevalence than HSS in three States where PPTCT coverage was low. Overall HIV prevalence was 0.31 per cent in HSS and 0.22 per cent in PPTCT (P<0.001). Interpretation & conclusions: High-quality PPTCT programme data can provide reliable HIV trends in India. An operational framework for PPTCT-based surveillance should be pilot-tested in a phased manner before replacing HSS with PPTCT.

Causes of death in rural adult population of North India (2002-2007), using verbal autopsy tool.

Background: With the on-going epidemiological transition, information on the pattern of mortality is important for health planning. Verbal autopsy (VA) is an established tool to ascertain the cause of death in areas where routine registration systems are incomplete or inaccurate. We estimated cause-specific mortality rates in rural adult population of 28 villages of Ballabgarh in North India using VA. Materials and Methods: During 2002-2007, trained multi-purpose health workers conducted 2294 VA interviews and underlying cause of death was coded by physicians. Proportional mortality (%) was calculated by dividing the number of deaths attributed to a specific cause by the total number of deaths for which a VA was carried out. Findings: 61% of deaths occurred among males and 59% occurred among those aged ≥60 years. The leading causes of death were diseases of the respiratory system (18.7%) and the circulatory system (18.1%). Infectious causes and injuries and other external causes, each accounted for around 15% of total deaths followed by neoplasms (6.8%) and diseases of the digestive system (4%). Among those 45 years of age, more than half of deaths were attributed to non-communicable diseases (NCDs) alone. Accidents and injuries were responsible for one-fourth of deaths in 15-30 years age group. Conclusion: NCDs and injuries are emerging as major causes of death in this region thereby posing newer challenges to public health system.

Public health approach to address maternal mortality.

Reducing maternal mortality is one of the major challenges to health systems worldwide, more so in developing countries that account for nearly 99% of these maternal deaths. Lack of a standard method for reporting of maternal death poses a major hurdle in making global comparisons. Currently much of the focus is on documenting the "number" of maternal deaths and delineating the "medical causes" behind these deaths. There is a need to acknowledge the social correlates of maternal deaths as well. Investigating and in-depth understanding of each maternal death can provide indications on practical ways of addressing the problem. Death of a mother has serious implications for the child as well as other family members and to prevent the same, a comprehensive approach is required. This could include providing essential maternal care, early management of complications and good quality intrapartum care through the involvement of skilled birth attendants. Ensuring the availability, affordability, and accessibility of quality maternal health services, including emergency obstetric care (EmOC) would prove pivotal in reducing the maternal deaths. To increase perceived seriousness of the community regarding maternal health, a well-structured awareness campaign is needed with importance be given to avoid adolescent pregnancy as well. Initiatives like Janani Surakhsha Yojna (JSY) that have the potential to improve maternal health needs to be strengthened. Quality assessments should form an essential part of all services that are directed toward improving maternal health. Further, emphasis needs to be given on research by involving multiple allied partners, with the aim to develop a prioritized, coordinated, and innovative research agenda for women's health.

ASHA’s Involvement in Newborn Care: A Feasibility Study.

We assessed the feasibility of involvement of Accredited Social Health Activist (ASHA) in newborn care. All the ASHAs (n = 33) of PHC Dayalpur, Faridabad district of Haryana were trained for one day which was followed by two refresher trainings. The mean (SD) knowledge score (out of 11) of ASHAs were 6.45 (2.44), 6.50 (2.01), 7.45 (1.36) and 7.15 (1.27) at pre-training, immediately after training, and after three and six months, respectively. Four fifth (83%) of the newborns born at home were weighed within 3 days of birth. About half (44%) of ASHAs weighed the neonates within ±250 grams of the weight recorded by the author. We conclude that ASHAs could be involved in providing care for newborn. However, such efforts should ensure a stronger focus on skill development and practical experience.

Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': A qualitative study in a low performing state of India.

Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.

A two-site hospital-based study on factors associated with nonadherence to highly active antiretroviral therapy.

Objectives : To describe the pattern of adherence to Highly Active Antiretroviral therapy (HAART) and ascertain the factor(s) associated with nonadherence. Methods: This was a cross-sectional, two-site, hospital-based study. The study was undertaken in 2005; as a result of phased roll out of free HAART as part of National AIDS Control Program, patients at Lok Nayak Jai Prakash (LNJP) hospital were receiving free HAART, while patients at All India Institute of Medical Sciences (AIIMS) had to bear out-of-pocket expenses for HAART. Adherence was defined as not having missed even a single pill over the previous 4-day period on self-reporting. Results: Adherence at AIIMS was 47%, whereas it was 90% at LNJP. The difference was statistically significant. Multivariate analysis showed that nonadherence was associated with not having been told about the importance of HAART, having to pay out-of-pocket for HAART and reported continued risk behavior post HAART. Conclusion: With the provision of free HAART, adherence is likely to be high. Emphasis should be given on simultaneous recruitment of counselors, and physicians should be made aware about the need to inquire and counsel patients against continued risk behavior.

Intensified pulse polio immunization: Time spent and cost incurred at a primary healthcare centre.

Background. Despite launching the polio eradication initiative in 1995, India is among the world’s largest reservoir of wild poliovirus with 559 cases of poliomyelitis reported in 2008. This continued failure has been criticised for its negative impact on routine healthcare delivery. We assessed the impact of the pulse polio immunization programme at the primary health level in terms of services, time and cost. Methods. All activities during a single round of intensified pulse polio immunization were modelled on actual requirements at the primary health centre at Dayalpur in Haryana. Total person-hours and cost per child vaccinated at the primary health centre were computed. Results. Almost all routine healthcare services at the primary health centre were suspended during the round. Total person-hours consumed were 4446 and the total direct cost was Rs 24.2 per child vaccinated during a single round of the intensified pulse polio immunization programme. Conclusion. A single round of intensified pulse polio immunization consumes a substantial number of person-hours and leads to a temporary suspension of routine services provided at the primary health centre. This should be factored in while planning any future strategy of polio eradication or control and suggests the need to re-think the ‘intensified pulse polio strategy’.

Linking undergraduate medical education to primary health care.

Under graduate medical education aims at producing doctors who are competent in preventive, promotive and curative knowledge and skills. The community medicine curriculum in All India Institute of Medical Sciences, New Delhi has been designed with this objective in view. Students are given community oriented training in urban and rural settings whereby students are taught to carry out various activities under the guidance of faculty members. This curriculum has evolved over many years and provides ample exposure to the students to understand the health problems, and health system of the country especially at the primary and secondary level. There is a sequential teaching of community medicine, which starts from fourth semester through internship. Successful training in community medicine lies outside the walls of the department and the involvement of other partners like the community, health systems etc contribute largely.