How reliable and valid are the self-reports of sexual behavior among HIV discordant couples in Pune, INDIA.

Reliability of self-reported sexual and safe sex behavior among heterosexual HIV discordant couples was assessed by matching individual responses of couples to a common set of questions and validated by matching with pregnancy and seroconversion during study period. Demographic, clinical and sexual behavior information was collected individually from 457 consenting married discordant couples using structured questionnaires at screening, enrollment and at four quarterly visits. Reliability of self-reports tested using Kappa statistics. At screening, level of agreement about spouse being regular partner (Kappa = 0.96) and having had sexual intercourse with spouse in the last quarter (Kappa = 0.84) was noted. Moderate agreement observed about frequency of condom use (Kappa = 0.639) and condom tear (Kappa = 0.428). Agreement on reporting sexual contacts with spouse and consistent condom use increased (P < 0.001) over follow-ups. Four of 6 couples that seroconverted reported using condoms consistently, and 2 of these seroconverted. Couple histories of all 11 sero-discordant couples reporting pregnancy matched, of these 8 couples reported use of condoms and only 3 couples reported non-use of condoms during the preceding period. Sensitive sexual information can be collected using self-reports but it should be used with caution. Involving couples and using biological parameters concurrently may enhance validity of self-reports.

Male circumcision for HIV prevention in India: emerging viewpoints and practices of health care providers.

A compelling case for promoting male circumcision (MC) as an intervention for reducing the risk of heterosexually acquired HIV infection was made by dissemination of the results of three studies in Africa. The WHO/UNAIDS recommendation for MC for countries like India, where the epidemic in concentrated in high-risk groups, advocates MC for specific population groups such as men at higher risk for HIV acquisition. A multicentre qualitative study was conducted in four geographically distinct districts (Belgaum, Kolkata, Meerut and Mumbai) in India during June 2009 to June 2011. Two categories of health care providers: Registered Healthcare Providers (RHCPs) and traditional circumcisers were interviewed by trained research staff who had received master's level education using interview guides with probes and open-ended questions. Respondents were selected using purposive sampling. A comparative analysis of the perspectives of the RHCP vs. traditional circumcisers is presented. Representatives of both categories of providers expressed the need for Indian data on MC. Providers feared that promoting circumcision might jeopardize/undermine the progress already made in the field of condom promotion. Reservation was expressed regarding its adoption by Hindus. Behavioural disinhibition was perceived as an important limitation. A contrast in the practice of circumcision was apparent between the traditional and the trained providers. MC should be mentioned as a part of comprehensive HIV prevention services in India that includes HIV counselling and testing, condom distribution and diagnosis and treatment of sexually transmitted infections. It should become an issue of informed personal choice rather than ethnic identity.

Feasibility of using partograph by practitioners of Indian system of medicine (AYUSH): An exploratory observation.

OBJECTIVE: to understand the use of the partograph by Skilled Birth Attendance/Basic Emergency Obstetric Care (SBA/BEmOC) trained practitioners from Indian systems of medicine called AYUSH practitioners (APs). DESIGN: mixed method observational study, including an exploration of the views of APs, programme managers and SBA trainers on the necessity, feasibility and barriers to the use of partograph. SETTING: primary and community health centres in two purposively selected districts in each of the three states (Rajasthan, Maharashtra and Odisha) in India where SBA/BEmOC trained APs are deployed to provide SBA services. In-depth interviews with state, district and block level programme managers were held at their respective headquarters. PARTICIPANTS: 83 APs plotted the simplified partograph based on a given labour case scenario. In-depth interviews were conducted with 36 programme managers and 37 APs (24 Ayurvedic and 13 Homoeopathic). MEASUREMENTS AND FINDINGS: the completed simplified partograph was analysed according to a previously devised scoring system with a score of 70% or more indicating competency. APs in Rajasthan and Maharashtra demonstrated good partograph plotting skills (72.1% and 82% respectively) obtaining a competency score of more than 70%. However, overall performance of APs in Odisha was poor (11.1%) and except correct recording of fetal condition, the APs did not score well in the plotting of the other partograph components. Errors occurred mainly in the recording of cervical dilatation and uterine contractions. The in-depth interviews revealed that most APs demonstrated a good understanding of the tool in the context of decision making regarding timely referral in case of prolonged labour or fetal distress. There was a high perception of the need for more hands-on training in the SBA training curriculum. The programme managers also expressed the need for appropriate training and supervision to ensure good plotting of partograph. The barriers for partograph use included increased workload, insufficient training, unavailability of partograph forms and its non-utility for women coming late in labour. KEY CONCLUSIONS: knowledge of plotting and correct interpretation of partograph were generally good in two states but more practice is needed to improve providers׳ skills. Identified barriers could be addressed with further training and local managerial support. An analysis of the causes for the poor performance of APs in Odisha should be carried out. Pre-service and periodic in-service training of APs on the completion of the partograph, regular supportive supervision, implementation of programme guidelines on mandatory completion of partograph and an environment that supports its correct and consistent use are recommended. IMPLICATIONS FOR PRACTICE: with appropriate training, it is feasible for AYUSH practitioners to use partograph for monitoring progress of labour.

Task-shifting challenges for provision of skilled birth attendance: a qualitative exploration.

BACKGROUND: Shortage of skilled birth attendants (SBA) is one of the determinants of maternal mortality in India. To combat this shortage, innovative task-shifting strategies to engage providers of the Indian system of medicine (Ayurveda and Homeopathy), called AYUSH practitioners (AP), to provide SBA services is being implemented. METHODS: Engagement of APs for SBA service provision was assessed in 3 states of India (Maharashtra, Rajasthan and Odisha) through 73 in-depth interviews (37 with APs and 36 with programme managers). The interviews explored the providers' SBA training experience, barriers for SBA service provision, workplace and community acceptance, and the perspective of programme managers on the competence and quality of SBA services provided. RESULTS: SBA training led to skill enhancement with adoption of appropriate maternal and newborn care practices. A dedicated trainer, more hands-on practice, and strengthening training on newborn care practices and management of complications emerged as the training needs. Conditional involvement in SBA-related work, a discriminatory attitude at the workplace and lack of legal/regulatory authorisation were identified as barriers to the inclusion of APs in SBA service provision. CONCLUSIONS: Quality skill enhancement measures, an enabling work environment, a systematic task-shifting process, role definition, supportive supervision and credentialing could be key for the integration of APs and their acceptance in the health system.

Correlates of lower comprehension of informed consent among participants enrolled in a cohort study in Pune, India.

BACKGROUND: Optimum comprehension of informed consent by research participants is essential yet challenging. This study explored correlates of lower comprehension of informed consent among 1334 participants of a cohort study aimed at estimating HIV incidence in Pune, India. METHODS: As part of the informed consent process, a structured comprehension tool was administered to study participants. Participants scoring ≥90% were categorised into the 'optimal comprehension group', whilst those scoring 80-89% were categorised into the 'lower comprehension group'. Data were analysed to identify sociodemographic and behavioural correlates of lower consent comprehension. RESULTS: The mean ± SD comprehension score was 94.4 ± 5.00%. Information pertaining to study-related risks was not comprehended by 61.7% of participants. HIV-negative men (adjusted OR [AOR] = 4.36, 95% CI 1.71-11.05) or HIV-negative women (AOR = 13.54, 95% CI 6.42-28.55), illiteracy (AOR= 1.65, 95% CI 1.19-2.30), those with a history of multiple partners (AOR = 1.73, 95% CI 1.12-2.66) and those never using condoms (AOR = 1.35, 95% CI 1.01-1.82) were more likely to have lower consent comprehension. CONCLUSIONS: We recommend exploration of domains of lower consent comprehension using a validated consent comprehension tool. Improved education in these specific domains would optimise consent comprehension among research participants.

Declining HIV incidence among patients attending sexually transmitted infection clinics in Pune, India.

OBJECTIVE: A recent report suggesting declining HIV transmission rates in southern India has been based on HIV seroprevalence data to estimate HIV incidence. We analyzed HIV incidence rates among 3 cohorts (male, female non-sex worker, female sex worker [FSW]) presenting to sexually transmitted infection (STI) clinics in Pune, India over 10 years. METHODS: Between 1993 and 2002, consenting HIV-uninfected individuals were enrolled in a prospective study of the risks for HIV seroconversion. Standardized HIV incidence estimates were calculated separately for the 3 cohorts. RESULTS: HIV acquisition risk declined by more than 70% for FSWs (P = 0.02) and men (P < 0.001) attending the STI clinics. There was no significant reduction in HIV incidence among women attending STI clinics (P = 0.74). The decline in HIVacquisition risk among male patients with STIs was associated with an increase in reported condom use with recent FSW contact and a decrease in genital ulcer disease. CONCLUSIONS: We report the first direct evidence for a decline in HIV incidence rates in FSWs and male patients with STIs over time. The lack of change in HIV infection risk among non-sex worker women highlights the need for additional targeted HIV prevention interventions.

Correlates and trend of HIV prevalence among female sex workers attending sexually transmitted disease clinics in Pune, India (1993-2002).

In India, substantial efforts have been made to increase awareness about HIV/AIDS among female sex workers (FSWs). We assessed the impact of awareness regarding safe sex in a cohort of FSWs by studying trends in HIV prevalence, sexually transmitted diseases (STDs), and risk behaviors measured from 1993 to 2002 in Pune, India. A total of 1359 FSWs attending 3 STD clinics were screened for HIV infection, and data on demographics, sexual behaviors, and past and current STDs were obtained. The overall HIV prevalence among FSWs was 54%. Not being married (adjusted odds ratio [AOR] = 1.74, 95% confidence interval [CI]: 1.17 to 2.59), being widowed (AOR = 2.10, 95% CI: 1.16 to 3.80), inconsistent condom use (AOR = 1.60, 95% CI: 1.02 to 2.50), clinical presence of genital ulcer disease (GUD; AOR = 1.66, 95% CI: 1.07 to 2.56), and genital warts (AOR = 4.70, 95% CI: 1.57 to 14.08) were independently associated with HIV infection among FSWs. The prevalence of HIV remained stable over 10 years (46% in 1993 and 50% in 2002; P = 0.80). The prevalence of GUD decreased over time (P < 0.001), whereas that of observed genital discharge remained stable. Reported consistent condom use as well as the proportion of FSWs who refused sexual contact without condoms increased over time (P < 0.001). These data collectively suggest that safe sex interventions have had a positive impact on FSWs in Pune, India.