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Eastern J Med: 16 (2)
Volume: 16  Issue: 2 - 2011
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EDITÖRE MEKTUP
1.Social and behavioural research: tool for intensifying fight against AIDS in India
Nita Mawar, Ramesh S Paranjape, Mohamed Ejazuddin Khan
Pages 94 - 98
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ORIJINAL MAKALE
2.Understanding HIV epidemic in India: analyses of the HIV program data
Ruchi Sogarwal, Damodar Bachani, S. Venkatesh
Pages 99 - 106
We describe the current status of the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic among adults in India. Analyses of data relating to HIV positive persons aged 15 to 49 years as reported to the national HIV/AIDS Reporting System from the major states provide trends in HIV prevalence based on sentinel surveillance from 2004 through 2008. Analyses reveal that the number of HIV positive pregnant women had increased from 8991 in 2005 to 20027 in 2008. Five states (Maharashtra, Andhra Pradesh, Tamil Nadu, Karnataka and Gujarat) contributed 17097 (85%) of 20027 positive pregnant women identified in the same year. Seropositvity among general clients and pregnant women has declined from 11.55% to 5.33% and 0.77% to 0.43% from year 2005 to 2008, respectively. Five states of the southern and western region account for more than three-fourths of the volume of HIV infected persons. Government of India’s policy of categorizing districts and states based on prevalence and other program data appears justified. Study reveals success of NACP III in combating the HIV epidemic which is reflection of comprehensive evidence based planning which gives judicious focus on prevention but at the same time does not ignore care and treatment.

3.Integrated behavioral and biological assessment: methodological issues in social and behavioral research
Thilakavathi Subramanian, Lakshmi Ramakrishnan, Ramesh S. Paranjape
Pages 107 - 112
The IBBA round 1 was the first large-scale probability sample survey in India that included both behavioral and biological indicators among populations most at risk of HIV transmission. The survey was conducted in six endemic states: Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu, Manipur and Nagaland and among four segments of the National Highways. The IBBA collected data on prevalence of HIV and sexually transmitted infections, HIV risk behaviour and exposure to intervention programs, in a total of more than 25,000 respondents, over a 19 month period between November 2005 and June 2007, across 29 districts in India where Avahan program for these high risk groups were implemented. The survey was implemented by the respective state Indian Council of Medical Research institutes except in Karnataka where Karnataka Health Promotion Trust was responsible for IBBA. Methodological challenges related to social and behavioral areas faced during the implementation of IBBA in various areas like co-ordination of activities and proposed time line, identification and sampling of the target groups, establishment and feed back from the community board members, proper selection and setting up of temporary clinics, maintenance of quality control for both biological and behavioral data and how these challenges were handled are discussed in this paper.

4.Determinants of youth sexual behaviour: program implications for India
Beena Joshi, Sanjay Chauhan
Pages 113 - 121
The objective of this paper is to review the current trend of premarital sexual behaviour among youth in India and the factors influencing this behaviour. Studies done in India in the last two decades were considered for the review. However due to paucity of data it could not be a systematic review and data from other developing countries was considered for comparison. Available data indicates high level of premarital and unsafe sexual activity among youth in India. Limited evidence reveals that the risk and protective factors, which play a role in determining the sexual activity of youth in developing countries are different from those in the west and they are more centered on the youth themselves. Small-scale studies done in India also highlight the factors related to the environment such as peers and family apart from individual factors. However the review highlights the need to conduct large-scale representative studies to explore the comprehensive picture of risk and protective factors that could apply to the youth in India, which has a diverse socio-cultural milieu across regions. Programs must focus on the interventions, which improve the protective factors and reduce the risk factors and not focus only on risk awareness alone. Adolescent's access to friendly services and an enabling environment in the community can improve their health seeking behavior. However multiple players other than health sector such as education, media and social agencies need to work in unison to promote protective factors that prevent unwanted health outcomes due to unsafe premarital sex.

5.Correlates of sexual behaviour of rural college youth in Maharashtra, India
Mohan Ghule, Balaiah Donta
Pages 122 - 132
Although premarital sex relationships are widely discouraged in India, some youth do form such relationships. It is important to understand the nature and extent of youth sexual behaviour and examine the relationship between individual characteristics, knowledge and attitude towards reproductive health issues and sexual behaviour. In order to study the sexual behaviour of rural youth, quantitative data have been collected among 1500 students (800 male and 700 female) and qualitative data through 4 focus group discussions & 4 in-depth interviews, in the age group 15-24 years in Thane district of Maharashtra during 2005. Chi-square test and regression analysis was performed using the sexual experience (penetrative and non-penetrative sex) as the dependent variable to find out the association and relationship with individual characteristics (age, education, working status, peer interaction, erotic exposure, and habits), knowledge and attitude towards reproductive health issues. Boys and girls lacked scientific information and misconceptions are widespread on various reproductive health issues. Boys had more liberal attitudes towards premarital sex as compared to the girls. Proportion of students with any sexual experience (penetrative and non-penetrative sex) was much higher in boys (29.8%) compared to girls (4.9%). Around 11 percent boys and 1 percent girls who reported penetrative sex (vaginal, /oral / anal), around half of them did not use condom. Homosexual experience was reported by 11 percent boys and 3 percent girls. AIDS awareness was observed high (89% & 87 % respectively among boys and girls). However the knowledge of sexually transmitted diseases was limited. Exposure to alcohol, drugs, pornographic films, having more frequent interaction with peers and working status of the students were positively related with penetrative and non-penetrative sex relationships for both boys and girls. Over 83 percent youth expressed a need for interactive communication on reproductive health issues be available in their colleges. The rural youth engaged in penetrative sex and use condom inconsistently are at risk of STIs and HIV transmission to their partners. Findings underscore the need for sexual and reproductive health interventions to target not only young people but also their peers.

6.Social change communication: a panacea for HIV and AIDS?-An outlook of a program manager
Rajesh Gopal
Pages 133 - 136
For about three decades of the pandemic of HIV and AIDS, need for an effective response has been felt very strongly. Human behavior being complex; widespread behavior changes are challenging to achieve. Understanding of the dynamics of HIV transmission cannot be separated from an understanding of the broader context of poverty, inequality and social exclusion which create conditions under which unsafe behavior flourishes HIV/AIDS is not a mere health issue: its occurrence is influenced by a number of socio-economic, cultural and ecological determinants. Thus social change communication incorporating the enhanced behavior change communication emerges as an inclusive way of responding to HIV/AIDS issues. Social change communication can tackle structural drivers of the HIV epidemic, with a particular focus on the drivers of gender inequality, stigma, discrimination and denial and human rights violations. Based on his understanding of social change communication as a practitioner and an AIDS control program manager, the author examines whether the issues related to social change communication make it an effective instrument for the containment of HIV and AIDS.

7.Lessons learnt from ongoing counseling during follow-up visits by men and women attending a VCTC
Nita Mawar, Rajani Bagul, Suvarna Sane, Tuman Katendra, Srikanth Prasad Tripathy, Ramesh Shivram Paranjape
Pages 137 - 146
Documenting behavior change through ongoing counseling is critical when HIV counseling strategies are being formulated. This study aims to demonstrate risk reduction behavior in a year in the context of HIV related problems in men and women attending ongoing counseling at a Voluntary Counseling and Testing Centre during their regular follow-ups. This is a descriptive study based on one year observation of 253 HIV infected men (112) and women (141) attending a Voluntary Counseling and Testing Centre for ongoing counseling of a research institute in Pune during six-monthly follow-up visits. A face to face interview using a 22 item semi-structured questionnaire administered after an informed consent to collect data on sexual history since last visit, condom use, HIV related problems etc. SPSS and Pearson’s chi-square test Association was used. The HIV infected ever married men (91%) and women (98% married including widows) have significant differences with respect to age, marital status, occupation (p < 0.01), and similarity in education. There is an increase in condom usage with spouse with advancing follow-up i.e. increasing dose effect through ongoing counseling is observed, it being statistically significant for men (P value < 0.004). Consistent condom use with other partners is reported by men and widows. The participants reported problems ranging from health, economic, social, support issues like stigma and concerns of future. Economic problems are reported in those having frequent follow-ups, being more in men than women (34%, 29% resp.).An ongoing counseling of follow-up participants is a useful opportunity to reinforce behavior change, demonstrated by safer behaviors, especially reduction in partners, consistent condom use with spouse and other partners. The problems faced by HIV infected require support of Non- governmental organizations to address their problems like alternative source of incomes, health care, children’s education, and women’s right to property etc. Networking of Non- governmental organizations for support, capacity strengthening including gender sensitivity should go hand in hand with ongoing counseling to bring sustained behavior change when other interventions are planned for HIV infected persons.

8.Relationship between social factors and treatment adherence: a study from south India
Kidangazhiathmana Ajithkumar, Poovassery Govindhan Neera, Parassery Parameswaran Rajani
Pages 147 - 152
This study tries to assess the association of social factors and treatment adherence of people living with HIV/AIDS (PLHIV) in a south Indian ART clinic. Methods: 350 patients who completed at least one year of ART were included in the study. The data was collected using an interview schedule containing questions on personal, social and treatment factors of PLHIV. The results show that majority of PLHIV attending this clinic (84%) had good adherence. Factors such as older age (?40), female sex, absence of alcoholism, good family bonding, personal ability to follow treatment needs, having hope in life, absence of past history of psychiatric illness, presence of a care giver, having trust and faith in the care giver, having anxiety regarding the future of their family, good understanding of HIV disease and nuclear family were found to be associated with good adherence by univariate analysis and the first seven were associated with good adherence by multivariate analysis. This study highlights the importance of social factors which influence ART adherence in an Indian context. We suggest further studies of this kind to examine whether our findings can be generalized and be used in the national programme.

9.Mainstreaming gender in HIV programs: issues, challenges and way forward
Aprajita Mukherjee, Madhumita Das
Pages 153 - 159
It is increasingly being recognized that gender inequality is a critical factor fuelling the HIV epidemic in India and elsewhere in the world. To undertake a research and programmatic review to understand how gender has been integrated in existing HIV interventions in India and to highlight the challenges associated with gender mainstreaming to propose recommendations to fill the gaps. Review of literature both published and grey along with exploration of selected HIV program both HIV focused (targeted interventions) and non HIV focused programs interventions across the country. While gender mainstreaming as a process finds mention in program plans and priorities, efforts to operationalize gender within HIV prevention programs have not been easy. This is largely due to the structure of programs which are target driven and defined. While efforts to reduce structural vulnerability of women to HIV like violence against women have been introduced in some targeted interventions, they are largely perceived as ‘additional components’ which put emphasis on service delivery. The lack of gender sensitive indicators presents another challenge for most programs. To reduce the vulnerability and risk of women to HIV, current HIV programming in India should expand its focus from only ‘risk reduction’ to include ‘vulnerability reduction’ measures as well so that structural inequities that emanate from gendered relations are addressed within programs. In this effort, men along with women should be seen as allies leading this process. In addition, gender indicators should be developed that are mapped regularly along with service delivery indicators to measure impact of program. A robust monitoring and evaluation mechanism should be considered a critical part of project design and delivery.

10.HIV risk behavior and acceptability of microbicides in chennai, India
Suniti Solomon, Kathleen Morrow, AK Srikrishnan, Jessica Buck, Sreekanth Chaguturu, Rochelle Rosen, Rochelle D'Souza Yepthomi, Kenneth Mayer
Pages 160 - 167
To determine and compare the HIV/STI risk perceptions and behavior among men and women with traditionally high-risk and low-risk behavior in Chennai, India. To explore knowledge of HIV and Sexually transmitted infections (STI) and interest in and acceptability of potential microbicides and their characteristics in various subgroups. A cross-sectional survey investigating HIV knowledge, risk behavior and microbicide acceptability was conducted among 2072 participants. Participants were recruited from five target populations traditionally viewed as high- and low-risk: truck drivers, STI clinic patients, sex workers, married monogamous women, and the general population. Most participants were aware of HIV and its transmission routes, though many participants who engaged in risk behavior did not perceive themselves to be at risk for infection. Overall interest in microbicides was high. Most female participants reported willingness to use a microbicide to prevent HIV/STI transmission, but not pregnancy. Men were willing to let other sexual partners, but not primary partners, use microbicides to prevent HIV/STI. HIV/STI risk is high in men and women with high risk behavior as well as those generally considered low risk. Risk perceptions and condom use reflect concordance only in high-risk women. Interventions should be tailored to different subgroups of the population to improve accurate perceptions of risk while decreasing risky behaviors and promoting use of prevention methods and women’s ability to negotiate their use. Microbicides were acceptable in some situations, but not others. Microbicides should come in multiple formulations with and without contraceptive properties and interventions should target increasing acceptability within primary partnerships.

11.Engaging community to support HIV prevention research
Seema Sahay, Sanjay Mehendale
Pages 168 - 177
Actively engaging communities in effective partnerships is considered critical for ethically robust and locally relevant HIV prevention research. This can be challenging in developing countries that have little prior experience in this area. This paper summarizes processes and lessons learnt while setting up the Community Involvement Plan of National AIDS Research Institute, Pune, India. Formal partnerships were established with voluntary agencies. The focus was on using strategies adapted from participatory learning and action techniques. The community program was implemented through peer educators specifically identified from the communities where partner non-governmental organizations function. At the grass root level, peer educators imparted education to the common people about research studies and helped to implement community based recruitment and retention activities. The focus was on facilitating periodic interaction between the outreach workers of the research team and the peers and modifying the strategies till they were found locally implementable and appropriate. Through adequate time investment, mutually beneficial and respectful partnerships with community based organizations and grass root level workers, the community became actively involved in clinical research. The program helped in developing a sense of partnership among the peers for the research conducted by the research organization, widening the net of community education and identification of research participants. By building trust in the community and implementing research within an ethical framework, culturally sensitive matters were appropriately addressed. The community involvement process is long, laborious and ever-evolving. Effective community engagement requires institutional leadership support, adequate funding and commitment by researchers. It is possible to sustain such a model in a resource limited setting.



 
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