Background: The mobilization of resources to prevent and treat human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is unparalleled in the history of public health. The uptake of antiretroviral therapy (ART) has been rapid and unprecedented and made possible by the availability of funding – external and domestic. To justify continuous funding of ART in resource-scarce settings, a spate of cost-effectiveness studies has been undertaken in a number of countries. This paper is based on a systematic review of global studies on cost-effectiveness analysis of ART. Objectives: The major objective was to review the existing literature on cost-effectiveness of ART to determine whether ART has been cost-effective (CE) in different settings. Methods: We searched PubMed and Google Scholar for articles published between 2008 and 2017. We included studies that measured costs as well as effectiveness of HIV treatment – specifically ART – using incremental cost-effectiveness ratio as one of the outcomes. Results: We identified 15 studies that met the search criteria for inclusion in the systematic review. The review confirms that ART programs have been CE across different settings, contexts, and strategies. Conclusion: The review would be useful for countries that are straining to raise funds for the health sector, generally, and for AIDS prevention and control program, specifically. This would also be beneficial for carrying out similar studies, if necessary, and as an advocacy tool for garnering additional funding.

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People living with HIV are gradually getting older as a result of better survival with increased uptake of antiretroviral treatment in India. We aimed to quantify the aging HIV-infected population in India by undertaking a mathematical model analysis of 2017 rounds of HIV burden estimations under the National AIDS Control Programme. Our analysis projects that the mean age of HIV-infected people will increase from 38.4 years in 2005 to 45.5 years in 2025 with the proportion of HIV-infected people aged 50 years or older increasing from 19% in 2005 to 37% in 2025. This aging HIV epidemic is anticipated to lead to more non-AIDS morbidities, increased treatment complexity, and an inevitable need for multidisciplinary health-care services to ensure continued high-quality survival.

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Background: Hijra or transgender (H/TG) people are significantly affected by HIV in India. HIV prevalence among H/TG is the second highest after people who inject drugs. Effective interventions require understanding about various risk behaviors and associated factors for high prevalence. Objectives: This study analyzes the known risk behaviors and vulnerabilities of HIV-positive and HIV-negative H/TG people to identify the determinants of HIV seropositivity in this high-risk group. Methods: Using secondary data from India's 2014 to 2015 Integrated Biological and Behavioural Surveillance survey, this analysis was conducted among 3325 H/TG people across seven states. Probability-based sampling methods were used to recruit H/TG people. Informed consent was obtained for the collection of behavioral information and blood samples for HIV testing. Multivariable binary logistic regression analysis was undertaken to identify the determinants of HIV seropositivity. Results: HIV prevalence for this group of respondents was 9.5%. Multivariable analysis of survey data revealed higher odds of HIV infection if H/TG had regular male partners (adjusted odds ratio [AOR]: 1.81, confidence interval [CI]: 1.07–3.06), were living in the states of Maharashtra (AOR: 6.08, CI: 3.02–12.22) and Odisha (AOR: 2.91, CI: 1.05–8.06), and were members of self-help groups (AOR: 2.08, CI: 1.04–4.14). None of the demographic or behavioral correlates of risk were found to be associated with HIV infection. Conclusion: The findings suggest that community and structural factors, which are inadequately covered in surveys such as IBBS, play a more important role than individual behavioral factors.

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Background: Quality of HIV sentinel surveillance (HSS) depends on preparedness of the site and adherence to the standard operating procedures (SOPs) for HSS. A designated sentinel site is considered prepared for the round of sentinel surveillance based on the availability of infrastructure, human resource, and consumables. Objectives: The study objectives were to describe the site level preparedness and adherence to SOP of antenatal care clinic (ANC) sites during the 16^th round of HSS in India. Methods: This was a cross-sectional study based on the findings of the supervisory visits conducted by public health specialists in ANC sites during the 16^th round of HSS from January to March 2019. Semi-structured checklists were used to assess site-preparedness and adherence to the SOP for HSS. All supervisors were expected to upload the filled pro forma to the HSS management information system (MIS). We present here a descriptive analysis of the uploaded visit reports. Results: Of 870 HSS sites, 783 (90%) were visited, and 479 (61.2%) reports were uploaded to MIS. Preround HSS training was not attended by one-fifth (22.6%) of the site in-charges; 35.8% of them had never received any HSS training. SOP was followed at most (94%) of the sites. The most frequently reported problem at the sites was inadequate or delayed availability of consumables. Conclusion: The overall quality of site-level preparedness at antenatal clinic sites in India was good. Attention needs to be given to timely and adequate availability of consumables at sentinel sites along with proper administrative support and preround training of site in-charges.

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Background: Targeted interventions (TIs) are one of the most effective strategies to control HIV/AIDS transmission, especially among the high-risk groups (HRGs). Implementation of HIV/AIDS control strategies relies heavily on estimation of the size of HRG population. Size estimation for key populations such as female sex workers (FSWs), men who have sex with men (MSM), and injecting drug users (IDUs) is a crucial component of national HIV strategic planning. Objective: The objective of this study was to estimate the size of FSWs, MSM, and IDUs in various states of India. Methods: The program multiplier method was used to estimate the size of FSWs, MSM, and IDUs across the country using two distinct but overlapping data sources – Integrated Bio-Behavioral Surveillance and TI program from the same geographical area at the same time period. Results: In India, as on 2018–2019, there were nearly 18.2 lakhs estimated FSWs accounting to 0.53% among female population aged 15–49 years, with a highest in West Bengal (4.5 lakhs); 5.7 lakhs estimated MSM accounting to 0.16% among male population aged 15–49 years, with a highest in Gujarat (0.7 lakh); and 3.9 lakhs estimated IDUs accounting to 0.11% among male population aged 15–49 years, with a highest in Uttar Pradesh (0.5 lakh). Conclusions: The current size estimates on HRGs will support the development of projections and estimations of the HIV epidemic at national and state levels. These estimates also help in framing national guidelines such as HIV strategic planning, program design, allocation of resources, prioritizing the interventions, and monitoring and evaluation.

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Background: Long-distance truckers (LDTs) belong to a special sentinel group with potentially high risk of acquisition of HIV owing to their high mobility, sociodemographic vulnerability, and high-risk behaviors. Objective: The objective is to estimate the prevalence of HIV and identifies its sociodemographic correlates among a representative population of LDTs in West Bengal, India. Methods: Between May and July 2017, HIV Sentinel Surveillance (HSS) was conducted in West Bengal by the National AIDS Control Organization. A total of 749 LDTs were recruited for the study, were interviewed, and tested for HIV. Descriptive and logistic regression analysis of socio-demographics, sexual risk behavior, and HIV serostatus were performed using SAS 9.3.2. Results: The prevalence of HIV among LDT was 1.2% (95% confidence interval [CI] = 0.4–2.0). Mean age was 32.8 years (standard deviation 8.5), 77.1% were currently married, 89.9% were literate, 85.7% visited HSS site for collecting condoms or seeking medical care and treatment, 53.1% were rural residents, 86.7% had sex at least once with a female partner other than wife in the past 6 months, 2.7% had sex with a male partner and 1.7% injected drugs for recreational purpose. Higher age (odds ratio [OR] = 1.1 [95% CI = 1.0–1.1]), literate (OR = 0.3 [95% CI = 0.1–0.9]), visiting HSS sites for collecting condoms or seeking medical care and treatment (adjusted OR [AOR] = 0.2 [95% CI = 0.1–0.6]), rural residence (OR = 0.2 [95% CI = 0.1–0.3]) and duration of stay in home (AOR = 1.3 [95% CI = 1.1–1.5]) were found to be significant predictors of having sex with a female partner other than wife.Conclusion: High HIV burden calls for urgency in the implementation of targeted intervention to minimize HIV risk among LDTs in West Bengal to fight against HIV/AIDS.

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Background: HIV/AIDS is a global public health issue and its transmission in a defined geographic region is influenced by the interplay of sociodemographic and behavioral factors. Better understanding of sociodemographic characteristics of HIV-positive individuals is required to prevent the spread of HIV among the general population. Objectives: The objective of the study was to find the association between HIV prevalence and sociodemographic characteristics of pregnant women aged 15–49 years attending the antenatal clinics (ANCs) in six Southern states of India. Methods: The data from the latest round of HIV sentinel surveillance, a cross-sectional study, conducted during January–March 2017 among ANC attendees were considered for this analysis. Blood samples along with other relevant information were collected from 98,634 pregnant women from 248 sites across the states. The association between HIV prevalence and sociodemographic variables was examined using multivariable logistic regression. Results: The highest HIV prevalence was reported in Karnataka (0.38%) and Andhra Pradesh (0.38%), followed by Telangana (0.33%), Odisha (0.28%), Tamil Nadu (0.27%), and Kerala (0.05%). In all states, the prevalence was highest among illiterate pregnant women exception being Kerala, wherein the prevalence was highest in pregnant women with schooling up to primary education. A significant association was found between HIV prevalence and spouse occupation in Karnataka and Odisha and spouse migration in Andhra Pradesh and Karnataka. Conclusions: Need for improvising the interventions for the young, illiterates, having a migrant spouse, and spouse occupation as truckers/hotel staff is recommended to the stakeholders involved in HIV management of the six southern states of India.

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Background: The National AIDS Control Programme provides support for HIV prevention services to pregnant women attending antenatal care (ANC) clinics through testing, kit delivery, counseling, and treatment services. The impact of HIV prevention programs in the general population is assessed by monitoring trends and progress made against the HIV epidemic among pregnant women attending ANC clinics during HIV Sentinel Surveillance (HSS). Objectives: This study explores the association of HIV risk with educational attainment for Indian women across different age groups from four repeated cross-sectional surveillance of antenatal clinics in six states from the southern part of India. Methods: Data collected from the repeated cross-sectional HSS conducted during the year 2010–2011 (baseline) and 2016–2017 (end line) across six states were used for this analysis. The total sample size was 94,266 at baseline and 99,434 at end line. In the logistic regression analysis, we focused on identifying the association between educational attainment, and HIV prevalence adjusting for period effects across two age groups for women attending ANC clinics. Results: The analysis showed an inverse association between education and HIV risk across different age groups. The age-segregated and survey period adjusted analysist showed that for older women (≥25 years), the HIV risk in 2010 ranged from 41% lower among 5^th Grade to 80% lower among postgraduates than illiterates. For the <25 year age group, this risk of HIV for pregnant women was 35% to 49% lower. Conclusions: To ensure an effective national response to control and prevent HIV infection, policymakers in India need to focus on ≥25 years' age group of women attending ANC for designing educational interventions to reduce HIV risk as well as the prevention of mother-to-child transmission of HIV.

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Prevalence of adult HIV infection in India is still high in certain North-eastern (NE) states, particularly among injecting drug users (IDUs). This study aims at exploring IDU behavior profile and their variation across the different states of NE region, India. Data were drawn from a population-based, cross-sectional survey of IDU in the integrated bio-behavioral surveillance from 2014 to 2015. A total of 4272 IDUs from four states (Manipur, Meghalaya, Mizoram, and Nagaland) aged ≥15 years were interviewed. Descriptive analysis was conducted to identify the variation in demographic and IDU behavior across four states. Youth predominance in Mizoram was evident by the mean age of initiation <18 years; 74% and 65% had the first exposure of any drug and injecting drug in <20 years. In Manipur and Nagaland, 60% and 49% of IDUs, respectively, were ≥30 years of age. These specific age groups may be targeted for IDU risk mitigation addressing the state-specific determinants.

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The introduction of antiretroviral therapy (ART) has substantially improved the survival of persons infected with HIV. In India, the aggregated HIV prevalence among transgender (TG) community was found 7.5%. West Bengal, with over 30,000 TG population recorded HIV prevalence of 4.8%. The qualitative study was conducted in 2019 with the objective to explore the motivating factors for adherence to ART treatment among TG people living with HIV (PLHIV) in an ART center. Respondents were motivated PLHIVs on ART with suitable treatment adherence recorded. Data were inductively analyzed, using thematic analysis, to identify themes central to ART adherence. Five themes emerged with prime acknowledgment of respondents that ART medication is lifelong for their survival with receiving support. Notwithstanding the chronic nature of the disease, TG PLHIV patient stands a better chance of maintaining treatment adherence if they are involved in treatment plans with their community-based members' helping as peer navigators.

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Background: Female sex workers (FSWs) have been identified as an important target group for human immunodeficiency virus (HIV)/sexually transmitted infections prevention. Objectives: This study aimed to describe sociodemographic and sex work characteristics and to identify the risk factors for HIV infection with special focus on the variations between home-based (HB) and non-HB (NHB) FSWs in three high-prevalent North-Eastern states of India: Manipur, Mizoram, and Nagaland. Methods: Data from the National Integrated Bio-Behavioural Surveillance (IBBS) conducted in India during 2014–2015 were utilized in the study. IBBS is a quantitative survey conducted among identified high risk sub within India. Logistic regression analyses were performed using SAS 9.3.2 to determine the distribution and associations of sociodemographics and risk behaviors with HIV seropositivity of HB and NHB FSWs. Results: HIV prevalence was found higher among NHB FSWs compared to HB FSW (7.3% vs. 4.6%). The proportions of FSW among HB (66.7%) were in sex work for longer duration are significantly higher than for NHB (60.2%) while risk of HIV infection due to injecting drug use was higher in NHB FSW (11.7% vs. 8.7%). Reference to FSW who were currently married, those who were widowed/divorced/separated had 2.73-fold risk of HIV. FSW who did not have any other income source were associated with 1.73 times more risk of HIV infection. Injecting drugs user among FSW respondents had four times higher likelihood to be HIV positive. Conclusion: A substantial proportion of NHB FSWs is mobile in nature. Targeted interventions are required urgently to minimize HIV risk among those FSWs especially the widowed/divorced/separated, sex work is only income source and who used injecting drugs for nonmedical purpose.

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Background: The proximity of Northeast India to the Golden Triangle facilitates easy accessibility to illicit drugs, resulting in a higher proportion of injecting drug users (IDUs) in the states of Northeast India. The estimated human immunodeficiency virus (HIV) prevalence among IDU in Manipur which is 1.43% is higher than that of the national figure. Objectives: The objectives of the study were to find the factors associated with HIV infection and correlate the association between HIV status and self-assessed risk to HIV among IDUs in Manipur. Methods: National Integrated Biological and Behavioral Surveillance (2014–2015) data were used for the study; all analyses done were weighted. In Manipur, information was collected from 1594 IDUs during the surveillance between 2014 and 2015 across four domains, namely Chandel (396), Imphal East (397), Thoubal (401), and Senapati (400). Chi-square test was performed to test the association between the independent and dependent variables. Multivariable logistic regression was performed to identify risk factors associated with HIV positivity. Results: Higher age, unsafe injecting practice, low education status, and low-income status were significantly (P < 0.05) associated with HIV infection among IDUs in Manipur. Self-assessed risk of HIV infection by IDU was significantly associated with HIV positivity. Conclusion: Interventions among IDUs in Manipur should focus on emphasizing safe injecting practices along with creating awareness on HIV prevention and management.

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Background: During round 2017 of HIV Sentinel Surveillance (HSS) for men who have sex with men (MSM) in India, sampling strategy was changed from consecutive sampling to random sampling, and recruitment was conditioned on informed written consent. Objective: The study aimed to explore whether inclusion of informed consent is associated with HIV seropositivity rates among MSM population in select four states of Central India. Methods: The cross-sectional study was conducted in four states of Delhi, Jharkhand, Uttar Pradesh, and Uttarakhand that were supervised by All India Institute of Medical Sciences, New Delhi. We did analysis of data collected during 2017 HSS, supplemented with additional program data from targeted intervention (TI) sites. All nine MSM sites in four states were included. Participants were defined as all those MSM who participated in HSS 2017 irrespective of whether they were mentioned in the random list or were selected by the TI partner. The MSM in the random list who either refused to participate or could not be contacted even after three attempts were classified as “nonparticipants.” Seropositivity of both groups was compared. Descriptive statistics were derived. Results: Overall nonparticipation rate was 14.7%, the highest being in Jharkhand (26%) and lowest in Uttarakhand (6.8%). Overall HIV positivity rate was significantly higher (P < 0.001) in nonparticipants (4.2%) when compared to participants (1.42%). Conclusion: The change in sampling strategy and introduction of written informed consent for recruitment of high-risk groups in HSS 2017 round could have led to an underestimation of HIV seropositivity rate among MSM in the states in Central Zone.

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Background: In 2017, the sampling procedure for HIV sentinel surveillance (HSS) among all high-risk groups was changed from the consecutive sampling to random sampling along with the introduction of linked anonymous testing strategy with informed written consent. Objective: The objective of this study was to assess whether the inclusion of informed consent affects the HIV positivity rate among the participants and nonparticipants injecting drug users (IDU) in HSS 2017 in four states of Central Zone of India. Methods: This study was a cross-sectional study. All sentinel sites from Delhi, Uttar Pradesh, Jharkhand, and Uttarakhand located at targeted intervention facilities in 2017 were included in the study. Information about the participation and nonparticipation of each high-risk individual at the sentinel site was gathered from the master list, respective registers, and website portal of the National AIDS Control Organization. A total of 8639 individuals were included in the analysis. Results: Overall, 16 sites in four states were included in the study. Overall, the nonparticipation rate of IDUs was 14.3%; highest being for Delhi (17.2%), followed by Uttar Pradesh (14.6%), Uttarakhand (10.9%), and Jharkhand (4.4%). Overall, the HIV-positivity rate among nonparticipants (9.6%) was significantly higher (P = 0.009) compared to the participants (6.7%). Conclusion: Change in methodology and seeking written informed consent might have an effect on the nonparticipation in all four states. This, in turn, could have led to the underestimation of HIV-positivity rates among IDU in the states.

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