Nossal Institute for Global Health - Research Publications
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ItemDocumenting a long-term development model in the slums of Delhi(BIOMED CENTRAL LTD, 2016-04-28)BACKGROUND: Achieving development outcomes requires the inclusion of marginalised populations that have the least opportunity to participate in and benefit from development. Slum dwellers often see little of the 'urban advantage', suffering more from infectious diseases, increasing food costs, poor access to education and health care, inadequate water and sanitation, and informal employment. A recent Cochrane Review of the impact of slum upgrading strategies found a dearth of unbiased studies, making it difficult to draw firm conclusions. The Review calls for greater use of process data, and qualitative alongside quantitative methods of evaluation. India is a lower middle income nation with large gender disparities and around 65 million slum inhabitants. The Asha Community Health and Development Society, a non-governmental organisation based in Delhi, has delivered a multi-sectoral program across 71 slums since 1988. This article reports on a mixed-method study to document measureable health and social impacts, along with Asha's ethos and processes. METHODS: Several observational visits were made to 12 Asha slums where informal discussions were had with staff and residents (n = 50). Asha data records were analysed for change over time (and differences with greater Delhi) in selected indicators (maternal-child health, education, child sex ratio) using descriptive statistics. 34 semi-structured individual/small group interviews and 14 focus group discussions were held with staff, residents, volunteers, elected officials, civil servants, bankers, diplomats, school principals, slumlords and loan recipients (n = 147). RESULTS: Key indicators of health and social equity improved over time and compared favourably with those for greater Delhi. The Asha model emphasises rights, responsibilities, equity and non-violence. It employs strategies characterised by long-term involvement, systematic protocols and monitoring, development of civil society (especially women's and children's groups) to advocate for rights under the law, and links with foreign volunteers and fund-raisers. Stakeholders agreed that changes in community norms and living conditions were at least partly attributable to the Asha model. CONCLUSIONS: While lacking a control group or complete baseline data, evidence suggested substantial improvements in slum conditions and social equity. The Asha model offers some lessons for slum (and broader) development.
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ItemNo Preview AvailableMale-to-male sex among men who inject drugs in Delhi, India: Overlapping HIV risk behaviours(ELSEVIER, 2015-04)BACKGROUND: HIV among people who inject drugs (PWID) is a major public health challenge in India. This paper examines PWID in Delhi who also have male-to-male sex with a focus on overlapping HIV risk behaviours and the psychosocial correlates of a history of male-to-male anal sex. METHODS: We analysed data collected in April-May of 2012 from a community-based sample of 420 male PWID in Delhi obtained using time location sampling. RESULTS: One third (37%) of the men reported a history of anal sex with men, among whom just 16% used a condom at last anal sex. Almost all (93%) participants who had a history of anal sex with men also had sex with women. Chi-square tests revealed that a history of anal sex with men was associated with a higher number of female sexual partners and sharing of needles and syringes. Additionally, unprotected sex at last sex with a male partner was significantly associated with unprotected sex at last sex with regular and paid female partners. Multivariate binary logistic regression revealed that the psychosocial correlates of a history of anal sex with other men were: being aged 18-24 (OR = 2.4, p = 0.014), illiteracy (OR = 1.9, p = 0.033), having never been married (OR = 2.6, p = 0.007), a main source of income of crime/begging (OR = 3.1, p = 0.019), a duration of injecting drug use greater than 20 years (OR = 3.4, p = 0.035) and suicidal ideation (OR = 1.7, p = 0.048). CONCLUSION: Male-to-male sex was associated with psychosocial vulnerability, including a longer history of injecting drug use, suicidal ideation and socio-economic disadvantage. Given the extent of overlapping HIV risk behaviours, HIV programs for PWID would benefit from a strong focus on prevention of sexual HIV transmission, especially among male injectors who also have sex with other men.
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ItemHIV risks vary according to type of sex work in a cross-sectional survey from Nagaland, India(BMC, 2014-11-12)BACKGROUND: Human immunodeficiency virus (HIV) infection is a significant problem among female sex workers (FSWs) in Nagaland, India. Place of solicitation and sex vary considerably in this context. The aim of this study was to investigate the relationship between categories of sex work and HIV risks. METHODS: In 2009 a survey was undertaken among 417 FSWs in Dimapur, Nagaland using an interviewer-administered questionnaire and blood and urine samples. Using this data, we constructed a typology of sex work by combining usual place of solicitation and place of sex, and examined variations in demographics, sex work patterns, sexually transmitted infections (STIs) and HIV prevalence across typology categories. Binary logistic regression analyses were done to examine the association between category of sex work and HIV, STIs, and condom use. RESULTS: By combining place of solicitation with place of sex, seven distinct categories of sex work emerged. The largest category were women who usually solicited in a public place and had sex in a rented room or lodge (31.7%, n = 132). One-tenth of participants were HIV positive (10.3%) and 35.4% had at least one STI (reactive syphilis serology, gonorrhoea or chlamydia). FSWs who both solicited and entertained in a rented room or lodge (OR = 13.3; 95% CI 2.2, 81.5) and those who solicited by phone and had sex in a rented room or lodge (OR = 6.3; 95% CI 1.0, 38.0) were more likely to be HIV positive compared to home-based FSWs. Women who both solicited and entertained in public (OR = 6.7; 95% CI 1.6, 28.0) and who solicited in public and entertained in a rented room or lodge (OR = 2.5; 95% CI 1.1, 6.0) were more likely to test positive for an STI compared to home-based FSWs. CONCLUSION: The results indicate that different categories of sex work are associated with different HIV and STI risk profiles. Local contextual understanding of the different types of sex work and the associated levels of risk assist NGOs to target their interventions more effectively and efficiently in order to reduce STI and HIV prevalence among FSWs and their clients.
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ItemUndiagnosed HIV among people who inject drugs in Manipur, India(ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2015-03-04)Manipur is a geographically isolated state of India characterised by a high HIV prevalence among people who inject drugs (PWID). A low-to-moderate lifetime rate of HIV testing has been documented amongst PWID in Manipur. Little is known about the extent of undiagnosed HIV in this setting and whether uptake of HIV testing (and knowledge of a positive diagnosis) leads HIV-positive PWID to change their risk behaviours. The cross-sectional data (n = 821) analysed for this paper were collected in 2009 for the Integrated Behavioural and Biological Assessment (IBBA) using interviewer-administered questionnaires and the collection of de-linked blood and urine samples. Almost one-third (30.7%) of the participants tested HIV positive. The majority knew where to obtain a confidential HIV test (80.7%), however, half of the HIV-positive participants had either never had an HIV test (37.7%), or had undertaken a test without collecting the result (12.7%). Almost one-quarter (23.4%) of the HIV-positive participants and 17.4% of the HIV-negative participants had shared a needle/syringe with at least one other injector during the preceding month. Encouragingly, HIV-positive participants were significantly more likely than HIV-negative participants to use condoms with their regular sexual partners, however, there was still a high proportion of HIV-positive participants who did not use a condom at last sex with their regular (47.2%) or casual (48.0%) partners. Having taken an HIV test and collected the result was associated with a reduction in HIV-risk behaviours among HIV-positive participants, but not among HIV-negative participants. In conclusion, we found that a substantial proportion of the HIV-positive PWID in Manipur were not aware of their positive status, and risky injecting and sexual practices were commonplace. However, HIV-positive PWID appear to reduce their high-risk behaviours when they become aware of their HIV status highlighting the importance of taking HIV testing coverage to scale.
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ItemInjecting drug use in Manipur and Nagaland, Northeast India: injecting and sexual risk behaviours across age groups(BIOMED CENTRAL LTD, 2014-10-13)BACKGROUND: There is an HIV epidemic among people who inject drugs (PWID) in Manipur and Nagaland, Northeast India. Approximately one-third of PWID across these two states are aged below 25 years, yet until now there has been no systematic investigation of the differences between the younger and older PWID. We sought to profile differences in drug use and sexual practices across age groups and to examine whether age is associated with injecting and sexual risk behaviours. METHODS: We used combined cross-sectional survey data collected in 2009 from two surveys involving a total of 3,362 (male) PWID in eight districts of Manipur and Nagaland. All data were collected using interviewer-administered questionnaires. RESULTS: Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were more likely share needles/syringes in both Manipur (OR =1.8) and Nagaland (OR =1.6). Compared to PWID aged 35 years or older, PWID aged 18 to 24 years were almost two times as likely to draw up drug solution from a common container at their last injection in Manipur (OR =1.8). In Nagaland, PWID aged 18 to 24 years were more likely to use condoms consistently with both casual (OR =3.1) and paid (OR =17.7) female sexual partners compared to PWID aged 35 years or older. CONCLUSION: Risky injecting practices were more common among younger PWID in both Manipur and Nagaland, while unprotected sex was more common among older PWID in Nagaland. There is a clear need to focus public health messages across different age groups.
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