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Peer education with micro-planning has been integral to scaling up key population (KP) HIV/STI programmes in Kenya since 2013. Micro-planning reinforces community cohesion within peer networks and standardizes programme inputs, processes and targets for outreach, including peer educator (PE) workloads. We assessed programme performance for outreach-in relation to the mean number of KPs for which one PE is responsible (KP:PE ratio)-and effects on HIV/STI service utilisation. Quarterly programmatic monitoring data were analysed from October 2013 to September 2016 from implementing partners working with female sex workers (FSWs) and men who have sex with men (MSM) across the country. All implementing partners are expected to follow national guidelines and receive micro-planning training for PEs with support from a Technical Support Unit for KP programmes. We examined correlations between KP:PE ratios and regular outreach contacts, condom distribution, risk reduction counselling, STI screening, HIV testing and violence reporting by KPs. Kenya conducted population size estimates (PSEs) of KPs in 2012. From 2013 to 2016, KP programmes were scaled up to reach 85% of FSWs (PSE 133,675) and 90% of MSM (PSE 18,460). Overall, mean KP:PE ratios decreased from 147 to 91 for FSWs, and from 79 to 58 for MSM. Lower KP:PE ratios, up to 90:1 for FSW and 60:1 for MSM, were significantly associated with more regular outreach contacts (p<0.001), as well as more frequent risk reduction counselling (p<0.001), STI screening (p<0.001) and HIV testing (p<0.001). Condom distribution and reporting of violence by KPs did not differ significantly between the two groups over all time periods. Micro-planning with adequate KP:PE ratios is an effective approach to scaling up HIV prevention programmes among KPs, resulting in high levels of programme uptake and service utilisation.

Background India lacks data on the incidence of Paediatric HIV. In 2010, the Indian Council of Medical Research commissioned a task force study to estimate the paediatric HIV burden in Belgaum district, Karnataka, India. We estimated the HIV incidence, prevalence and associated risk factors of mother to child transmission of HIV among children exposed to maternal HIV by age 24 months. Methods We included Belgaum resident pregnant women who tested HIV positive between January 1st, 2011 and May 31st, 2013 and who provided consent. Their babies were tested for HIV at three time intervals using DNA PCR dry blood spot (DBS) method at 6–10 weeks and 6–9 months, and using Antibody tests at 18–24 months of age. We estimated cumulative incidence using survival analysis that considered censoring of cases and prevalence rates of HIV by age 24 months. Using competing-risk survival regression model, we examined the correlates of transmission of HIV among babies exposed to maternal HIV. Results Among 487 children of HIV positive mothers recruited in the study, the cumulative incidence rate by 24 months of age was 4.8 per 1000 person months [95% CI: 3.5–6.6]. The HIV prevalence rate among babies exposed to maternal HIV until 24 months was 7.8% [95% CI: 5.7–10.7]. Mother’s age above 30 years, and breastfeeding duration of more than six months were factors that significantly increased the HIV transmission; adjusted hazard ratio (AHR) 6.98 [95% CI: 1.73–28.16] and 5.28 [95% CI, 1.75–15.90], respectively. The risk of MTCT was significantly reduced if both mother and baby had received Nevirapine at delivery [AHR 0.25; 95%CI: 0.10–0.61] and if either mother or baby had been given Nevirapine at delivery [AHR 0.12; 95%CI: 0.03–0.49]. Conclusion The study findings suggest that mother’s age above 30 years and breastfeeding beyond 26 weeks is associated with higher rates of HIV transmission from mother to child. It confirms the benefits of providing anti-retrovirals (Nevirapine) in reducing mother to child transmission of HIV. Effective strategies to promote safe infant feeding practices, including avoidance of mixed feeding beyond 26 weeks among HIV infected mothers, is critical to reduce incidence of paediatric HIV in India.

Background Mental health disorders among adolescents have emerged as a major public health issue in many low and middle-income countries, including India. There is a paucity of research on the determinants of psychological distress, particularly among the poorest girls in the poorest communities. The purpose of this study was to assess the prevalence and correlates of different indicators of psychological distress among 13–14 year old low caste girls in rural, south India. Methods Cross-sectional survey of 1191 low caste girls in two districts in north Karnataka, conducted as part of a cluster randomised-control trial. Bivariate and multivariate logistic regression analysis assessed correlates of different indicators of psychological distress. Results More than one third of girls (35.1%) reported having no hope for the future. 6.9% reported feeling down, depressed or hopeless in the past 2 weeks. 2.1% reported thinking they would be better off dead or of hurting themselves in some way in the past 2 weeks. 1.6% reported sexual abuse, 8.0% rrecent eve teasing and 6.3% having no parental emotional support. Suicidal ideation was independently associated with sexual abuse (AOR 11.9 (3.0–47.0)) and a lack of parental emotional support (AOR 0.2 (0.1–0.5)). Feeling down, depressed or hopeless was independently associated with recent eve-teasing (AOR 2.9 (1.6–5.4)), a harassing or abusive school environment (AOR 3.9 (1.8–8.2)), being frequently absent (AOR 2.8 (1.5–5.5)) or having dropped out of school (AOR 2.1 (1.0–4.3)), and living in Vijayapura district (AOR 2.5 (1.6–4.1)). Having no hope for the future was independently associated with a range of factors, including recent “eve-teasing” (AOR 1.5 (1.0–2.4)), being engaged (AOR 2.9 (0.9–9.7)), not participating in groups (AOR 0.5 (0.4–0.6)) and a lack of emotional support (AOR 0.6 (0.4–0.7)). Conclusions Rather than being a time of optimism, a third of low caste girls in rural north, Karnataka have limited hope for the future, with some contemplating suicide. As well as having important development benefits, interventions that address the upstream structural and gender-norms based determinants of poor mental health, and provide adolescent services for girls who require treatment and support, should have important benefits for girls’ psychological wellbeing. Trial registration Prospectively registered at ClinicalTrials.GovNCT01996241 . November 27, 2013

Family planning is a key means to achieving many of the Sustainable Development Goals. Around the world, governments and partners have prioritized investments to increase access to and uptake of family planning methods. In Uttar Pradesh, India, the government and its partners have made significant efforts to increase awareness, supply, and access to modern contraceptives. Despite progress, uptake remains stubbornly low. This calls for systematic research into understanding the 'why'-why people are or aren't using modern methods, what drives their decisions, and who influences them. We use a mixed-methods approach, analyzing three existing quantitative data sets to identify trends and geographic variation, gaps and contextual factors associated with family planning uptake and collecting new qualitative data through in-depth immersion interviews, journey mapping, and decision games to understand systemic and individual-level barriers to family planning use, household decision making patterns and community level barriers. We find that reasons for adoption of family planning are complex-while access and awareness are critical, they are not sufficient for increasing uptake of modern methods. Although awareness is necessary for uptake, we found a steep drop-off (59%) between high awareness of modern contraceptive methods and its intention to use, and an additional but smaller drop-off from intention to actual use (9%). While perceived access, age, education and other demographic variables partially predict modern contraceptive intention to use, the qualitative data shows that other behavioral drivers including household decision making dynamics, shame to obtain modern contraceptives, and high-risk perception around side-effects also contribute to low intention to use modern contraceptives. The data also reveals that strong norms and financial considerations by couples are the driving force behind the decision to use and when to use family planning methods. The finding stresses the need to shift focus towards building intention, in addition to ensuring access of trained staff, and commodities drugs and equipment, and building capacities of health care providers.

In India, the HIV epidemic is concentrated among Key Populations (KPs), such as men who have sex with men (MSM), who bear a disproportionate burden of HIV disease. Conventional targeted interventions (TI) mitigate HIV transmission among MSM by focusing on physical hotspots. As increasingly, there is a shift within India's MSM community to connect with sex partners online, novel approaches are needed to map virtual platforms where sexual networks are formed. The objective of this study was to estimate the number of MSM in Delhi using virtual platforms to connect for sex and to describe patterns of their use. The study was conducted in the state of Delhi among MSM over 18 years of age who used virtual platforms to look for sexual partners. Virtual platforms were identified through community consultations. Size estimation was carried out by enumerating the number of online users, accounting for duplication across sites and time and based on interviews with 565 MSM. 28,058 MSM (95% CI: range 26,455-29,817) use virtual sites to find sexual partners. We listed 14 MSM specific virtual sites, 14 general virtual sites, 19 social networking pages and 112 messenger groups, all used by MSM. Five virtual sites met feasibility criteria to be included in the virtual mapping. Of the MSM on these sites, 81% used them at night and 94% used them on Sundays, making these the peak time and day of use. Only 16% of users were aware of organizations providing HIV services and 7% were contacted by peer educators in the preceding three months. Two-fifths (42%) also visited a physical location to connect with sexual partners in the month prior to the study. TI programs that focus on physical hotspots do not reach the majority of MSM who use virtual sites. MSM active on virtual sites have a low awareness of HIV services. Virtual mapping and programmatic interventions to include them must be incorporated into current public health interventions to reach MSM at risk of HIV.

Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation. Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses. Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating. In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication.

Background We sought to estimate the prevalence and describe heterogeneity in experiences of gender-based violence (GBV) across subgroups of adolescent girls and young women (AGYW). Methods We used data from a cross-sectional bio-behavioural survey among 1299 AGYW aged 14–24 in Mombasa, Kenya in 2015. Respondents were recruited from hotspots associated with sex work, and self-selected into one of three subgroups: young women engaged in casual sex (YCS), young women engaged in transactional sex (YTS), and young women engaged in sex work (YSW). We compared overall and across subgroups: prevalence of lifetime and recent (within previous year) self-reported experience of physical, sexual, and police violence; patterns and perpetrators of first and most recent episode of physical and sexual violence; and factors associated with physical and sexual violence. Results The prevalences of lifetime and recent physical violence were 18.0 and 10.7% respectively. Lifetime and recent sexual violence respectively were reported by 20.5 and 9.8% of respondents. Prevalence of lifetime and recent experience of police violence were 34.7 and 25.8% respectively. All forms of violence were most frequently reported by YSW, followed by YTS and then YCS. 62%/81% of respondents reported having sex during the first episode of physical/sexual violence, and 48%/62% of those sex acts at first episode of physical/sexual violence were condomless. In the most recent episode of violence when sex took place levels of condom use remained low at 53–61%. The main perpetrators of violence were intimate partners for YCS, and both intimate partners and regular non-client partners for YTS. For YSW, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence. Conclusions AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, AGYW are not a homogeneous group, and there are heterogeneities in prevalence and predictors of violence between subgroups of AGYW that need to be understood to design effective programmes to address violence.

Background Leave No One Behind (LNOB) is a central, transformative promise of the 2030 Agenda for Sustainable Development Goals. To attain LNOB, systematic analysis of patterns and distributions of inequalities in coverage of health outcomes on a continuous basis at different program delivery layers is required to design tailored health interventions. We analysed the patterns of change and geographic distribution of inequalities in coverage of antenatal care and facility-based delivery in Uttar Pradesh (UP), India and developed a framework to guide health programmers to understand inequalities better, to accelerate progress by reaching those left behind. Methods Data from five-rounds of National Family Health Survey (1992–2021) and two-rounds of Community Behaviour Tracking Survey (2014–2018) is used. Education and wealth have been used as stratifiers. Three measures of inequality- mean difference from mean, slope index of inequality, and inequality pattern index are used to depict the state, district and sub-district level inequalities. Results UP observed a substantial reduction in the education-related inequality in ANC and facility-delivery during 1992–2021. The slope index of inequality declined from 65.3 [95%CI:60.0-70.6] to 9.3 [95%CI:7.8–10.8] for ANC and from 44.7 [95%CI:38.5–50.9] to 29.9 [95%CI:27.8–32.0] for facility-delivery during 1992–2021. The inequality pattern index showed that, with improved reach of interventions, many districts moved towards bottom inequality from top inequality for any ANC while fewer districts for facility-delivery. Even in districts with high coverage and low inequality, sub-district level(blocks) inequality persisted. Similarly, in blocks with high coverage and low inequality, Accredited Social Health Activist (ASHA) level inequality persisted. Interestingly, for the same ASHA area, the patterns of inequality differed for any ANC and facility delivery; in some districts, inequality direction changed based on the stratifier chosen. Conclusions The proposed health equity framework suggests that to achieve LNOB status, understanding inequality with the coverage status is important. If coverage is high and inequality persists, identify the program layer at which maximum inequality persists to identify the left behinds. Whereas, if coverage is poor, programs are required to improve coverage first. Findings also call for a systematic way of collecting and organizing granular data to understand inequality and identify the left-behinds.

The Kenya National AIDS and STI Control Programme (NASCOP) conducted annual polling booth surveys (PBS) in 2014 and 2015 to measure outcomes from the national HIV prevention programme for key populations (KPs), comprising behavioural, biomedical and structural interventions. KPs included female sex workers (FSWs), men who have sex with men (MSM) and people who inject drugs (PWID). We compared survey results from the first and second rounds. Comparing the second to the first round, significantly more FSWs (93% vs. 88%, p<0.001) and MSM (77% vs. 58%, p<0.001) reported condom use at last sex with a paying client, and at last anal sex among MSM (80% vs. 77%, p<0.05) and PWID (48% vs. 27%, p<0.01). However, condom use with regular partners remained low, at less than 53% for FSWs and 69% for MSM. Among PWID, there was a significant increase in use of new needles and syringes at last injection (93% vs. 88%, p<0.001), and a significant decrease in reported non-availability of clean needles (23% vs. 36%, p<0.001). The number of overdoses in the past six months reduced significantly but remained high (40% vs. 51%, p<0.001). FSWs and MSM reported significantly higher HIV testing, and in all KP groups, over 93% reported ever having been tested for HIV. Among the respondents self-reporting to have tested HIV positive (24% of FSW, 22% of MSM and 19% of PWID), 80% of FSWs, 70% of MSM, and 73% of PWID reported currently taking antiretroviral therapy (ART). While the experience of forced intercourse by partners declined among FSWs (18% vs. 22%, p<0.01) and MSM (13% vs. 17%, p<0.01), more FSWs reported violence by law enforcement personnel (49% vs. 44%, p<0.001). These findings provide valuable information on the programme's progress, and a signpost for the integrated behavioural, biomedical and structural interventions to achieve their HIV prevention targets.

Background It is argued that Indian gender minorities displayed differential mental health problems and suicide attempts. Hence, the study was intended to understand the prevalence of anxiety, depression and suicidality among this group, specifically those living in a metropolitan city in South India. Methods The data was generated from a cross-sectional study that employed a structured questionnaire to collect information about experiences of anxiety, depression and suicidal behavior among gender-diverse individuals in Bangalore, the capital city of Karnataka state. The study used stratified simple random sampling of eligible individuals who were 18 years of age and older and who were enrolled in an HIV prevention program implemented for gender-diverse individuals run by the Karnataka Health Promotion Trust and the University of Manitoba at the time of the study (2012). Bivariate and multivariate analyses were used to assess the relative contribution of various factors that affect suicide ideation or actual attempts among the gender diverse participants. Results Results showed that 62% whose main source of income was Basti (socially sanctioned practice of begging) , 52% of Hijras, 56% who lived with their Gurus, 58% who were not happy with their physical appearance, 55% who consumed alcohol daily, and 63% who experienced high depression had ever thought of or attempted suicide in the month prior to the survey. However, multivariate analysis showed that respondents who were not happy with their physical appearance and thought of changing it had significantly higher odds (AOR = 2.861; CI 1.468,5.576; p  = 0.002) of either having thoughts that it was better being dead or wished they died. Similarly, those who experienced high depression, their odds of either having had thoughts of or having attempted suicide increased by three times (AOR = 3.997; CI 1.976, 8.071; p  < 0.000). Conclusions It is observed that a high percentage of gender minorities had attempted suicide or thought of suicide during the month preceding the data collection. The findings bring new insights on the proximate determinant of physical appearance on the suicidality of gender minorities assigned male at birth and appropriate to account for this while addressing the mental health issues.