Exploring barriers and facilitators to HIV+ MSM and TG/Hijra in anti-retroviral treatment (ART) adherence in Mumbai, India

Abstract

Background: Though HIV prevalence in refugee settlements in subSaharan Africa is usually unknown, the majority of refugees come from neighboring countries where HIV prevalence is high. In Nakivale Refugee Settlement in southwestern Uganda, there are 64,000 refugees from 12 countries. The prevalence of HIV is unknown. We implemented a routine HIV testing program in Nakivale and examined factors associated with new HIV diagnosis. Methods: FromMar-Sept 2013, research assistants routinely offered free HIV-testing to all clients in the Nakivale Clinic Outpatient Department while they waited for their clinic visit. Tested participants were surveyed to obtain demographic information, mode of transport and travel time to clinic. We compared variables for HIV-infected clients and clients not infected with HIV using the Wilcoxon rank sum and Fisher’s exact test (continuous, categorical data). We used a logistic regression model to identify predictors of a newdiagnosis ofHIV-infectionamong those tested. Findings: Over the 6-month intervention,155 (4.4%) of 3,558 individuals tested were identified with HIV infection. Compared to those without HIV infection, HIV-infected clients had a similar median age (30 vs 29, p1⁄40.3), were more likely female (68% vs 56%, p1⁄40.0047), less often refugee (41% vs 71%, p < 0.0001), and had longer median travel time to clinic (90 min vs 60 min, p < 0.0001). Of those tested, males were 0.56 times as likely, those not traveling to clinic on foot were 1.65 times as likely, and those taking longer to reach clinic were 1.07 times (per 15 minutes of travel time) as likely to be found HIV-infected. Likelihood of testing as HIV-infected was significantly associated with country of origin. People from Uganda had the highest prevalence among the individual countries reported, with 93/1,069 (8.7%). Interpretation: In a routine HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk than most refugees tested. Decentralized testing throughout the refugee settlement may help to identify more individuals with HIV that live further from a health clinic. Given the close physical proximity of refugees and the surrounding Ugandan nationals, future studies should aim to discern if there is HIV transmission and HIV viral mixing among these populations. Funding: Harvard University Center for AIDS Research (NIH/ NIAID 5P30AI060354-10), Harvard Global Health Institute. Abstract #: 02CD021