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We carried out a secondary analysis of data of Comprehensive National Nutrition Survey 2016-18 to analyze the prevalence and predictors of vitamin D deficiency (VDD) among Indian children and adolescents.The overall prevalence of VDD in preschool children (1-4 years), school age (5-9 years) children, and adolescents (10-19 years) was 13.7%, 18.2%, and 23.9%, respectively. Age, living in urban area, and winter season were significantly associated with VDD. Vegetarian diet and high-income households were the main risk factors observed in 5-19 years age category. Female sex and less than three hour of physical activity/week were independent risk factors among adolescents.The prevalence and determinants of VDD across different agegroups are reported, and these should be interpreted and addressed to decrease the burden of VDD in India.

BACKGROUND It is thought that there is a high risk of zinc deficiency in India, but there are no representative national estimates. OBJECTIVES We aimed to evaluate the national and state-level prevalence of low serum zinc concentrations (SZCs) in Indian children from the nationally representative Comprehensive National Nutrition Survey. METHODS Prevalence of low SZC, adjusted for C-reactive protein, was estimated among preschool (1-4 y; n = 7874) and school-age children (5-9 y; n = 10,430) and adolescents (10-19 y; n = 10,140), using SZC cutoffs defined by the International Zinc Nutrition Consultative Group. RESULTS Prevalence of low SZC was high among adolescents (31.1%; 95% CI: 29.8%, 32.4%), compared with school-age (15.8%; 95% CI: 15.3%, 16.3%) or preschool children (17.4%; 95% CI: 16.7%, 18.0%). However, stratification of prevalence by fasting status or using an alternative lower SZC cutoff independent of fasting status led to a reduction in prevalence by 3.7% or 7.8% in children

Background In India, the prevalence of overweight among adolescents is on the rise, setting the stage for an increase in metabolic syndrome (MS). This paper presents the national prevalence of MS in adolescents in India. Methods A nationally representative data of adolescents (10–19 years) from the Comprehensive National Nutrition Survey was used. MS was defined based on the NCEP–ATP III criteria for adolescents. Bivariate analysis was used to report socio-demographic differentials in prevalence and to assess interstate variability. Multivariate logistic regression model was constructed to measure the association between socio-demographic characteristics and prevalence of MS. Census data from 2011 was projected to 2017 to calculate burden. Results The prevalence of MS was 5.2% among adolescents. 11.9%, 15.4%, 26.0%, 31.9% and 3.7% had central obesity, high blood pressure, hypertriglyceridemia, low HDL-cholesterol and high fasting glucose, respectively. The prevalence was higher among males (5.7% vs. 4.7%, adjusted odds ratio (AOR): 1.3, 95% confidence interval [CI]: 1.0, 1.6), those residing in urban areas (7.9% vs 4.2%, AOR: 1.4, 95% CI: 1.1, 1.8), and from wealthier households as compared to their counterparts (8.3% vs. 2.4%, AOR: 3.4, 95% CI: 2.1, 5.5). There was wide interstate variability in the prevalence of MS (0.5% – 16.5%). In 2017, 14.2 million adolescents had MS in India. Conclusions The prevalence of MS among adolescents in India is low and clustered in urban areas and richer households. Early prevention interventions promoting a healthy lifestyle, especially in high prevalence areas, are needed to keep MS from becoming a public health issue.

Background Conventional indicators used to access the nutritional status of children tend to underestimate the overall undernutrition in the presence of multiple anthropometric failures. Further, factors contributing to the rich-poor gap in the composite index of anthropometric failure (CIAF) have not been explored. This study aims to estimate the prevalence of CIAF and quantify the contribution of factors that explain the rich-poor gap in CIAF. Methods The present study used data of 38,060 children under the age of five years and their biological mothers, drawn from the nationally representative Comprehensive National Nutrition Survey of children and adolescents aged 0–19 years in India. The CIAF outcome variable in this study provide an overall prevalence of undernutrition, with six mutually exclusive anthropometric measurements of height-for-age, height-for-weight, and weight-for-age, calculated using the World Health Organization (WHO) Multicenter Growth Reference Study. Multivariate regression and decomposition analysis were used to examine the association between covariates with CIAF and to estimate the contribution of different covariates in the existing rich-poor gap. Results An overall CIAF prevalence of 48.2% among children aged aged under 5 years of age was found in this study. 6.0% children had all three forms of anthropometric failures. The odds of CIAF were more likely among children belonging to poorest households (AOR: 2.41, 95% CI: 2.12–2.75) and those residing in urban area (AOR: 1.06, 95% CI 1.00–1.11). Children of underweight mothers and those with high parity were at higher risk of CIAF (AOR: 1.51, 95% CI: 1.42–1.61) and (AOR: 1.15, 95% CI: 1.08–1.22), respectively. Children of mother exposed to mass media were at lower risk of CIAF (AOR: 0.87, 95% CI: 0.81–0.93). Conclusion This study estimated a composite index to assess the overall anthropometric failure, which also provides a broader understanding of the extent and pattern of undernutrition among children. Findings show that maternal covariates contribute the most to the rich-poor gap. As well, the findings suggest that intervention programs with a targeted approach are crucial to reach the most vulnerable groups and to reduce the overall burden of undernutrition.

Alcohol use has a deleterious effect on the health status of persons living with HIV, negatively affecting antiretroviral adherence and increasing the risk of transmission. Alcohol use is not an isolated behavior but intimately linked to stigma and poor psychological status among other factors. This paper utilizes a crossover design to test the efficacy of three multilevel interventions, individual counselling (IC), group intervention (GI) and collective advocacy (CA) for change, among HIV positive males who consume alcohol, treated at five ART Centers in urban Maharashtra, India. While GI shows a significant effect on the largest number of outcome variables, IC through its psychosocial emphasis demonstrated a significant impact over time on stigma and depression, and CA with its emphasis on societal change showed positive impact on stigma and advocacy for self and others. Each of the interventions had variable effects on CD4 count and viral load.Clinical Registration Number: NCT03746457; Clinical Trial.Gov.

Objective Nationally representative percentiles for waist circumference (WC), waist‐to‐height‐ratio (WHtR), and body mass index (BMI) are not available for children and adolescents in India. Methods Using LMS method, age‐ and gender‐specific reference growth charts were constructed for WC (n = 68,261), WHtR (n = 68,261), and BMI (n = 67,741) from children/adolescents aged 5–19 years who participated in a nationally representative survey. General obesity, indicating overall obesity, was defined as age–sex‐specific BMI z‐scores ≥ 95th percentile. Central obesity was defined in three ways: WC ≥ 90th percentile, WHtR ≥ 0.5, and both WC ≥ 90th percentile and WHtR ≥ 0.5. Findings WC and BMI percentiles for boys and girls are lower than those previously reported from India and several other countries. The BMI percentiles are lower than the WHO 2007 reference population. The prevalence of general obesity using India specific BMI centiles was 2.9% (95% CI: 2.6–3.2). The prevalence of central obesity was 6.1% (95% CI: 5.7–6.6) using WC ≥ 90th percentile, 5.3% (95% CI: 5.0–5.7) using WHtR ≥ 0.5, and 3.6% using both criteria. Three‐fourth of children with general obesity also had central obesity based on WC ≥ 90th. Conclusions Indian children are thinner than Caucasian and other Asian children, and the global WHO reference population. Using India specific reference, the prevalence of central obesity is higher than general obesity with a significant overlap between the two.

Summary Background Anaemia is a serious public health concern in India. However, national estimates for its prevalence are not available for the 5–14 years age group, nor are estimates available for the types of anaemia among children and adolescents (1–19 years). We aimed to assess the prevalence of anaemia among children and adolescents in India and to categorise types of anaemia on the basis of micronutrient deficiencies. Methods We assessed the prevalence of anaemia among children (1–4 years and 5–9 years) and adolescents (10–19 years) using nationally representative data from the Comprehensive National Nutrition Survey. Anaemia was classified on the basis of age and sex-specific WHO cutoffs and serum ferritin, soluble transferrin receptor, folate, cyanocobalamin, and C-reactive protein concentrations as iron deficiency anaemia, folate or vitamin B12 deficiency anaemia, dimorphic anaemia (iron deficiency anaemia and folate or vitamin B12 deficiency anaemia), anaemia of other causes (anaemia not classified as iron deficiency anaemia and folate or vitamin B12 deficiency anaemia), and anaemia of inflammation. Findings We included 26 765 children (11 624 aged 1–4 years and 15 141 aged 5–9 years) and 14 669 adolescents. In the weighted sample, anaemia prevalence was 40·5% (4553 of 11 233) among 1–4 year-olds, 23·4% (3439 of 14 664) among 5–9 year-olds, and 28·4% (4064 of 14 300) among adolescents. Among 2862 children aged 1–4 years, iron deficiency anaemia (1045 [36·5%]) was the most prevalent type, followed by anaemia of other causes (702 [24·5%]), folate or vitamin B12 deficiency anaemia (542 [18·9%]), dimorphic anaemia (387 [13·5%]), and anaemia of inflammation (186 [6·5%]). Among 2261 children aged 5–9 years, anaemia of other causes was the most common (986 [43·6%]), followed by folate or vitamin B12 deficiency anaemia (558 [24·6%]), iron deficiency anaemia (353 [15·6%]), dimorphic anaemia (242 [10·7%]), and anaemia of inflammation (122 [5·4%]). 861 (31·4%) of 2740 adolescents had anaemia of other causes, 703 (25·6%) had folate or vitamin B12 deficiency anaemia, 584 (21·3%) had iron deficiency anaemia, 498 (18·2%) and dimorphic anaemia, and 94 (3·4%) had anaemia of inflammation. Interpretation Iron deficiency anaemia is the most common form of anaemia among younger children and anaemia of other causes among 5–9-year-old children and adolescents. Folate or vitamin B12 deficiency anaemia accounts for more than a third of anaemia prevalence. Anaemia prevention efforts should focus on strengthening the existing iron and folate supplementation programmes and prevention of folate or vitamin B12 deficiency anaemia. Funding The Mittal Foundation.

We examined the association between alcohol consumption, adherence and viral load (VL) in a cohort of 940 alcohol-consuming, human immunodeficiency virus (HIV)-positive men receiving antiretroviral therapy in Mumbai. Some of the participants (16.7%) had missed >1 doses in the last four days and 17.6% reported >1 treatment interruptions in the last 12 months; 60.8% of the participants consumed alcohol >2 times/month, 62.8% consumed >3 drinks/typical day and 11.5% reported binge drinking >1 times/month; 76.4% of the participants had VL

Child undernutrition remains an area of public health concern across the globe, particularly in developing countries like India. Previous studies have focused on the association of maternal nutrition with premature pregnancy and birthweight of child, with few establishing the intergenerational effect but limited to select populations and geography.This study used data from 35,452 children aged under 5 years and their biological mother from nationally representative Comprehensive National Nutrition Survey (CNNS) in India. The outcome variables were anthropometric indices: height-for-age, weightfor- height, and weight-for-age. The exposure variables were maternal height and body mass index (BMI). Multivariate regression analysis was used to examine the association between maternal height and BMI with child undernutrition.Out of total number of mothers, 11.1% were short in stature and 28% were underweight. Of total number of children, 33.9%, 17.3% and 32.7% were stunted, wasted, and underweight respectively. Children born to mother with short stature were more likely to be stunted (OR=1.73, 95% CI 1.59-1.89), wasted (OR=1.26, 95% CI 1.12-1.41) and underweight (OR=1.64, 95% CI 1.50-1.79). Similarly, children with underweight mother were more likely to be stunted (OR=1.63, 95% CI 1.53-1.73), wasted (OR=1.64, 95% CI 1.52-1.77) and underweight (OR=2.14, 95% CI 2.01-2.27).The study shows a strong association between maternal and child undernutrition demonstrating intergenerational linkage between the two. The national programme needs to focus on holistic and comprehensive nutrition strategy with targeted interventions to improve both maternal and child health.

Objective To examine the prevalence of DBM at national, state, regional level and its proximate determinants in households with a mother and child under 5 years of age. Methods The present study includes data on 38,060 children under 5 years of age and their biological mothers, drawn from the nationally representative Comprehensive National Nutrition Survey (CNNS) of children and adolescents aged 0–19 years in India. The outcome variable for this study was the double burden of malnutrition at the household level. A child was classified as stunted if the height was at least -2SD below the mean for their age. A mother with a body mass index (BMI) of more than or equal to 25kg/m2 (BMI ≥ 25 kg/m2) was considered as overweight. A binary variable with coexistence of both conditions was created and categorized as 1 (existence of stunted child and overweight mother), and 0 otherwise. Multivariate regression analysis was used to examine the association between DBM and covariates at maternal, child and household level. Results 3.4% of households were found to be with DBM, with higher prevalence in urban areas (6.2%) as compared to rural areas (2.5%). Inter-state and regional variations were present in the prevalence of DBM. The proportion of DBM was higher in households with mothers aged 30 years or more, mothers not working and those who had cesarean births. Prevalence of DBM was found to be higher in urban area and rich households. Conclusion This study shows the prevalence of DBM and its proximate determinants. These findings highlight the need for a comprehensive nutrition programme that targets both undernutrition and overnutrition. While formulating standalone policies for both forms of malnutrition is relatively easier, customized policies and programmes are needed to combat the conflicting situation of dietary excess and deprivation at the household level.

Summary Background WHO's haemoglobin cutoffs to define anemia were based on five studies of predominantly White adult populations, done over 50 years ago. Therefore, a general re-examination of the existing haemoglobin cutoffs is warranted for global application, in representative healthy populations of children and adults. Such data are scarce in low-income and middle-income countries; however, a 2019, large-scale, nationally representative survey of children and adolescents aged 0–19 years in India (Comprehensive National Nutrition Survey [CNNS]) offered an opportunity for this re-examination. Using this survey, we aimed to assess the age-specific and sex-specific percentiles of haemoglobin and cutoffs to define anaemia in the CNNS population. Methods For this population-based study, we constructed age-specific and sex-specific haemoglobin percentiles from values reported for a defined healthy population in the CNNS, which used rigorous quality control measures during sample collection and in the laboratory analyses. To obtain a healthy population, we excluded participants with iron, folate, vitamin B12, and retinol deficiencies; inflammation; variant haemoglobins (haemoglobin A2 and haemoglobin S); and history of smoking. We considered age-specific and sex-specific 5th percentiles of haemoglobin derived for this healthy population as the study cutoff to define anaemia. We compared these with existing WHO cutoffs to assess significant differences between them at each year of age and sex for quantifying the prevalence of anaemia in the entire CNNS sample. Findings Between Feb 24, 2016, and Oct 26, 2018, the CNNS survey collected blood samples from 49 486 individuals. 41 210 participants had a haemoglobin value, 8087 of whom were included in our study and comprised the primary analytical sample. Compared with existing WHO cutoffs, the study cutoffs for haemoglobin were lower at all ages, usually by 1–2 g/dL, but more so in children of both sexes aged 1–2 years and in girls aged 10 years or older. Aanemia prevalence with the study cutoffs was 19·2 percentage points lower than with WHO cutoffs in the entire CNNS sample with valid haemoglobin values across all ages and sexes (10·8% with study cutoffs vs 30·0% with WHO cutoffs). Interpretation These findings support the re-examination of WHO haemoglobin cutoffs to define anaemia. Our haemoglobin reference percentiles, derived from healthy participants in a large representative Indian survey, are suitable for national use in India. Substantial variations in the 5th percentile of haemoglobin values across the 1–19 years age range and between sexes argue against constructing common cutoffs in stratified age groups for convenience. Funding None. Translations For the Hindi, Punjabi, Tamil and Kannada translations of the abstract see Supplementary Materials section.

Background The stability of biological samples is vital for reliable measurements of biomarkers in large-scale survey settings, which may be affected by freeze-thaw procedures. We examined the effect of a single freeze-thaw cycle on 13 nutritional, noncommunicable diseases (NCD), and inflammatory bioanalytes in serum samples. Method Blood samples were collected from 70 subjects centrifuged after 30 minutes and aliquoted immediately. After a baseline analysis of the analytes, the samples were stored at − 70°C for 1 month and reanalyzed for all the parameters. Mean percentage differences between baseline (fresh blood) and freeze-thaw concentrations were calculated using paired sample t-tests and evaluated according to total allowable error (TEa) limits (desirable bias). Results Freeze-thaw concentrations differed significantly (p < 0.05) from baseline concentrations for soluble transferrin receptor (sTfR) (− 5.49%), vitamin D (− 12.51%), vitamin B12 (− 3.74%), plasma glucose (1.93%), C-reactive protein (CRP) (3.45%), high-density lipoprotein (HDL) (7.98%), and cholesterol (9.76%), but they were within respective TEa limits. Low-density lipoprotein (LDL) (− 0.67%), creatinine (0.94%), albumin (0.87%), total protein (1.00%), ferritin (− 0.58%), and triglycerides (TAG) (2.82%) concentrations remained stable following the freeze-thaw cycle. In conclusion, single freeze-thaw cycle of the biomarkers in serum/plasma samples after storage at − 70°C for 1 month had minimal effect on stability of the studied analytes, and the changes in concentration were within acceptable limit for all analytes.

Alcohol use has a deleterious effect on the health status of persons living with HIV, negatively affecting antiretroviral adherence and increasing the risk of transmission. Alcohol use is not an isolated behavior but intimately linked to stigma and poor psychological status among other factors. This paper utilizes a crossover design to test the efficacy of three multilevel interventions, individual counselling (IC), group intervention (GI) and collective advocacy (CA) for change, among HIV positive males who consume alcohol, treated at five ART Centers in urban Maharashtra, India. While GI shows a significant effect on the largest number of outcome variables, IC through its psychosocial emphasis demonstrated a significant impact over time on stigma and depression, and CA with its emphasis on societal change showed positive impact on stigma and advocacy for self and others. Each of the interventions had variable effects on CD4 count and viral load.Clinical Registration Number: NCT03746457; Clinical Trial.Gov.El consumo de alcohol tiene un efecto nocivo en el estado de salud de las personas que viven con VIH, afectando negativamente la adherencia a los antirretrovirales y aumentando el riesgo de transmisión del virus. El consumo de alcohol no es un comportamiento aislado, sino que está íntimamente relacionado con el estigma y el mal estado psicológico, entre otros factores. Este documento utiliza un diseño cruzado para evaluar la eficacia de tres intervenciones: asesoramiento individual, intervención grupal y defensa colectiva para el cambio, entre hombres con VIH que consumen alcohol que reciben tratamiento en cinco centros de terapia antiretroviral en la zona urbana de Maharashtra, India. Si bien la intervención grupal muestra un efecto significativo en el mayor número de variables de interés, el asesoramiento individual a través de su énfasis psicosocial demostró un impacto significativo en el estigma y la depression a largo plazo, y la defensa colectiva con su énfasis en el cambio social mostró un impacto positivo en el estigma y la defensa de sí mismo y otros.

Tailored, one-on-one counseling delivered via cell phone was very effective in retaining mothers with HIV in care and in promoting infant HIV testing and antenatal and postnatal care attendance. The highest risk of loss to follow-up among women with HIV accessing PMTCT services was prior to delivery and then after infant HIV testing at 6 weeks. Challenges include continued limited access to cell phones, difficulty with reaching participants on the phone, and poor adherence to antiretroviral therapy for a substantial percentage of the population., Background: We evaluated the effectiveness of a cell phone counseling intervention to promote retention in care and HIV testing of infants among women with HIV accessing prevention of mother-to-child services in Kisumu, Kenya. Methods: Between May 2013 and September 2015, we recruited 404 pregnant women with HIV who were between 14 and 36 weeks of gestation and randomly assigned them to the intervention (n=207) or control arm (n=197). Retention was assessed at delivery and at 6 and 14 weeks postpartum. We also measured uptake of infant HIV testing. The intervention comprised a fixed protocol of counselor-delivered phone calls to provide one-to-one need-based support. The number of calls made varied depending on when participants presented for antenatal care services; the maximum number was 42. The control group received routine care. We evaluated retention at 3 time points using the complementary log-log regression model taking into account factors associated with retention and loss to follow-up time. We calculated the incidence rate for HIV transmission among infants and used binary logistic regression to identify predictors of HIV infection among infants. Results: Participants attended on average 63% of the required number of counseling calls during the study period. Retention was higher in the intervention arm than the control arm at delivery (95.2% vs. 77.7%, respectively); 6 weeks postpartum (93.9% vs. 72.9%, respectively); and 14 weeks postpartum (83.3% vs. 66.5%, respectively) (P90%, used to assess adherence to ART, was associated with lower odds of a positive HIV test among infants (adjusted odds ratio=0.20; 95% CI=0.04, 0.99). Attendance at antenatal and postnatal care visits was higher among participants in the intervention arm than the control arm. Conclusions: The one-on-one tailored counseling delivered via cell phone was effective in retaining mothers with HIV infection in care and promoting uptake of infant HIV testing and antenatal and postnatal care services. Phone counseling offers a practical approach to reach and retain pregnant women with HIV infection and postpartum mothers in care, but greater emphasis on collection of medications and adherence is required.

Background: Stunting and underweight are the most commonly used indicators to assess the nutritional status of children. Prior research has highlighted the problems encountered while measuring the height of child. The current paper aims to assess the relationship between stunting and underweight and derive regression equations to predict stunting from underweight prevalence among children under five years of age.Method: Data was drawn from 38,060 and 219,796 nationally representative sample of children aged 0-4 years, from Comprehensive National Nutrition Survey (CNNS, 2016-18) and National Family Health Survey 4 (NFHS-4, 2015-16), respectively. Anthropometric indicators, stunting and underweight was calculated based on the 2006 WHO Child Growth Standards. Univariate and bivariate analysis was done to obtain estimates for stunting and underweight. A series of regression models were run to obtain an estimate of percent stunted as a function of percent underweight at the national and regional level. Predicted stunting prevalence was estimated from regression equation for selected states and compared with observed prevalence from other studies. Data were analysed using STATA V.16.0. Results: Nearly one out of four children under 5 years of age were stunted and underweight in CNNS and NFHS-4. Out of those stunted, 67% and 65% were underweight in CNNS and NFHS-4, respectively. At the national level, there was high correlation between the two indicators (r > 0.7) in both CNNS and NFHS-4, whereas at the regional level in NFHS-4, the correlation coefficient ranged from 0.32 for central region to 0.86 for southern region. At the national level the slope was 0.557 in CNNS and 0.610 in NFHS-4. At the regional level, it varied from 0.334 in the central region to 0.847 in the western region. Similarly, at the national level, the intercept (α) was almost same when we analyzed CNNS data or NFHS-4 data or both together (~15), however, wide variability was observed between different regions (4.61 in western region to 30.14 in central region).Conclusion: Our analysis shows that regression equations with child underweight prevalence may be used to predict stunting where the quality of length/ height measurement is poor or unavailable, in regions where high correlation between the two indicators was found.

Background: Malnutrition is a complex phenomenon that has become a universal problem inhibiting human development. India is home of disproportionate height and weight of children including anemia are sign of malnutrition. This study aimed to examine child malnutrition by considering three parameters—stunting (short), underweight (thin), and/or anaemia—among children aged 1–9 years. Methods: This study used nationally representative data from the Comprehensive National Nutrition Survey (CNNS). The analytic sample was restricted to 25,885 children aged 1–9 years for whom data on height, weight, and haemoglobin level was available. This analytic sample was not significantly different from the total sample of 69,413. Based on World Health Organisation’s (WHO) cut-off for child growth standards, child malnutrition is defined as ‘severe’ if a child has suffered all 3 parameters—stunting, underweight, and anaemia, ‘mild/moderate’ if a child has suffered 1 or 2 parameters and ‘none’ if a child has not suffered from any of the 3 parameters. Univariate and bivariate analysis were used for descriptive associations and marginal effects probabilities were calculated using the ordinal logit regression model to identify the correlates of severe malnutrition. Results: Nine percent of children aged 1-9 years were severely malnourished in the country. The prevalence of malnutrition declined considerably with increasing age of children—13% in children aged 1–4 years to 6% in children aged 5–9 years. Severe malnutrition was significantly higher among higher birth order children, children born to illiterate mothers, children belonging to Scheduled Tribes and poor families, children living in rural areas and the eastern region of the country. Zinc deficiency was found more (22%, 95% CI:18.2–26.0) among severely malnourished children as compared to normal children (16%, 95% CI:13.9–17.3). Conclusions: Malnutrition is widely prevalent in children belonging to illiterate mothers, Scheduled Tribes, poor families, rural areas, and eastern region of the country. Frontline workers should identify such vulnerable children through regular monitoring of height, weight, and haemoglobin testing in their coverage areas.

Background Conventional indicators used to access the nutritional status of children tend to underestimate the overall undernutrition in the presence of multiple anthropometric failures. Further, factors contributing to the rich-poor gap in the composite index of anthropometric failure (CIAF) have not been explored. Objective To estimate the prevalence of CIAF and quantify the contribution of factors that explain the rich-poor gap in CIAF. Methods The present study used data of 38,060 children under the age of five and their biological mothers, drawn from the nationally representative Comprehensive National Nutrition Survey of children and adolescents aged 0–19 years in India. The CIAF outcome variables in this study provide an overall prevalence of undernutrition, with six mutually exclusive anthropometric measurements of height-for‐age, height‐for‐weight, and weight‐for‐age, calculated using the WHO Multicenter Growth Reference Study. Multivariate regression and decomposition analysis were used to examine the association between covariates with CIAF and to estimate the contribution of different covariates in the existing rich-poor gap. Results An overall CIAF prevalence of 48.2% among children aged 0–4 years was found in this study. 6.0% children had all three forms of anthropometric failures. The odds of CIAF were more likely among children belonging to poorest households (AOR: 2.41, 95% CI: 2.12–2.75) and those residing in urban area (AOR: 1.06, 95% CI 1.00-1.11). Children of underweight mothers and those with high parity were at higher risk of CIAF (AOR: 1.51, 95% CI: 1.42–1.61) and (AOR: 1.15, 95% CI: 1.08–1.22), respectively. Children of mother exposed to mass media were at lower risk of CIAF (AOR: 0.87, 95% CI: 0.81–0.93). Conclusion This study estimated a composite index to assess the overall anthropometric failure, which also provides a broader understanding of the extent and pattern of undernutrition among children. Findings show that maternal covariates contribute the most to the rich-poor gap. As well, the findings suggest that intervention programs with a targeted approach are crucial to reach the most vulnerable groups and to reduce the overall burden of undernutrition.

BackgroundIntraindividual coexistence of anthropometrically defined undernutrition and “metabolic obesity”, characterised by presence of at least one abnormal cardiometabolic risk factor, is rarely investigated in young children and adolescents, particularly in Low-and-Middle-Income-Countries undergoing rapid nutrition transition. MethodsPrevalence of biomarkers of metabolic obesity was related to anthropometric and socio-demographic characteristics in 5-19 years old participants from the population-based Comprehensive National Nutrition Survey in India (2016-2018). The biomarkers, serum lipid-profile (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides), fasting glucose, and glycosylated hemoglobin (HbA1C), and all jointly were analysed in 22567, 23192, 25962 and 19143 participants, respectively.ResultsOverall (entire dataset), the prevalence of abnormalities was low (4.3-4.5%) for LDL and TC, intermediate for dysglycemia (10.9-16.1%), and high for HDL and triglycerides (21.7-25.8%). Proportions with ≥1 abnormal metabolic obesity biomarker(s) were 56.2% overall, 54.2% in thin (BMI-for-age 1SD BMI-for-age). Among poor participants, triglyceride, glucose and HDL abnormalities were higher. ConclusionsA paradoxical, counter-intuitive prevalence of metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents. There is a crucial need for commensurate investments to address overnutrition along with undernutrition. Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry alone.

Intra-individual coexistence of anthropometrically defined undernutrition and 'metabolic obesity', characterised by presence of at least one abnormal cardiometabolic risk factor, is rarely investigated in young children and adolescents, particularly in Low-and-Middle-Income-Countries undergoing rapid nutrition transition.Prevalence of biomarkers of metabolic obesity was related to anthropometric and socio-demographic characteristics in 5-19 years old participants from the population-based Comprehensive National Nutrition Survey in India (2016-2018). The biomarkers, serum lipid-profile (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides), fasting glucose, and glycosylated hemoglobin (HbA1C), and all jointly were analysed in 22567, 23192, 25962 and 19143 participants, respectively.Overall (entire dataset), the prevalence of abnormalities was low (4.3-4.5%) for LDL and TC, intermediate for dysglycemia (10.9-16.1%), and high for HDL and triglycerides (21.7-25.8%). Proportions with ≥1 abnormal metabolic obesity biomarker(s) were 56.2% overall, 54.2% in thin (BMI-for-age -2 SD) and 59.3% in stunted (height-for-age -2 SD) participants. Comparable prevalence was evident in mild undernutrition (-1 to -2 SD). Clustering of two borderline abnormalities occurred in one-third, warranting active life-style interventions. Metabolic obesity prevalence increased with BMI-for-age. Among those with metabolic obesity, only 9% were overweight/obese (1 SD BMI-for-age). Among poor participants, triglyceride, glucose and HDL abnormalities were higher.A paradoxical, counter-intuitive prevalence of metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents. There is a crucial need for commensurate investments to address overnutrition along with undernutrition. Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry alone.

HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and

Objective: Nationally representative percentiles for Waist Circumference (WC), Waist-to-Height-Ratio (WtHR) and Body Mass Index (BMI) are not available for children and adolescents in India. Methods: Using LMS method, age- and gender-specific reference growth charts were constructed for WC (n=68,261), WtHR (n=68,261) and BMI (n=67,741) from subjects aged 5-19 years who participated in a nationally representative survey. General obesity was defined as age-sex-specific BMI z-scores ≥95th percentile. Central obesity was defined in three ways: WC≥90th percentile, WtHR≥0·5 and both WC≥90th percentile and WtHR≥0·5 Findings: WC and BMI percentiles for boys and girls are lower than those previously reported from India and several other countries. The BMI percentiles are lower than the WHO 2007 reference population. The prevalence of general obesity using India specific BMI centiles was 2·9% (95%CI: 2·6,3·2). The prevalence of central obesity was 6·1% (95%CI: 5·7,6·6) using WC≥90thpercentile, 5·3% (95%CI: 5·0,5·7) using WtHR≥0·5 and 3·6% using both criteria. Three-fourth of children with general obesity also had central obesity based on WC≥90th. Conclusions: Indian children are thinner than Caucasian and other Asian children, and the global WHO reference population. Using India specific reference, the prevalence of central obesity is higher than general obesity, with a significant overlap between the two.

People living with HIV (PLHIV) on anti-retroviral treatment (ART) who drink are less adherent and more likely to engage in unprotected sex but the connections among these events are correlational. Using an adapted Timeline Follow-Back (A-TLFB) procedure, this paper examines the day by day interface of alcohol, medication adherence and sex to provide a fine grained understanding of how multiple behavioral risks coincide in time and space, explores concordance/discordance of measures with survey data and identifies potential recall bias. Data are drawn from a survey of behavior, knowledge and attitudes, and a 30 day TLFB assessment of multiple risk behaviors adapted for the Indian PLHIV context, administered to 940 alcohol-consuming, HIV positive men on ART at the baseline evaluation stage of a multilevel, multi-centric intervention study. On days participants drank they were significantly more likely to be medication non-adherent and to have unprotected sex. In the first day after their alcohol consuming day, the pattern of nonadherence persisted. Binge and regular drinking days were associated with nonadherence but only binge drinking co-occurred with unprotected sex. Asking about specific "drinking days" improved recall for drinking days and number of drinks consumed. Recall declined for both drinking days and nonadherence from the first week to subsequent weeks but varied randomly for sex risk. There was high concordance and low discordance between A-TLFB drinking and nonadherence but these results were reversed for unprotected sex. Moving beyond simple drinking-adherence correlational analysis, the A-TLFB offers improved recall probes and provides researchers and interventionists with the opportunity to identify types of risky days and tailor behavioral modification to reduce alcohol consumption, nonadherence and risky sex on those days.

Introduction Preanalytical conditions are critical for blood sample integrity and poses challenge in surveys involving biochemical measurements. A cross sectional study was conducted to assess the stability of select biomarkers at conditions that mimic field situations in surveys. Material and methods Blood from 420 volunteers was exposed to 2 - 8 °C, room temperature (RT), 22 - 30 °C and > 30 °C for 30 min, 6 hours, 12 hours and 24 hours prior to centrifugation. After different exposures, whole blood (N = 35) was used to assess stability of haemoglobin, HbA1c and erythrocyte folate; serum (N = 35) for assessing stability of ferritin, C-reactive protein (CRP), vitamins B12, A and D, zinc, soluble transferrin receptor (sTfR), total cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), tryglicerides, albumin, total protein and creatinine; and plasma (N = 35) was used for glucose. The mean % deviation of the analytes was compared with the total change limit (TCL), computed from analytical and intra-individual imprecision. Values that were within the TCL were deemed to be stable. Result Creatinine (mean % deviation 14.6, TCL 5.9), haemoglobin (16.4%, TCL 4.4) and folate (33.6%, TCL 22.6) were unstable after 12 hours at 22-30°C, a temperature at which other analytes were stable. Creatinine was unstable even at RT for 12 hours (mean % deviation: 10.4). Albumin, CRP, glucose, cholesterol, LDL, triglycerides, vitamins B12 and A, sTfR and HbA1c were stable at all studied conditions. Conclusion All analytes other than creatinine, folate and haemoglobin can be reliably estimated in blood samples exposed to 22-30°C for 12 hours in community-based studies.

Unprotected sex, common among people who inject drugs, puts them and their partners at risk of sexually transmitted infections including human immunodeficiency virus (HIV). This analysis assesses the changes in sexual risk behavior with regular female partners (RFPs), among married men who inject drugs, before and after implementation of a HIV prevention intervention, and identifies correlates of unprotected sex. People who inject drugs (PWID) were assessed at three points: baseline, preintervention follow-up visit (FV)1, and postintervention FV2. Descriptive analysis was used for reporting changes in sexual behavior over time. Generalized estimating equation assessed the population-averaged change in self-reported unprotected sex with an RFP, attributable to intervention uptake. Multivariable logistic regression determined correlates of self-reported unprotected sex with an RFP at FV2. Findings suggest that the proportion of men reporting any unprotected sex remained high (baseline = 46.0%, FV1 = 43.5%, FV2 = 37.0%). A reduction was observed in unprotected sex after the intervention phase, but this could not be attributed to uptake of the intervention. Higher odds of self-reported unprotected sex with an RFP in the past three months at FV2 were associated with self-reported unprotected sex at baseline, living with family, and being HIV-negative. Married male PWID should receive counseling for safe sex with RFPs, especially those who are HIV-negative and live with their families.

This paper reports the results of a three-country study of the social, economic and health vulnerabilities of migrants from Bangladesh and Nepal living in India and of returnees. Overall, migration was found to be economically beneficial for those who succeed in the host labour market. However, it is associated with significant psychosocial and health vulnerabilities for most migrants in both communities. Further, migrants returning to their home countries with expectations of a better life continue to be in debt and experience poor health, indicating that migration may not always alleviate economic distress and highlighting the need for financial guidance.

To assess the prevalence and correlates of perinatal depression, 200 HIV-positive pregnant/post-partum women receiving antiretroviral therapy (ART) were interviewed at eight government ART centers in four states across India. 52.5% (105) participants had depressive symptomology (Edinburgh Postnatal Depression Scale score > 13) while 23% of the participants reported thoughts of self-harm; there was no difference between pregnant and postpartum participants. Poor illness perception was associated with depression (AOR, 1.09; 95%CI, 1.05, 1.14); there was no association between adherence and depression in this population.

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Background WHO, UNODC, and UNAIDS recommend a comprehensive package for prevention, treatment, and care of HIV among people who inject drugs (PWID). We describe the uptake of services and the cost of implementing a comprehensive package for HIV prevention, treatment, and care services in Delhi, India. Methods A cohort of 3774 PWID were enrolled for a prospective HIV incidence study and provided the comprehensive package: HIV and hepatitis testing and counseling, hepatitis B (HB) vaccination, syndromic management of sexually transmitted infections, clean needles-syringes, condoms, abscess care, and education. Supplementary services comprising tea and snacks, bathing facilities, and medical consultations were also provided. PWID were referred to government services for antiretroviral therapy (ART), TB care, opioid substitution therapy, and drug dependence treatment/rehabilitation. Results The project spent USD 1,067,629.88 over 36 months of project implementation: 1.7% on capital costs, 3.9% on participant recruitment, 26.7% for project management, 49.9% on provision of services, and 17.8% on supplementary services. Provision of HIV prevention and care services cost the project USD 140.41/PWID/year. 95.3% PWID were tested for HIV. Of the HIV-positive clients, only 17.8% registered for ART services after repeated follow-up. Reasons for not seeking ART services included not feeling sick, need for multiple visits to the clinic, and long waiting times. 61.8% of the PWID underwent HB testing. Of the 2106 PWID eligible for HB vaccination, 81% initiated the vaccination schedule, but only 29% completed all three doses, despite intensive follow-up by outreach workers. PWID took an average of 8 clean needles-syringes/PWID/year over the project duration, with a mid-project high of 16 needles-syringes/PWID/year. PWID continued to also procure needles from other sources, such as chemists. One hundred five PWID were referred to OST services and 267 for rehabilitation services. Conclusions A comprehensive HIV prevention, treatment, and care package is challenging to implement. Extensive efforts are needed to ensure the uptake of and retention in services for PWID; peer educators and outreach workers are required on a continuous basis. Services need to be tailored to client needs, considering clinic timing and distance from hotspots. Programs may consider provision of ART services at selected drop-in centers to increase uptake.

We present qualitative research investigating demand-side barriers to uptake of paediatric HIV services in Kenya. We explore community perceptions of services in 3 provinces where paediatric treatment is readily available but under-utilised, aiming to focus on demand-side obstacles and derive strategies for increasing uptake. We conducted focus-group discussions with openly HIV-positive parents and caregivers of children aged up to 15 years (n = 7 groups), and clinic- and community-based healthworkers (n = 13 groups); and individual in-depth interviews with managers and Ministry of Health representatives (n = 6 interviews). Results revealed low community awareness of medical indications for paediatric HIV testing, alongside widespread anxieties about potential infection routes. Care-seeking delays reflect strong perceived associations between antiretroviral treatment (ART) and mortality. Despite free drugs available from the Kenyan government, costs for laboratory services, medications for opportunistic infections, transportation and nutritional needs remain major obstacles. Attitudinal barriers include fatalistic beliefs about early death for infected children and reliance on traditional healers. Stigma reduces access, especially as paediatric testing represents a “window” into parental HIV status. Apprehensive caregivers fear the lifelong nature of ART and report adherence struggles. Even when paediatric ART is relatively accessible, demand-side barriers impede uptake and must be addressed at community and facility levels.

BACKGROUND: India has an estimated 177000 injection drug users (IDU) with a national HIV prevalence of 7.14%. Reliable estimates of HIV incidence are not available for this population. METHODS: We report HIV incidence in a cohort of male HIV-negative IDUs recruited through peer-referral targeted outreach and as walk-in clients in Delhi from May to October 2011. Fourth-generation Antigen-Antibody tests were used to diagnose new infections and results were confirmed using Western blot tests. HIV incidence based on HIV seroconversion was calculated as number of events/person-years. Cox regression was used to identify significant (p

Objectives Country decision-making regarding adoption of new health technologies is a lengthy process that is informed by scientific, public health, and policy analyses. Key Opinion Leaders (KOLs), who include a range of influential individuals (e.g., Ministry of Health officials, leaders of medical and pharmacy associations, civil society representatives, donors), play a critical role in country decision-making around adoption and availability of new HIV-prevention tools. Their perspectives can shape public opinion and influence policy, programming, and procurement decisions. Methods In-depth face-to-face interviews with a dozen purposefully selected national KOLs in India were conducted to gain their perspectives around ARV-based prevention for women, focusing on microbicides in general and tenofovir vaginal gel specifically. Theme-based content emerged and was analyzed using ATLAS.ti software. Results While generally supportive, KOLs expressed caveats regarding the role tenofovir gel might play in the overall HIV-prevention program. Key outstanding issues that would need to be addressed include product effectiveness, potential for resistance, product cost, feasibility of HIV testing and re-testing, and effective targeting of key populations for public health impact. Conclusions As new HIV-prevention technologies advance through clinical trials, there is a concomitant necessity to engage in policy analysis exercises. Formative research with stakeholders early in the process is an important yet often overlooked step. The potential role that the tenofovir gel could play in India will depend in large part on epidemiological, public health, and economic factors. Understanding target populations' perspectives on the product will also be critical for its successful introduction.

We report baseline findings from a longitudinal cohort study to examine HIV incidence, high-risk injection and sexual behaviors of 3,792 male injection drug users (IDUs) in Delhi. The majority (95.4 %) accepted HIV testing; HIV prevalence was 21.9 %. In multivariate analysis, belonging to states adjacent to Delhi (AOR: 1.23; 95 % CI: 1.07-1.52), earning INR 500-1,500 (AOR: 2.38; 95 % CI: 1.43-3.96); duration of drug use 2-5 years (AOR: 2.02; 95 % CI: 1.09-3.73), 6-10 years (AOR: 2.81; 95 % CI: 1.55-5.11), ≥11 years (AOR: 3.35; 95 % CI: 1.84-6.11); prior HIV testing (AOR: 1.60; 95 % CI: 1.35-1.91), self-reported risky-injection behavior (AOR: 1.60; 95 % CI: 1.33-1.92), and utilization of harm-reduction services (AOR: 1.32; 95 % CI: 1.11-1.58) were positively associated with HIV infection. Alcohol use ≤2 times/week (AOR: 0.67; 95 % CI: 0.55-0.82) or ≥3 times/week (AOR: 0.74; 95 % CI: 0.54-1.01), unit increase in age (AOR: 0.99; 95 % CI: 0.98-1.00), ≥7 years of schooling (AOR: 0.82; 95 % CI: 0.66-1.02) and unsafe sex with any female partner (AOR: 0.69; 95 % CI: 0.55-0.86) were negatively associated with HIV infection. HIV prevalence remains high among male IDUs in Delhi. HIV prevention programs should include comprehensive package of services for IDUs.

Respondent-driven sampling was used to recruit female sex workers (FSWs) for a community survey conducted in southern India. After survey completion, participants were given a brochure describing a clinical trial that entailed daily use of a placebo vaginal gel for four months. This study assessed predictors of screening among survey respondents, predictors of enrollment among those eligible for the trial, and predictors of visit attendance and retention among those enrolled. FSWs who reported having symptoms of sexually transmitted infections (STI), engaging in sex work in the past month, and living in a subdistrict easily accessible by public transportation with a high concentration of FSWs, were more likely to screen. FSWs who had never been tested for HIV were more likely to enroll. This analysis suggests that the primary reason FSWs participated in the trial was a desire for health care-not other factors hypothesized to be important, e.g., HIV risk perception and poverty status.

Background The reliability and validity of self-reports of vaginal microbicide use are questionable given the explicit understanding that participants are expected to comply with study protocols. Our objective was to optimize the Population Council's previously validated dye stain assay (DSA) and related procedures, and establish predictive values for the DSA's ability to identify vaginally inserted single-use, low-density polyethylene microbicide applicators filled with hydroxyethylcellulose gel.

HIV and AIDS remain highly stigmatised. Modified directly observed therapy (m-DOT) supports antiretroviral treatment (ART) adherence but little is known about its association with perceived stigma in resource-constrained settings. In 2003, 234 HIV-infected adults enrolled in a two-arm randomised trial comparing a health centre-based m-DOT strategy with standard self-administration of ART. Data on perceived stigma were collected using Berger's HIV stigma scale prior to starting ART and after 12 months. This was a secondary analysis to examine whether perceived stigma was related to treatment delivery. Perceived stigma scores declined after 12 months of treatment from a mean of 44.9 (sd=7.6) to a mean of 41.4 (sd=7.7), (t=6.14, P

The effectiveness of modified-directly observed therapy (m-DOT), an adherence support intervention adapted from TB DOTS programmes, has been documented. Describing the implementation process and acceptability of this intervention is important for scaling up, replication in other settings and future research. In a randomised trial in Mombasa, Kenya, patients were assigned to m-DOT or standard of care for 24 weeks. m-DOT entailed twice weekly visits to a health centre for medication collection, ongoing adherence counselling and nurse-observed pill ingestion. Community health workers (CHWs) traced non-attendees, observing pill taking at participant's home. Using process indicators and a semi-structured questionnaire, implementation of m-DOT was evaluated among 94 participants who completed 24 weeks m-DOT (81%; 94/116). Two-thirds of m-DOT recipients were female (64%; 74/116) and a mean 37 years (SD = 7.8). Selection of the m-DOT observation site was determined by proximity to home for 73% (69/94), with the remainder choosing sites near their workplace, or due to perceived high-quality services. A median 42 of 48 scheduled m-DOT visits (IQR = 28-45) were attended. Most found m-DOT is very useful (87%; 82/94) and had positive attitudes to the services. A high proportion received CHWs home visits (96%; 90/94) and looked forward to these. Use of CHWs and several satellite observation sites facilitated provision of services closer to patient's homes. A substantial number, however, thought 24 weeks of m-DOT was too long (43%; 42/94). Our experience suggests that m-DOT services could be implemented widely and are acceptable if delivered with adequate attention to coordination, provision of a broad set of interventions, shifting tasks to less-specialised workers and integration within the health system. m-DOT programmes should utilise existing resources while simultaneously expanding capacity within communities and the public sector. These findings could be used to inform replication of such services and to improve the design of m-DOT in future studies.