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As UNAIDS 90-90-90 targets for people living with HIV are increasingly being reached in many contexts, health-related quality of life (HRQoL), the ”fourth 90”, warrants special attention. HIV-related stigma and discrimination remain major barriers for overall HRQoL despite impressive clinical and virological improvements in HIV care. We reviewed original publications examining the impact of interventions to reduce stigma as experienced by people living with HIV in all income settings between 2010–2018. Our search identified a lack of well-designed intervention studies that documented stigma reduction and few studies that specifically assessed the impact of stigma on HRQoL. Further, few interventions targeted discrimination from providers outside HIV-specific care or involved people living with HIV in both the design and implementation. Lastly, evidence on methods to reduce stigma among several underrepresented key populations and geographic regions was limited and research on intersectional stigma, i.e. the convergence of multiple stigmatized identities, needs further attention.

Introduction: HIV epidemic has become the major problems among people with injecting drugs (PWIDs) in Nepal. The study was carried out to assess the prevalence of sexually transmitted diseases including HIV/AIDS among PWIDs. Methods: This descriptive cross-sectional survey was conducted in male PWIDs of age more than 16 years residing in Western to Far West Terai Districts of Nepal who had been injecting drugs for three months prior to the date of the survey" March-April 2017. A two-stage cluster sampling was used to recruit 300 PWIDs from seven Districts. HIV was diagnosed by using standard techniques approved by WHO. Similarly, Syphilis was tested using the "Rapid Plasma Reagin" and Hepatitis C, as well as Hepatitis B, was tested by using rapid test kits. Demographic data were collected by using a structured questionnaire and the data obtained were entered in MS excel was transformed into the SPSS version 21 for the descriptive as well as inferential analysis. Results: Prevalence of HIV, HBV, HCV, and STI among PWIDs were 5.3%, 2.7%, 23.7%, and 2.0% respectively. Majority of the PWIDs were literate (93.7%) and their age was below 35 years. Among the married PWIDs, 32.4% had got married before the age of 19. Similarly, 53.7% of them were living with their female sexual partner, and 95.0% were living with their wife. Ninety-six per cent of the respondents reported to be ever involved in sexual activity, 77.1% of them initiated the sexual intercourse before the age of 20 years and 41.9% of them had more than one female sexual partner. The survey indicated that 36.3% had been injecting drugs for more than 5 years while 27.7% had been injecting for last 2-5 years and 55.0% of the respondents had injected for the first time at the age of 16-24 years. About one in 10 respondents had started injecting drugs recently. Conclusion: There is a high prevalence of HIV, HCV, HBV and active syphilis among the PWIDs. Co-infection of HIV and HCV, as well as Hepatitis B and C, were also prevalent among PWIDs. Comprehensive education and awareness program is required to reduce the prevalence. Keywords: Prevalence, people with injecting drugs, HIV/AIDS, Nepal DOI: http://doi.org/10.3126/jkahs.v2i2.25168

Background Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico. Methods We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017. Results All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries—apart from Ecuador—across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups—the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017. Conclusions Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Additional file 1: Table S1. Participant characteristics of the Integrated Biological Behavioural Surveys, Pokhara Valley (Nepal).

Background HIV is a major public health issue around the world, especially in developing countries. Although the overall prevalence of HIV in Nepal is relatively low, there are specific sub-populations where the prevalence is far higher than the national average. One of these sub-groups is male people who inject drugs (male PWIDs). In order to understand the reasons for the differences in prevalence, a series of socio-demographic, behavioural and knowledge-based risk factors need to be assessed. Methods The study used a series of 7 cross-sectional survey datasets from Pokhara (Nepal), collected between 2003 and 2017 (N = 2235) to investigate trends in HIV prevalence among male PWIDs by socio-demographic and behavioural and knowledge-based risk factors. A series of logistic regression models were conducted to investigate the association between study factors and HIV. Results HIV prevalence decreased from the levels seen in 2003 (22.0%) and 2005 (21.7%), with the lowest prevalence recorded in 2015 (2.6%), however prevalence has increased in the most recent period (4.9%). A lower risk of HIV was associated with younger age ( 24 years, OR = 0.17, 95% CI = 0.10–0.31), being married (OR = 1.91, 95% CI = 1.25–3.02) and shorter duration of drug use ( 4 years, OR = 0.16, 95% CI = 0.09–0.29). A higher risk of HIV was associated with low (compared to secondary or higher) education level (OR = 2.76, 95% CI = 1.75–4.36), a lack of addiction treatment (OR = 2.59, 95% CI = 1.64–4.08), and recent use of unsterilized injection equipment (OR = 2.22, 95% CI = 1.20–4.11). Conclusion The prevalence of HIV in male PWIDs in Pokhara has been variable, but overall has reduced in recent years to 2.6% before increasing in 2017 to 4.9%. The main determinants which increase the risk of HIV among male PWIDs in Pokhara are low education level, a lack of treatment for drug addiction and the recent use of unsterilised equipment. Each of these indicate the need to improve addiction treatment and education programs for intra-venous drug use to aid this key population in avoiding risk-taking behaviours.

Background HIV is a major public health issue around the world, especially in developing countries. Although the overall prevalence of HIV in Nepal is relatively low and the country itself is considered low risk, there are specific sub-populations where the prevalence is far higher than the national average. One of these sub-groups is male injection drug users (IDUs). In order to understand the reasons for the differences in prevalence, a series of socio-demographic, behavioural and knowledge-based risk factors need to be assessed.Methods The study used a series of 7 cross-sectional survey datasets, collected between 2003 and 2017 (N=2,235) to investigate trends in HIV prevalence among male IDUs by key socio-demographic and behavioural and knowledge-based risk factors. A series of logistic regression models were conducted to investigate the association between study factors and HIV in the Pokhara valley, Nepal.Results A lower risk of HIV was associated with younger age (≤24 years compared to >24 years, OR = 0.17, 95% CI = 0.10, 0.31), not being married (OR = 0.51, 95% CI = 0.33, 0.80) and shorter duration of drug use (≤4 years compared to >4 years, OR = 0.16, 95% CI = 0.09, 0.29). A higher risk of HIV was associated with low (compared to secondary or higher) education level (OR = 2.76, 95% CI = 1.75, 4.36), a lack of addiction treatment (OR = 2.59, 95% CI = 1.64, 4.08), and recent use of unsterilized injection equipment (OR = 2.22, 95% CI = 1.20, 4.11).Conclusion Although knowledge of HIV is high among male IDUs, the prevalence of individuals who possess comprehensive knowledge and the number of individuals who have received treatment for drug addiction has decreased. This may indicate that addiction treatment and HIV education programs need to be strengthened.

ObjectivesWe examined the prevalence of inconsistent condom use and its correlates among people living with HIV (PLHIV) in the Asia-Pacific region.MethodsBetween 1 October 2012 and 31 May 2013, a total of 7843 PLHIV aged 18–50 years were recruited using targeted and venue-based sampling in Bangladesh, Indonesia, Lao People’s Democratic Republic (PDR), Nepal, Pakistan, Philippines and Vietnam. Logistic regression was used to explore the association between condom use behaviour and demographics, social support, stigma and discrimination and various health-related variables.ResultsOverall, 43% of 3827 PLHIV practised inconsistent condom use at sexual intercourse with their regular partner. An even higher proportion, 46% of 2044 PLHIV admitted that they practised unprotected sex with a casual partner. Participants from Lao PDR reported the lowest prevalence of inconsistent condom use for both regular and casual partners, while participants from the Philippines had the highest risk behaviour. Inconsistent condom use was significantly associated with belonging to a key population (drug user, sex worker or refugee subpopulation), not knowing that condoms are still needed if both partners are HIV positive, having a regular partner whose HIV status was either positive or unknown, having experienced physical assault and not receiving antiretroviral treatment.ConclusionsThis large seven-country study highlights a high prevalence of inconsistent condom use among PLHIV in the Asia-Pacific region. In addition to knowledge-imparting interventions, the adoption and expansion of the ‘Test and Treat’ strategy could help to maximise the prevention benefits of antiretroviral treatment.

Background: MSM and TG in Nepal experience considerable discrimination and marginalisation: they are subject to abuse from legal authorities and suffer from mental health issues and substance abuse. This study aims to assess the prevalence of HIV and syphilis, in addition to how individual and socio-structural factors influence sexual risk behaviour and health care service uptake, among MSM and TG in the Terai highway districts of Nepal. Methods: A cross-sectional survey was conducted in June 2016 among MSM and TG in eight Terai highway districts of Nepal, recruiting 340 MSM and TG through respondent driven sampling. The primary outcome variables were HIV and syphilis prevalence. The secondary outcome variables were sexual risk behaviour and health care service uptake. Logistic regression models were used to assess the individual and socio-structural determinants of sexual risk behaviour and health care service uptake. Results: The prevalence of HIV among MSM was 5%, whereas it was 13% in TG. The prevalence of active syphilis was 4% in the MSM group and 11% among TG. Among TG, 76% were involved in sex work, and 51% reported having experienced discrimination in one or more settings. In multivariable analysis, having visited an outreach centre was positively associated with condom use in the most recent sexual encounter among both MSM (AOR: 5.37, 95% CI: 2.42 - 11.94, p

BACKGROUND Most low-income settings experiencing concentrated HIV epidemic lack information about key populations (KPs), including people who inject drugs (PWID), men who have sex with men (MSM), male sex workers (MSW), transgender (TG) and female sex workers (FSW) because they are hidden and marginalised in society and frequently undocumented. Out of several approaches to size estimation, mapping and size estimation is particularly useful when local estimates are needed for planning and monitoring of prevention programmes. OBJECTIVE To locate hot spots related to sex work, cruising spots, and injecting drug use, and to estimate the number of sex workers, PWID, MSM, MSW and TG at the district level (adjusting for double-counting, frequency of visiting spots, and low visibility), and at the national level using extrapolation algorithms . METHODS The mapping exercise among MSM, MSW, TG, PWID and FSW was carried out in 44 districts of Nepal between July and November 2016 by collecting relevant information directly from hotspots where KPs members congregate. Districts to be mapped were selected purposively, to both provide data to local programmes in areas with high concentrations of KPs, and inform extrapolation to unmapped districts as part of national estimation procedures. RESULTS Altogether 11056 KPs and 10977 non- KPs informants were interviewed from across the 44 mapped districts to identify the hotspots. District level adjustment factors (mobility adjustment, frequency adjustment and invisibility adjustment) were sequentially applied. The final estimates used all three adjustment factors. We found that the national estimate of FSW in Nepal ranges between 43,829 to 54,207. The national estimate of MSM/TG lies between 88,009 and 112,150, of which a minimum of 18,704 and maximum 24,216 are TG, and a minimum 53,373 and maximum 67,292 are MSM. And finally the national estimate of PWID ranges between 27,248 to 34,487. Among them, a minimum 24,572 and a maximum 30,561 are men, and minimum 2,676 and maximum 3,926 are women. CONCLUSIONS The size of KPs provided through mapping exercise can be utilised for setting benchmarks and measuring program coverage. The major limitation is that mapping may count the majority of KPs who visit hotspots on a very regular basis, while missing the subset who are not “hotspot based” or who visit hotspots less frequently. However, the strength of mapping is that it reflects hands-on knowledge and experience of people who have access to communities that outside researchers may not have, thereby accounting for people who might otherwise be invisible.

ObjectivesTo assess the demographic, behavioural, psychosocial and structural factors associated with non-utilisation of HIV testing and counselling (HTC) services by female sex workers (FSWs) and men who have sex with men/transgender (MSM/TG).MethodsThis study involved a cross-sectional design. We used the national surveillance survey data of 2012, which included 610 FSWs and 400 MSM/TG recruited randomly from 22 and three districts of Nepal, respectively. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using modified Poisson regression was used to assess and infer the association between outcome (non-utilisation of HTC in last year) and independent variables.ResultsNon-utilisation of HTC in the last year was 54% for FSWs and 55% for MSM/TG. The significant factors for non-utilisation of HTC among FSWs were depression (aPR=1.4 (95% CI 1.1 to 1.6)), injectable drug abuse (ever) (aPR=1.4 (95% CI 1.1 to 1.8)), participation (ever) in HIV awareness programmes (aPR=1.2 (95% CI 1.0 to 1.4)), experience of forced sex in previous year (aPR=1.1 (95% CI 1.0 to 1.3)) and absence of dependents in the family (aPR=1.1 (95% CI 1.0 to 1.3)). Non-utilisation of HTC among MSM/TG had significant association with age 16–19 years (aPR=1.4 (95% CI 1.1 to 1.7)), non-condom use (aPR=1.2 (95% CI 1.0 to 1.4)), participation (ever) in HIV awareness programmes (aPR=1.6 (95% CI 1.3 to 2.0)), physical assault in previous year (aPR=1.8 (95% CI 1.0 to 3.1)), experience of forced sex in previous year (aPR=0.5 (95% CI 0.3 to 0.9)).ConclusionAlthough limited by cross-sectional design, we found many programmatically relevant findings. Creative strategies should be envisaged for effective behavioural change communication to improve access to HIV testing. Psychosocial and structural interventions should be integrated with HIV prevention programmes to support key populations in accessing HIV testing.

Objective To discuss the basic standards for HIV related integrated biological and behavioural surveillance (IBBS) survey implementation, specific challenges of survey management, and to propose brief practical guidelines for management of IBBS surveys in resource limited setting. Methods Two methods were used to address our study objectives: (a) a narrative review of the literature and (b) our experience as participant observer when working on IBBS survey management between July 2012 and January 2013 in Nepal. Results In Nepal, IBBS surveys are conducted among key populations at higher risk of HIV such as people who inject drugs, men who have sex with men, female sex workers, seasonal male labour migrants and truckers (proxy for clients of female sex workers). The involvement of different institutions, people, and procedures makes IBBS survey management-including planning, implementation, sharing of findings and possible uses of survey findings-complicated to perform. In addition, basic survey methods and techniques including respondent driven sampling and two stage cluster sampling, are sometimes not properly performed in practice. Conclusions This study showed that field implementation of some standards methods such as respondent driven sampling and cluster sampling for HIV related estimate or trends used for IBBS survey could be improved. This paper described lessons learnt and may be used as a guiding reference to improve and evaluate IBBS surveys in resource-poor settings also outside of Nepal.

Introduction The need for efficient retention in HIV care is more evident than ever because of the expansion of earlier ART initiation and the shift towards 'Test and Treat'. This study assesses factors affecting participation in the HIV care cascade among people living with HIV (PLHIV) in the Asia-Pacific Region. Methods A total of 7843 PLHIV aged 18-50 years were recruited using targeted and venue-based sampling between October 1, 2012, and May 31, 2013, across 59 sites in 7 countries (Bangladesh, Indonesia, Lao People's Democratic Republic (Lao PDR), Nepal, Pakistan, Philippines and Vietnam). Statistically significant associations between demographic and health system determinants, and various steps in the HIV care cascade were computed using a generalized structural equation model. Results A high proportion of PLHIV (40-51%) presented late for HIV care and delayed linkage to care in all seven countries. However, once PLHIV enrolled in care, retention in the various steps of the care cascade including adherence to antiretroviral treatment (ART) was satisfactory. The proportion still engaged in HIV care at 36 months post HIV diagnosis, varied from 78% in Nepal to >90% in Lao PDR. Similarly, the proportion of ART initiation who also were adherent to ART ranged from 91% in Bangladesh to >95% in Philippines/ Vietnam and from 70% in Lao PDR to 89% in the Philippines respectively. The following factors enhanced the likelihood of ART initiation and high adherence to HIV care and ART: good client-provider communication, high HIV treatment literacy, a referral from a health worker and TB/HIV co-infection. The following barriers were identified: young age, sex work, imprisonment, transgender identity, illiteracy, rural residence, alcohol/ injecting drug use, perceived poor health status, lack of health insurance, fear of confidentiality breach, self-referral for HIV testing, and public hospital as the place of HIV diagnosis. Conclusions HIV programme planners should ensure easy access to HIV testing and earlier linkage to HIV care among PLHIV. In addition, multiple socio-economic and health systems barriers need to be addressed along the HIV care cascade to reach the UNAIDS 90-90-90 target in the Asia-Pacific region.

We assessed changes in HIV prevalence and risk behaviours among young key populations in Nepal. A total of 7505 participants (aged 16–24 years) from key populations who were at increased risk of HIV infection (2767 people who inject drugs (PWID); 852 men who have sex with men/transgender (MSM/TG); 2851 female sex workers (FSW) and 1035 male labour migrants) were recruited randomly over a 12-year period, 2001–2012. Local epidemic zones of Nepal (Kathmandu valley, Pokhara valley, Terai Highway and West to Far West hills) were analysed separately. We found a very strong and consistent decline in HIV prevalence over the past decade in different epidemic zones among PWID and MSM/TG in Kathmandu, the capital city, most likely due to a parallel increase in safe needle and syringe use and increased condom use. A decrease in HIV prevalence in 22 Terai highway districts, sharing an open border with India, was also consistent with increased condom use among FSW. Among male labour migrants, HIV prevalence was low throughout the period in the West to Far West hilly regions. Condom use by migrant workers involved with FSW abroad increased while their condom use with Nepalese FSW declined. Other risk determinants such as mean age at starting first injection, injection frequency, place of commercial sex solicitation, their mean age when leaving to work abroad did not change consistently across epidemic zones among the young key populations under study. In Nepal, the decline in HIV prevalence over the past decade was remarkably significant and consistent with an increase in condom use and safer use of clean needles and syringes. However, diverging trends in risk behaviours across local epidemic zones of Nepal suggest a varying degree of implementation of national HIV prevention policies. This calls for continued preventive efforts as well as surveillance to sustain the observed downward trend.

Despite extensive distribution of free condoms and lubricants to prevent HIV transmission among men having sex with men (MSM) in Nepal, the prevalence of HIV and risky sexual behaviors remain high. The influence of individual-level, social-capital, and social-structural factors on HIV risk has been insufficiently explored in MSM. The authors assessed association of these factors with HIV risk among 150 MSM enrolled using snowball sampling in the Kathmandu Valley. HIV risk was calculated on the basis of number and type of sexual partners and condom use during anal sex. Multivariate analysis showed a high risk of HIV infection was significantly associated with being involved in sex work, having no knowledge of male sexually transmitted infection (STI) symptoms, and having a history of STI symptoms. HIV prevention could be made more effective by targeting MSM who are involved in sex work and by improving their knowledge of male STI symptoms and early diagnosis and treatment.

Objective: To estimate the prevalence of smoking among the college students and to identify the factors associated with smoking. Material & Methods: This is a cross sectional study carried out on 304 college students in Kathmandu valley using purposive sampling during the months of December 2009 to January 2010. The self administrated questionnaire was adopted from Global Youth Tobacco Survey 2007 (GYTS) and data were collected after the verbal consent taken. The statistical analysis was done using descriptive statistics, univariate and binary logistic regression to measure prevalence of smoking and to identify the association between dependent and independent variables. Results: We found 7 in 10 students were currently smokers. Among currently smokers, 78% were established smokers. The mean age of smoking onset was 14.15 years (SD=2.62). The mean number of cigarettes smoked per day was 5.03(SD=3.72) and average daily expenditure was Rs. 15.18 (SD=7.87). About 90% students tried to quit smoking and 17% non smokers were susceptibility smokers. The following factors: sex (adjusted odds ratio(aor)=3.88,95% CI= 2.12;7.11), living with or without family members (aor=1.79,95% CI=1.01;3.17), father occupation (aor=1.85,95% CI=1.04;3.30), and friend's smoking habits (aor=4.60,95% CI =1.92;11.0) were associated with cigarette smoking. Conclusion: There is the need of effective intervention programs to control cigarette smoking among college students. Key Words: Cigarette smoking; College students; Prevalence of smoking; Risk factors DOI: 10.3126/ajms.v1i2.3279Asian Journal of Medical Sciences 1 (2010) 53-58

Objectives: Sex workers face stigma, discrimination, and violence across the globe and are almost 14 times more likely to be HIV-infected than other women in low- and middle-income countries. In Asia, condom campaigns at brothels have been effective in some settings, but for preventive interventions to be sustainable, it is important to understand micro-level social and structural factors that influence sexual behaviours of sex workers. This study assessed the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers (FSWs) in Nepal. Methods: This quantitative study included 610 FSWs who were recruited using two-stage cluster sampling from September to November 2012 in 22 Terai Highway districts of Nepal. Rapid HIV tests and face-to-face interviews were conducted to collect biological and behavioural information. A count of physical (sexual violence and other undesirable events), social (poor social support and condom negotiation skills), and economic (unprotected sex to make more money) factors that operate at the micro-level was calculated to test the additive relationship to unprotected sex. Results: The HIV prevalence was 1%; this is presumably representative, with a large sample of FSWs in Nepal. The prevalence of unprotected sex with clients was high (24%). For each additional adverse physical, social, and economic condition, the probability of non-use of condoms with clients increased substantially: one problem = 12% (p

Sexual and gender minorities experience an elevated burden of suicidality compared with the general population. Still, little is known about that burden and the factors generating it in the context of low- and middle-income countries. The present study assessed the prevalence of suicidal ideation, planned suicide, and attempted suicide among men who have sex with men (MSM) and transgender people (TG) in Nepal, and examined the association of perceived discrimination on the basis of sexual orientation with suicidal ideation and with attempted suicide. Data were obtained from a surveillance survey among MSM and TG in Nepal in 2012. A sample of 400 MSM and TG, recruited using respondent-driven sampling, completed a structured face-to-face interview. Throughout their lifetime, 26.8% of the participants had experienced suicidal ideation, 12.0% had made a suicide plan, and 9.0% had attempted suicide. In particular, more TG than MSM had experienced suicidal ideation (39.8% vs. 21.3%), had made a suicide plan (19.5% vs. 8.9%), and had attempted suicide (15.3% vs. 6.4%). Overall, the odds of having experienced suicidal ideation was significantly higher among the 38.3% of participants who had perceived discrimination based on their sexual orientation (AOR: 3.17; 95% CI: 1.83-5.48). Moreover, the odds of suicidal ideation was significantly higher as the extent of perceived discrimination increased (AOR: 1.35; 95% CI: 1.15-1.60). However, the odds of attempted suicide was not significantly associated with perceived discrimination (AOR: 1.40; 95% CI: 0.62-3.15). The findings highlight perceived discrimination as an independent risk factor for suicidal ideation. Future suicide prevention programs should target sexual and gender minorities and include elements focusing on discrimination.

Background: Though financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal. Methods: This retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality. Results: The median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden 50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II). Conclusions: High mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients. publishedVersion

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold

Background Intimate partner violence (IPV) is an urgent public health priority. It is a neglected issue in women’s health, especially in urban slums in Nepal and globally. This study was designed to better understand the IPV experienced by young pregnant women in urban slums of the Kathmandu Valley, as well as to identify their coping strategies, care and support seeking behaviours. Womens’ views on ways to prevent IPV were also addressed. Methods 20 young pregnant women from 13 urban slums in the Kathmandu valley were recruited purposively for this qualitative study, based on pre-defined criteria. In-depth interviews were conducted and transcribed, with qualitative content analysis used to analyse the transcripts. Results 14 respondents were survivors of violence in urban slums. Their intimate partner(s) committed most of the violent acts. These young pregnant women were more likely to experience different forms of violence (psychological, physical and sexual) if they refused to have sex, gave birth to a girl, or if their husband had alcohol use disorder. The identification of foetal gender also increased the experience of physical violence at the prenatal stage. Interference from in-laws prevented further escalation of physical abuse. The most common coping strategy adopted to avoid violence among these women was to tolerate and accept the husbands’ abuse because of economic dependence. Violence survivors sought informal support from their close family members. Women suggested multiple short and long term actions to reduce intimate partner violence such as female education, economic independence of young women, banning identification of foetal gender during pregnancy and establishing separate institutions within their community to handle violence against young pregnant women. Conclusions Diversity in the design and implementation of culturally and socially acceptable interventions might be effective in addressing violence against young pregnant women in humanitarian settings such as urban slums. These include, but are not limited to, treatment of alcohol use disorder, raising men’s awareness about pregnancy, addressing young women’s economic vulnerability, emphasising the role of health care professionals in preventing adverse consequences resulting from gender selection technologies and working with family members of violence survivors. Electronic supplementary material The online version of this article (doi:10.1186/s12905-016-0293-7) contains supplementary material, which is available to authorized users.