School of Public Health
Respondent driven sampling (RDS): From surveillance to a novel intervention among men who sex with men and people who inject drugs in India
Globally, men who have sex with men (MSM) and people who inject drugs (PWID) continue to have a high burden of HIV infection despite an impressive scale up of HIV testing and prevention programs over the past decade. In India, MSM and PWID have the highest prevalence among all risk groups, approximately 15-25 times higher than the general population. The largest drop within the HIV care continuum for these populations occurs at diagnosis, with only 39% being aware of their positive status, well below the 90% goal set by UNAIDS by 2020. Significant attrition also occurs at the linkage and retention in care steps. Since many MSM and PWID are not self-referring for HIV testing and clinical care or sufficiently engaged by traditional outreach, novel strategies are needed to increase the number that are diagnosed and linked to care. For the purposes of surveillance, respondent-driven sampling (RDS), a sampling scheme that leverages peer network connections, has proved to be an efficient strategy for recruiting MSM and PWID in India, and particularly those undiagnosed and out of care. RDS through its utilization of peer-referral has the potential to be used beyond surveillance to become an intervention strategy to efficiently reach those that are not successfully engaged by other means. Therefore, this proposal seeks to inform and plan the implementation of a novel intervention strategy, which will use RDS to improve levels of awareness of HIV status and linkage to HIV care among MSM and PWID in India.
Global Health Project Grant Advisor/Mentor: Shruti Mehta, PhD
Upon arriving in Chennai, India, I was excited but also nervous about the upcoming time and work in India. Going into the experience, the only person that I knew in the city was the in-country faculty member. So, I was most apprehensive about starting out this experience alone. Of course, everyone that I met at YRG CARE, the partner organization working on the National Collaboration on AIDS (NCA) trial, was nice and welcoming. It was a real pleasure to finally meet in person those with which I had corresponded via email for the past three years! However, at first it was not easy to really get to know others working at YRG CARE. Most were busy with their work and everyday life. So it was a relief when a few days into my trip, I was introduced to an intern at the organization who was interested in public health and research. Being able to visit areas of the city and restaurants with a new friend automatically made me feel more comfortable in the strange surroundings of Chennai.
Most urban areas of India are chaotic, some would say perfect chaos. The constant sound of horns from buses, cars, and auto-rickshaws was an assault on my hearing, the heat and humidity made moving quite laborious, and exhaust and odors from trash, food, etc. made deep breaths difficult. By the end of my time in India, however, I can’t say I really noticed these things anymore. It is surprising what people can get used to. Adapting to local Indian culture took some time - with the exception of the food. I was already quite familiar with Indian food and as a vegetarian, it was a relief to always have delicious options available! I found ‘people watching’ to be a very good approach to learning about the local culture - watching how people interact with each other, what they wear, what and how they eat, etc. And, most people around you won’t necessarily give you instructions, so if you don’t know - ask! Living and working in a developing country requires a person to be kind, courteous, and proactive but most of all you have to be flexible. At some point (normally many points), things will not go as planned - whether it be in the work or just in a living situation. You must be willing to re-evaluate the situation and use all available resources to work towards a different outcome and/or compromise.
My time in India included questionnaire development, study staff training, and, in general, familiarization of field research. An important facet of global health that I learned during my GHFRA experience was the large number of people and effort it requires to implement a multi-site research study in an international setting. Questionnaire development, data analysis, and quality control/assurance is only a small part of the whole process. The NCA trial has a total of 22 sites (i.e., cities) across nearly all regions of India. This coordination needs smart and dedicated study staff including a very adept study manager that can effectively work with national and state governments as well as other non-governmental organizations. Buy-in from the government and other organizations means that this research is more likely to change how HIV-related healthcare is delivered to men who have sex with men (MSM) and people who inject drugs in India (PWID). The research findings are not the end goal - improving the health of MSM and PWID is.
I think what surprised me most during my experience in India - other than the incredible amount of traffic - was the general lack of sexual education, which as an HIV/AIDS researcher, was disappointing. I didn’t have a lot of opportunities to talk with Indians outside of the research work but in the few conversations I had, it was clear there was a gap in knowledge. Same-sex sex and sex outside of marriage were quite foreign ideas to some, despite these not being rare occurrences in India. Accurate and comprehensive sexual education in order to develop healthy attitudes and behaviors regarding reproductive and sexual health are desperately needed.
Chandigarh, Punjab, India - Training study staff on recent changes and answering questions about the survey for the National Collaboration on AIDS (NCA) trial’s evaluation cross-sectional assessment. The NCA trial will use respondent driven sampling (RDS) to accrue a sample of 22,000 men who have sex with men and people who inject drugs in India for a cluster-randomized trial to assess the effectiveness of community integrated care centers (ICCs) for HIV prevention, care, and treatment.
Chandigarh, Punjab, India - Testing biometric software as a part of the National Collaboration on AIDS (NCA) trial. This fingerprinting strategy tracks potential duplicate enrollment into the RDS as well as links study participants across the baseline and evaluation cross-sectional RDS samples and utilization of the community integrated care centers (ICCs).
Chandigarh, Punjab, India - Training an interviewer on how to administer the survey for the National Collaboration on AIDS (NCA) trial’s evaluation cross-sectional assessment. As a part of the training, I acted as a study participant in order for interviewers to become accustomed to asking questions and probing for answers as described in the study protocol.
New Delhi, India - The full study team for the National Collaboration on AIDS (NCA) trial’s New Delhi site. This team includes the site study coordinator, laboratory specialist, interviewers, counselor, and informed consent person as well as representatives from Johns Hopkins University and our partner organization in India, YRG CARE. This team will enroll and administer a survey to 1000 people who inject drugs in New Delhi over a period of approximately 3 months.
Chandigarh, Punjab, India - The staff of the community integrated care center (ICC) in Chandigarh, India. Care centers such as this are the intervention being assessed as a part of the National Collaboration on AIDS (NCA) trial. This center provides focused HIV-related care for people who inject drugs such as HIV testing and counseling, needle/syringe exchange, opiate agonist treatment, screening and treatment for sexually transmitted infections and TB, and medical care and treatment for those HIV-infected. This ICC in Chandigarh sees almost 40 clients daily.