Background : The national HIV scenario in India has improved impressively during past two decades. Contrastingly, the State-level HIV sentinel surveil-lance and routine programme data from various testing facilities indicated an increasing HIV prevalence among antenatal clinic attendees and female sex workers (FSWs) in three districts of Assam. Objectives: 1) To explore the reasons behind increasing adult HIV prevalence and 2) To understand the role of FSW and Migrants/long distance truckers as drivers of the HIV epi-demic in these districts. Methodology: Three sources of data were utilized in this concurrent mixed methods study—1) existing programme data for past three years; 2) questionnaire-based data for a case-control study, where dur-ing past six months at designated testing facilities HIV(+) married women were “cases” and age-matched HIV(?) women from the same district were “controls”. Spouses of these women were also interviewed separately; and 3) a qualitative study, where focus group discussions were conducted among FSWs, outgoing male migrant labourers and long-distance truckers. Results: The study revealed high levels of unsafe sexual practices among the FSWs. Sometimes in poverty-struck areas, women, not identifying themselves as sex workers, sold sex on a part-time basis to earn extra money for financial sup-port and often remained invisible to the programme. The clients of the sex workers, male migrants and truckers also revealed various risk behaviours for contracting and transmitting HIV infection. Conclusion: Population and context specific programme strategies are required to halt the rising trend of HIV infection in the general population in Assam.
The adult HIV prevalence at the national level in India has declined steadily from an estimated peak of 0.38% in 2001-03 through 0.34% in 2007 and then to 0.26% in 2015. Such decline has been consistently noted both among the males and the females. The total number of people living with HIV (PLHIV) in India is estimated at 2.17 million in 2015 compared to 2.23 million in 2007. Two-fifth (40.5%) of these total HIV infections are among females [
An estimated 86 thousand new HIV infections occurred in India in 2015, showing 66% decline in new infections from 2000 and 32% decline from 2007, the year set as the baseline under the National AIDS Control Program-Phase IV (NACP-IV). However, it was important to note that while the new HIV infections among adults decreased considerably in the so-called “high-prevalence” states, increasing trends of new infections were noted in some “low-prevalence” states [
The north-eastern state of Assam is one such example, which has long been considered as one of the low HIV prevalence States in India. However, the total number of HIV/AIDS cases in the State has showed a steady increase since 2007, and it nearly doubled to an estimated 12,090 cases in 2015 during this eight-year period. The HIV prevalence among adult populations also increased by 50%: from 0.04% in 2007 to 0.06% in 2015. More importantly, the long-term trend of HIV prevalence appears to be rising among the antenatal clinic (ANC) attendees [
In Assam, 85% of the HIV infections are reportedly transmitted through heterosexual route [
Linkages between out-migration from three Indian States and HIV prevalence/ vulnerabilities have been demonstrated by a study conducted by the Population Council in Bihar, Odisha and eastern UP [
It is noteworthy that despite being labelled as a low-prevalence state, Assam has always been highly vulnerable for HIV transmission because of a) being the gateway to the north-eastern states of India, b) being surrounded by two high prevalent states of Manipur and Nagaland, c) large number of female in-migrants from other states ending up in sex work, and several other reasons [
Thus, we conducted a preliminary study to explore the reasons behind increasing HIV prevalence among general populations (as indicated by ANC attendees) in Assam, with special focus on understanding the contributions of FSWs and migration in three select districts, namely Cachar, Karimganj and Nagaon (
The study employed a concurrent mixed methods approach where the convergence model was used for triangulation of results. Two quantitative and one qualitative data collection procedures were utilized―a) Collection of existing programme data―Within the National AIDS Control Programme, anyone, irrespective of age and gender, can be tested for HIV in the ICTCs, whereas all
consenting pregnant women are tested for HIV in the PPTCTs (Prevention of Parent to Child Transmission centres). Basic socio-demographic information as well as risk categories and HIV test results are captured anonymously in the registers of these centres. We extracted three years’ (2012-’13 to 2014-’15) retrospective from ICTCs/PPTCTs in the three study districts; b) Collection of structured questionnaire-based quantitative data―through face-to-face interviews from the consenting ICTC/PPTCT married women attendees (who attended during the previous six month period) as well as their spouses to explore sexual and other risk behaviours and practices in greater details; in addition, migration-related history of the spouses of the married women attendees were also obtained. Here, we undertook a case-control approach. Based on the register information, for each HIV(+) married woman we randomly selected two HIV(−) married women belonging to the same district and within ±5 years (minimum 18 years) age range; spouses of these women were also asked to participate and provide information through questionnaire-based interview; and c) Collection of qualitative data―through Focus Group Discussions (FGD) among selected population groups including female sex workers, long-distance truckers and male migrants. Broadly, the topics included issues on socio-economic and demographics, sexual and other risk behaviors, sexual partnerships, condom use, knowledge of HIV/AIDS and STIs, migration-related information as well as social and programme support. The FGDs were conducted in local language and were audio recorded. The recordings, along with the field notes, were transcribed within a few hours and translated into English later. All participants were aged 18 years or older.
This research project was approved by the Institutional Ethics Committee of ICMR-National Institute of Cholera and Enteric Diseases, Kolkata―700,010 vide approval letter no. A-1/2014-IEC dated 09.02.2015. In addition, for extracting existing data from the ICTC/PPTCT registers, approval was taken from the Data Sharing Committee of the Assam State AIDS Control Society as per the NACO Data Sharing Guidelines, 2015. Informed consent was taken from each client while collecting quantitative or qualitative data. Strict Confidentiality of all data was maintained and no personal identifiers were used in the analysis.
The extracted program data as well as quantitative data collected through structured interviews were entered into a pre-designed computerized database using MS-Excel. Following data cleaning and editing, descriptive analyses were carried out using STATA statistical software (STATA SE ver. 8.2). Quantitative interview data were analyzed using a case-control approach (HIV+ vs. HIV−), to identify risk/preventive factors for HIV infection. We used a step-by-step participatory procedure to analyze qualitative data thematically. For this, we undertook an iterative process of data collection and analysis through debriefing notes and periodic team meetings to identify emerging themes and follow-up questions. After all FGDs were completed, a data analysis workshop was organized and a codebook was developed based on both a priori and emerging themes. All transcripts were systematically coded using the software NVivo 10.
The results obtained from the data collected through different methods are presented below.
Analysis of retrospective HIV testing data was done for the general clients and pregnant women in the ICTCs and PPTCTs in the three study districts for three years (2012-’13 to 2014-’15). A total of 19640 clients were tested during this period in these three districts. As indicated in
Place of residence | Number tested | Number (%) HIV Positive |
---|---|---|
From Assam | ||
Cachar district | 15,314 | 482 (3.15) |
Karimganj district | 1553 | 115 (7.41) |
Nagaon district | 821 | 35 (4.26) |
Hailakandi district | 1370 | 39 (2.85) |
Dima-Hasao district | 31 | 1 (3.19) |
Other Assam districts | 37 | 0 (0.00) |
From other States | ||
Tripura | 381 | 29 (7.62) |
Manipur | 87 | 8 (9.19) |
Other states | 46 | 6 (13.17) |
Total | 19,640 | 715 (3.64) |
of Assam and even from other States also visited these ICTCs and they often had higher prevalence of HIV infection. Among those who visited from different districts of Assam, attendees belonging to Karimganj district showed the highest HIV positivity (7.41%).
Limited data were available for prevalence of HIV among the clients according to their reported risk behaviours (
A case-control approach was undertaken for the questionnaire-based interview.
Characteristics | Male | Female | |||||
---|---|---|---|---|---|---|---|
HIV (+) No. (%) | HIV (−) No. (%) | p-Value | HIV (+) No. (%) | HIV (−) No. (%) | p-Value | ||
Age groups (yrs): | <20 | 32 (2.1) | 1499 (97.9) | <0.00001 | 25 (1.8) | 1372 (98.2) | 0.00003 |
20 - 30 | 125 (4.0) | 2989 (96.0) | 108 (3.6) | 2883 (96.4) | |||
31 - 40 | 161 (8.3) | 1790 (91.7) | 60 (2.9) | 2030 (97.1) | |||
>40 | 93 (3.2) | 2771 (96.8) | 27 (1.5) | 1726 (98.5) | |||
Current marital status: | Unmarried | 110 (3.8) | 2747 (96.2) | <0.00001 | 18 (1.3) | 1385 (98.7) | <0.00001 |
Married | 291 (4.4) | 6283 (95.6) | 171 (2.7) | 6049 (97.3) | |||
Divorced/Widowed/Separated | 10 (40.0) | 15 (60.0) | 31 (5.1) | 577 (94.9) | |||
Educational status: | Illiterate | 26 (5.9) | 417 (94.1) | 0.7166 | 19 (1.5) | 1273 (98.5) | 0.1150 |
Primary | 31 (5.4) | 546 (94.6) | 13 (1.5) | 883 (98.5) | |||
Secondary | 14 (4.1) | 331 (95.9) | 5 (4.0) | 119 (96.0) | |||
Graduate+ | 1 (5.6) | 17 (94.4) | 0 (0.0) | 55 (100.0) | |||
Occupation groups: | Non-agricultural labour | 64 (5.0) | 1207 (95.0) | <0.00001 | 3 (3.2) | 91 (96.8) | <0.00001 |
Agricultural labour | 16 (1.7) | 904 (98.3) | 2 (33.3) | 4 (66.7) | |||
Service | 111 (5.7) | 1839 (94.3) | 5 (2.8) | 171 (97.2) | |||
Business | 80 (4.6) | 1664 (95.4) | 2 (3.5) | 55 (96.5) | |||
Student | 14 (1.5) | 916 (98.5) | 7 (1.1) | 604 (98.9) | |||
Trucker/Driver | 94 (7.8) | 1111 (92.2) | 0 (0.0) | 2 (100.0) | |||
Others | 5 (7.0) | 66 (93.0) | 4 (12.5) | 28 (87.5) | |||
Unemployed | 24 (2.8) | 844 (97.2) | 9 (1.9) | 470 (98.1) | |||
Housewife | --- | --- | 172 (2.6) | 6424 (97.4) |
Reported risk behaviors | Male | Female | ||||
---|---|---|---|---|---|---|
No. tested | No. positive | % Positive | No. tested | No. positive | % Positive | |
FSW | 0 | 0 | 0.00 | 1964 | 9 | 0.46 |
Heterosexual* | 424 | 68 | 16.04 | 44 | 14 | 31.82 |
MSM | 22 | 3 | 13.64 | 0 | 0 | 0.00 |
IDU | 66 | 16 | 24.24 | 5 | 0 | 0.00 |
Truckers | 333 | 12 | 3.60 | 0 | 0 | 0.00 |
General population | 927 | 18 | 1.94 | 429 | 22 | 5.13 |
*Heterosexual risk behavior: Male or Female clients reportedly involved in unsafe heterosexual practices.
Participant type | District | Total | ||
---|---|---|---|---|
Cachar | Karimganj | Nagaon | ||
Case Women | 15 | 04 | 06 | 25 |
Control Women | 21 | 08 | 12 | 41 |
Case Spouse | 11 | 04 | 06 | 21 |
Control Spouse | 17 | 08 | 12 | 37 |
Total | 64 | 24 | 36 | 124 |
All HIV(+) married women who attended the ICTCs/PPTCTs of these three districts during the previous six-month period were asked to participate as “cases”. Two randomly-chosen HIV(−) married women who attended from the same district and were within ±5 years of the age of the “case” women were recruited as “controls”. Interview-based data were also collected from their spouses wherever possible. Written informed consent was obtained from each participant before collection of any data.
A total of 25 HIV(+) women (“cases”) and 41 HIV(−) (“control”) women could be recruited in the study. Spouses of 21 “case” women and 37 “control” women could also be interviewed (
Socio-economic and demographic characteristics of study participants
The general characteristics of the spouses of the women are shown in
Characteristics | Cases | Controls | p-Value | |
---|---|---|---|---|
Age (years): | Mean ± SD | 24.1 ± 3.9 | 24.7 ± 3.6 | 0.55 |
Education (grades completed): | Primary (1 - 4) | 2/24 (8.3%) | 7/41 (17.1%) | 0.60 |
Middle (5 - 8) | 6/24 (25.0%) | 13/41 (31.7%) | ||
Secondary (9 - 10) | 7/24 (29.2%) | 11/41 (26.8%) | ||
Grades 11+ | 9/24 (37.5%) | 10/41 (24.4%) | ||
Religion: | Hindu | 14/25 (56.0%) | 32/41 (78.0%) | 0.06 |
Muslim | 11/25 (44.0%) | 9/41 (21.9%) | ||
Caste: | General | 16/25 (64.0%) | 24/41 (58.5%) | 0.64 |
SC* | 6/25 (24.0%) | 14/41 (34.1%) | ||
OBC* | 3/25 (12.0%) | 3/41 (7.3%) | ||
Marital status: | Currently married | 24/25 (96.0%) | 40/41 (97.6%) | 0.62 |
Separated | 1/25 (4.0%) | --- | ||
Widowed | --- | 1/41 (2.4%) | ||
Age at first marriage (years): | Mean ± SD | 21.2 ± 3.9 | 21.6 ± 3.7 | 0.72 |
*SC = Scheduled castes; OBC = Other backward classes.
Characteristics | Cases | Controls | p-Value | |
---|---|---|---|---|
Age (years): | Mean ± SD | 32.6 ± 4.3 | 31.6 ± 4.7 | 0.41 |
Education (grades completed): | Primary (1 - 4) | 4/20 (20.0%) | 5/37 (13.5%) | 0.011 |
Middle (5 - 8) | 3/20 (15.0%) | 12/37 (32.4%) | ||
Secondary (9 - 10) | 10/20 (50.0%) | 5/37 (13.5%) | ||
Grades 11+ | 3/20 (15.0%) | 15/37 (40.5%) | ||
Average monthly income (Rs.) | Up to 5000 | 6/21 (28.6%) | 15/37 (40.5%) | 0.14 |
>5000 to 10,000 | 8/21 (38.1%) | 18/37 (48.6%) | ||
>10,000 | 7/21 (33.3%) | 4/37 (10.8%) | ||
Age at (first) marriage (years): | Mean ± SD | 28.9 ± 4.1 | 28.3 ± 4.6 | 0.63 |
Sexual and other risk behaviours/practices of the study participants
Our analyses indicated that the “case” and “control” women were comparable in terms of their age (in years) at first sex (21.1 ± 3.9 vs. 21.5 ± 3.7; p = 0.64). Only one woman in each group had history of having pre-marital sexual experience while none of the women reported any extra-marital sexual relationships. Again, only one woman in the “control” group gave history of having anal sex ever. Eight percent (2 of 25) of “case” women and 12.2% (5 of 41) “control” women ever experienced any signs/symptoms of sexually transmitted infections (p = 0.70). Regarding substance use, 20% (5 of 25) “case” women and 15% (6 of 40) “control” women shared history of smoking cigarettes; however, none of them gave history of consuming alcohol or any other addictive substance.
Thus, the results of the quantitative data suggested that it was mostly the behaviours and practices of the male spouses of the women, especially their indulgence
Characteristics | Cases | Controls | p-Value | |
---|---|---|---|---|
Age at first sex (yrs): | Mean ± SD | 24.1 ± 4.0 | 28.1 ± 4.6 | 0.002 |
H/O Pre-marital sex: | Yes | 14/21 (66.7%) | 4/37 (10.8%) | 0.00001 |
No | 7/21 (33.3%) | 33/37 (89.2%) | ||
Partners of pre-marital sex: | Sex workers | 8/14 (57.1%) | 1/4 (25.0%) | 0.36 |
Friends/Relatives | 3/14 (21.4%) | 3/4 (75.0%) | ||
Current spouse | 1/14 (7.1%) | --- | ||
Others | 2/14 (14.3%) | --- | ||
Condom use during pre-marital sex: | Always | --- | 2/4 (50.0%) | 0.04 |
Mostly | 1/14 (7.1%) | --- | ||
Occasional | 6/14 (42.9%) | --- | ||
Never | 7/14 (50.0%) | 2/4 (50.0%) | ||
Condom use with spouse: | Always | 7/21 (33.3%) | 2/37 (5.4%) | 0.05 |
Mostly | 1/21 (4.8%) | 3/37 (8.1%) | ||
Occasional | 3/21 (14.3%) | 6/37 (16.2%) | ||
Never | 10/21 (47.6%) | 26/37 (70.3%) | ||
H/O Extra-marital sex: | Yes | 5/21 (23.8%) | 1/37 (2.7%) | 0.02 |
No | 16/21 (76.2%) | 36/37 (97.3%) | ||
Ever had any sign/symptom of STI | Yes | 2/21 (9.5%) | 2/37 (5.4%) | 0.61 |
No | 19/21 (90.5%) | 35/37 (94.6%) |
in pre- and extra-marital sex, having sex workers as their sex partners and negligible use of condoms during high risk sex that might put the women at risk of contracting HIV in these populations. Thus, more programmatic attention may be needed for this section of people, apart from high risk groups and the antenatal clinic attendees.
The purpose of collecting and analyzing qualitative data was to supplement the findings from the above-mentioned quantitative data, in order to enhance our understanding about the possible reasons of increasing HIV prevalence among general population (as indicated by prevalence among ANC attendees) in the three study districts. A total of 12 focus group discussions (FGDs) were conducted to explore relevant issues among different population groups [FSWs (home/street/brothel-based) = 6, Truckers = 3, Male migrant labourers = 3]. Each FGD had 6 - 9 attendees of various age groups.
Analyses of these qualitatively collected data provided clues to explaining some of the findings that emerged from quantitative data analyses. For example, analysis of existing ICTC/PPTCT data revealed a high prevalence of HIV among the housewives, especially in the Nagaon and Karimganj districts (7.71% and 6.5%, respectively); during FGDs with the sex workers in these two districts, it was found that many of them were actually married and were doing the sex work on a part-time basis at a distant place on the pretext of being engaged in some kind of job and without the knowledge of their family members. Many of these women do not consider them as sex workers and told that they indulged in such activities only to earn some extra money for sustaining themselves or their family, as quoted below for example:
FSW (home-based)/45y/Cachar: If anybody does sex work, she (usually) has some bindings … She is doing this work because of her children … because of her livelihood.
It was also noted through the FGDs with FSWs that despite having fair to good knowledge about HIV, its transmission and the consequences, many of them would often agree for unprotected sex if they were offered higher amounts of money.
FSW (home-based)/45y/Cachar: When sex work is my business, then so many types of people come … Someone may offer only Rs.10 and someone may offer Rs.1000 … for the sake of money then, we are forced to do sex without condoms FSW (street-based)/38y/Karimganj: Forget about customers … even they (the FSWs) also do not use condoms … condoms are supplied to them, but still they do not use. Because they need money… without condom, they earn more money
However, sometimes lack of proper knowledge about the utility of using condoms during sex might have also played a role for non-use of condoms, as demonstrated below:
FSW (street-based)/22y/Karimganj: HIV can spread if condom is not used. (However), some sex workers do not use condoms, they use Mala tablet (govt. supplied oral contraceptive pills) instead.
This could be one explanation for rising HIV prevalence among the female sex workers that drove this project to explore its possible reasons.
Through the FDGs conducted with the male migrant (out-migrant) labourers, it was understood that many young people, mostly in the range of 18 to 35 years, worked and stayed away from their families for a considerable period at a distant place (other districts or even in other states, like in Mumbai). Many of them would visit their families during harvesting seasons, but would go back again for work. The main motivation was better earning opportunities. The following accounts will give some perspective:
Male Migrant Labourer/(Age/Educ: 26y/Grade 5; 25y/Grade 7; 24y/Grade 9)/Nagaon About 60% - 70% of adult male population of this area seek jobs outside. Male Migrant Labourer/(24y/Grade 9)/Nagaon Payment is too low here. So, they go outside. Male Migrant Labourer/(26y, Grade 7)/Nagaon …. Also, there are lack of facilities [so, they go outside for work] Male Migrant Labourer/(26y/Grade 5; 22y/Grade 6)/Nagaon There are no … almost no company [industry] in Nagaon. Male Migrant Labourer/(24y/Grade 9)/Nagaon I can earn almost double there … it has changed my lifestyle, food habit, and made my health better [other participants also echoed the same]. We can also meet new people, even foreigners, which is not possible if we stay here in the village.
Many of these young males often indulge in high-risk behaviours like visiting sex workers.
Male Migrant Labourer/(24y/Grade 9)/Nagaon When 10 - 12 persons stay together, someone of them may have information about a sex worker’s home or workplace in the vicinity … if one of them visits her, then others also start to see her―it becomes like a habit then.
Asked about whether they would agree to pay more money to the sex workers to have sex without condoms, almost all of them responded that they would. Like the FSWs as mentioned earlier, these people also possessed misconceptions about condoms and its use, as exemplified below:
Male Migrant Labourer/(24y/Grade 9)/Nagaon There is a medication. Whoever doesn’t use condom, after eating that [the medication], there will be no need to use condoms. … I have heard like this, but have not seen yet. There is a medical drug―whatever you do in five minutes, nothing is needed [if that drug is taken].
Similarly, many of the truckers (especially the long distance truckers) also indulge in different risk behaviours, particularly unprotected sexual contacts with female sex workers. These people also have lower levels of awareness about HIV transmission and its implications.
It was worrisome that during the focus group discussions, especially with the street-based female sex workers, it was stated that there was a growing number of female students being involved in this profession―again, mostly to earn money to meet their personal and/or educational needs. Since many students now often access higher education at a place distant to their home―thus, remain in a comparatively more free environment and with different kinds of entertainment / addiction opportunities―such risk taking behaviours seem not very unusual, specially with peer-pressures.
Putting together, it appears that despite having high level of awareness about HIV-related matters, felt need for additional income is playing a crucial role for the females to indulge in high risk behaviours, although many of them do not identify them as sex worker. On the other hand, lack of adequate facilities and opportunities push the young males to seek job away from their residence, where circumstances facilitate risk-taking behaviours among them. Thus, along with the females themselves to some extent, their spouses or partners who might be a migrant labourer, trucker and/or a client of sex workers, may be playing important roles behind the rising trend of HIV infection among the general population in select districts of Assam.
Quite akin to India in general, heterosexual contact has been reported as the commonest mode of transmission of HIV in the north-eastern State of Assam [
Analyses of existing ICTC data in our study showed a high HIV prevalence among female general clients who reported heterosexual high-risk behaviors. We also noted that a significantly higher proportion of the spouses of the HIV positive women (cases) reported pre-marital and/or extra-marital sex compared to the spouses of HIV negative women (controls). Majority of the pre-marital sex partners of the “case” spouses were FSWs and all extra-marital sex partners of “case” spouses were FSWs only. Further, consistent condom use during such sexual encounters as well as during sex with their wives was very low. These findings suggest that the spouses of the married women may be playing an important role behind the rising HIV prevalence among the ANC attendees in the State, but detailed profiling of the spouses will be required to ascertain the sub-typologies of such bridge population. It is worth noting in this regard that the recently undertaken National Integrated Biological and Behavioral Surveillance (IBBS) [
The situation appears further grim when we consider the out-migration of young adult males for various reasons. Migrants and migration have strongly been linked with transmission of HIV in the general (source) populations and within the marital relationships in India [
The current study was taken up based on the background information of increasing trends of HIV prevalence among the general population (antenatal clinic attendees) and female sex workers (FSWs) in the three districts of Assam, although HIV prevalence in other districts in those population groups did not show a rising trend. The study of course suffered from limitations in terms of available resources, timeline, as well as scopes. Despite all these limitations, this explorative study using a mixed-methods approach could bring out several important points. The female sex workers in these districts probably were serving as the main reservoir for HIV wherefrom the infection was spread through unprotected sex. Although adequate HIV related knowledge was demonstrated by these sex workers, many of whom were married and having families, they indulged in unprotected sex, mostly to earn more. This highlighted the need of an intervention in this area, which might encompass appropriate behavioural as well women empowerment (especially economic empowerment) issues and linkages to social protection schemes. A school-based educational intervention might also help in the context of reportedly increasing number of female students taking up part-time sex work to earn money or otherwise. The (outgoing) migrant labourers and truckers showed comparatively lower levels of awareness about HIV/AIDS and many of them also engaged in high-risk behaviours, indicating the requirement and scopes for future work with these groups too. The study showed the possible role the bridge populations i.e., migrants and truckers may be playing in the rising HIV Prevalence among the ANC attendees in Assam. However, detailed profiling and analysis of the data of spouses of the HIV positive pregnant women will be required to produce more concrete association. Also, the Programme may consider adopting flexible working definitions for the bridge populations while planning the analysis. Lastly, the Programme also needs to consider adopting new strategies for covering the Key populations outside the TI NGOs. Thus, the study could bring out some possible factors that could be behind the observed increasing HIV prevalence among specific groups of populations in the three study districts and identified scopes for future interventions/studies in this respect.
This study was financially supported through a grant from the Indian Council of Medical Research (ICMR), New Delhi [RFC No. ECD/NER/1/2015-16 dated 12/05/2015]. We would like to thank National AIDS Control Organization (NACO) and Project Director, Assam State AIDS Control Society (ASACS) for the necessary guidance and support in carrying out this Research Project. We are grateful to Director, ICMR-National Institute of Cholera and Enteric Diseases (NICED) for support. The views expressed in this paper are those of the authors and do not necessarily reflect the views of NACO, ASACS and ICMR.
Bhattacharjya, C., Pathak, G., Mahanta, T.G., Singh, Y.M., Deka, R., Sen, M. and Deb, A.K. (2018) Emerging HIV Epidemic in the North-Eastern State of Assam, India: An Exploratory Study Using Mixed-Methods Approach. World Journal of AIDS, 8, 21-36. https://doi.org/10.4236/wja.2018.81003