Previous research has shown that HIV stigma in India can be characterized by a framework dividing manifestations into enacted (discrimination), vicarious (hearing stories of discrimination), felt normative (perceptions of stigma's prevalence) and internalized stigma (personal endorsement of stigma beliefs). We examined if this framework could explain associations among stigma, efforts to avoid HIV serostatus disclosure, and depression symptoms in a cohort of 198 HIVinfected individuals from southern India who were followed for one year as part of a study of antiretroviral adherence. Prior studies had suggested that disclosure avoidance was a primary outcome of stigma and that impaired well-being was a primary outcome of disclosure avoidance. Analyses from our longitudinal research revealed that the pattern of associations among stigma, disclosure avoidance, and depression symptoms remained consistent over time. Enacted and vicarious stigmas were correlated with felt normative stigma beliefs. In turn, felt normative stigma was correlated with disclosure avoidance. And enacted stigma, internalized stigma, and disclosure avoidance were all associated with depression symptoms. However, even though the overall framework held together, internalized stigma and depression symptoms dropped significantly over time while other components remained unchanged. These findings suggest that, although HIV stigma may limit disclosure, it does not invariably lead to psychological maladjustment. Amidst ongoing perceptions and experiences of stigma, HIV-positive individuals can achieve significant improvements in their acceptance of the disease and in mental wellbeing.Stigma has profound effects on the lives of people living with HIV. It results in prejudice, discounting, discrediting, and discrimination toward individuals perceived to have the disease (Herek, Capitanio, & Widaman, 2002;Herek et al., 1998;Mahajan et al., 2008;Tewksbury & McGaughey, 1997). Our research team previously reported that a multicomponent framework was appropriate for characterizing stigma-related experiences among HIV-infected individuals in India instances of hostility and discrimination (Scambler, 1989;Steward et al., 2008). Vicarious stigma is embodied in knowledge of stories and events that illustrate how others with HIV have been mistreated . The final two categories are intrapersonal manifestations. Felt normative stigma refers to people's beliefs about the prevalence of prejudicial attitudes in the local community (Scambler, 1989;Steward et al., 2008).Internalized stigma is the degree to which HIV-infected individuals personally endorse stigmatizing beliefs (Herek, 2008;Jones et al., 1984;Steward et al., 2008).Our prior work showed that all forms of stigma are ultimately associated with symptoms of depression ( Figure 1). The focus of these earlier cross-sectional analyses was testing the pathway by which interpersonal forms (enacted, vicarious) shape felt-normative stigma beliefs that, in turn, promote efforts to avoid disclosure of HIV sta...

This study was conducted to examine the relationship between adherence, viral load (VL) and resistance among outpatients receiving highly active antiretroviral therapy (HAART) in Bangalore, India. In total, 552 outpatients were recruited and VL testing was conducted for all study participants. HIV-1 genotypic resistance testing was performed for 92 participants with a VL ≥ 1000 copies/ml. Interpretation of resistance mutations was performed according to the Stanford database. Past-month adherence and treatment interruptions for >48 h were assessed via selfreport. At baseline, 34 participants (6%) reported <95% past-month adherence and 110 (20%) reported a history of >48 h treatment interruptions. Combining the two adherence measures, 22% of participants were classified as 'suboptimally adherent'. In total, 24% of study participants (n = 132) had a detectable VL. Among the 92 samples sent for resistance testing, 68% had at least one nucleoside reverse transcriptase inhibitor (NRTI) mutation, with M184V being the most common © 2010 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: +1 415 597 9160; fax: +1 415 597 9213. mekstrand@gmail.com; maria.ekstrand@ucsf.edu (M. Ekstrand). . Authors' contributions: MLE, GS and SC designed the study protocol; VM, SS and NK conducted the viral genotyping at YRGCARE, and in collaboration with AS and RS interpreted its results; RS supervised all laboratory procedures at St John's Research Institute; EH conducted all statistical analyses; MLE drafted the manuscript, with assistance from NK, AS, SS and VM. All authors read, provided feedback on and approved the final manuscript. MLE is guarantor of the paper.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conflicts of interest: None declared.Ethical approval: The study received ethical clearance from the University of California, San Francisco (UCSF) Committee on Human Research (CA, USA), the St John's Institutional Ethical Review Board (Bangalore, India) and the Indian Committee on Medical Research. (62%) and with 48% having thymidine analogue mutations. Moreover, 72% had at least one nonnucleoside reverse transcriptase inhibitor (NNRTI) mutation and 23% had three or more NNRTI mutations. Both adherence measures were significantly associated with VL (P < 0.001). Suboptimal adherence was significantly associated with resistance mutations (P < 0.02). The findings illustrate for the first time the strong association between suboptimal adherence, treatment failure and drug resistance to first-line HAART in India...

Insulin resistance, diabetes mellitus, and metabolic syndrome in patients with human immunodeficiency virus (HIV) infection are increasingly being reported in the global medical literature. This cross-sectional study was done to describe the occurrence of metabolic syndrome, diabetes mellitus, and insulin resistance in HIV-positive patients in a tertiary referral center in South India. A total of 60 patients who had HIV infection for 12 months or more were enrolled in the study. Of these, 30 patients were antiretroviral therapy (ART)-naïve, and 30 were treated with ART. Biochemical estimations (fasting blood glucose, 75 g oral glucose tolerance test, lipid profile, and fasting insulin) and anthropometric measurements (height, weight, and waist circumference) were performed for each patient. Metabolic syndrome was diagnosed using National Cholesterol Education Program–Adult Treatment Plan III criteria, and insulin resistance was calculated applying the homeostasis model assessment method. Diabetes mellitus, impaired fasting glycemia, and impaired glucose tolerance were diagnosed based on American Diabetes Association criteria. A high prevalence of metabolic syndrome was observed in patients with HIV (16/60), and was more prevalent in the ART-treated group (13/30; P = 0.028). Similarly, insulin resistance was also noted to be high (24/60), and of these patients, 15 were on ART. Seventy-five percent of patients with metabolic syndrome had insulin resistance. Diabetes was diagnosed in one patient who was ART-naïve and in six patients who were on ART. Our observations suggest an increased prevalence of metabolic syndrome, insulin resistance, and diabetes mellitus in ART-treated patients. These warrant attention and substantiation with larger studies. While ART improves survival, it may lead on to cardiovascular morbidity and mortality, especially in the Indian subcontinent where there is a genetic predisposition to cardiovascular risk.

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Aim. To compare two strengths of a fi xed drug combination (FDC) containing metoprolol XL and amlodipine (metoprolol/amlodipine 50/5; and metoprolol/amlodipine 25/2.5) with its components in hypertension. Methods . We conducted this multicentre, randomized, open-label, trial in Indian patients with hypertension (140 -180 mmHg/90 -114 mmHg) in 11 centres from nine cities. Eligible patients ( n ϭ 402) were randomized into one of fi ve treatment groups (metoprolol XL 50 mg ϩ amlodipine 5 mg, metoprolol XL 25 mg ϩ amlodipine 2.5 mg, metoprolol XL 50 mg, metoprolol XL 25 mg or amlodipine 5 mg) and treated for 8 weeks with fi ve follow-up visits to record blood pressure (BP) and clinical status. Results. At baseline, treatment groups were well balanced; mean Ϯ SD BP was 154.87 Ϯ 11.91/96.63 Ϯ 6.97 mmHg. The greatest reduction in BP from baseline to 8 weeks was seen in the high-dose FDC group (23.61/14.91 mmHg; p Ͻ 0.001). The remaining 4 groups too demonstrated a signifi cant reduction ( p Ͻ 0.001): low-dose FDC Ϫ 22.29/ Ϫ 14.66; metoprolol 50, Ϫ 23.17/ Ϫ 13.37; metoprolol 25, Ϫ 18.41/ Ϫ 12.50 and amlodipine 5, Ϫ 23.01/ Ϫ 13.08. BP reductions by FDCs, however, were not statistically superior to monotherapies. Responder rates (sitting diastolic BP Ͻ 90 mmHg or reduction Ն 10 mmHg) were 93% in the high-dose FDC group and 97% in the low-dose FDC group, and control rates (sitting BP Ͻ 140/90 mmHg) were 66% and 58%, respectively. These rates were higher than that seen in individual components. There were no reports of serious adverse events related to study medications. One each from the low-dose FDC and metoprolol 25 mg group discontinued because of adverse events. Conclusions. FDCs of metoprolol and amlodipine are effective and safe in mild to moderate hypertension.