India-US collaboration to prevent adolescent HIV infection: the feasibility of a family-based HIV-prevention intervention for rural Indian youth

Background
Despite the centrality of family in Indian society, relatively little is known about family-based communication concerning sexual behaviour and HIV/AIDS in rural Indian families. To date, very few family-based adolescent HIV-prevention interventions have been developed for rural Indian youth. This study conducted formative research with youth aged 14 to18 years and their parents in order to assess the feasibility of conducting a family-based HIV-prevention intervention for rural Indian adolescents.

Methods
Eight focus groups were conducted (n = 46) with mothers, fathers, adolescent females and adolescent males (two focus groups were held for each of the four groups). All focus groups consisted of same-gender participants. Adolescents aged 14 to18 years old and their parents were recruited from a tribal community in rural Maharashtra, India. Focus group transcripts were content analyzed to identify themes related to family perceptions about HIV/AIDS and participation in a family-based intervention to reduce adolescent vulnerability to HIV infection.

Results
Six primary thematic areas were identified: (1) family knowledge about HIV/AIDS; (2) family perceptions about adolescent vulnerability to HIV infection; (3) feasibility of a family-based programme to prevent adolescent HIV infection; (4) barriers to participation; (5) recruitment and retention strategies; and (6) preferred content for an adolescent HIV prevention intervention.

Conclusion
Despite suggestions that family-based approaches to preventing adolescent HIV infection may be culturally inappropriate, our results suggest that a family-based intervention to prevent adolescent HIV infection is feasible if it: (1) provides families with comprehensive HIV prevention strategies and knowledge; (2) addresses barriers to participation; (3) is adolescent friendly, flexible and convenient; and (4) is developmentally and culturally appropriate for rural Indian families.

—
Preventing the transmission of HIV in India remains a significant goal for global public health. In 2007, an estimated 2.4 million Indians were living with HIV [1]. Among the many states that comprise India, the western state of Maharashtra bears one of the highest HIV burdens. At least 20% of India’s estimated HIV cases are in Maharashtra, and the state has an overall prevalence rate of 0.74% [2]. Although adolescents and young adults aged 15 to 29 years old account for approximately 25% of India’s total population, they represent 31% of the country’s AIDS cases, indicating that many Indians are becoming infected during adolescence or early adulthood [2,3].

Recognizing that the successful prevention and treatment of HIV/AIDS requires international cooperation across multiple disciplines, the Indian Minister of Health and Family Welfare and the US Secretary of Health and Human Services signed a bilateral agreement in 2006 to collaborate on the prevention of sexually transmitted infections (STIs) and HIV/AIDS in India [4,5]. The overall goal of the bilateral agreement is to “promote and develop cooperation in the fields of HIV/AIDS and STI prevention, research, treatment and care, infrastructure development, training, and capacity-building on the basis of reciprocity and mutual benefit” [5]. The bilateral agreement also identifies a number of key areas for cooperation between India and the US, including “developing innovative intervention strategies for the prevention and treatment of HIV/AIDS” [5].

Our study is a collaboration between social scientists in India and the United States that was conducted as part of the Indo-US bilateral agreement. The overall goal of the collaboration is to conduct formative research that will inform the development of a family-based intervention to prevent HIV infection among Indian youth living in a rural community in Maharashtra. The family-based intervention will integrate the principles of “highly-active HIV prevention” by incorporating both biomedical (e.g., condoms) and behavioural prevention strategies that have been deemed efficacious for preventing HIV transmission [6].

A secondary goal is to scale up the knowledge base and research capacities of both Indian and American social scientists to develop and implement innovative, culturally appropriate, effective and sustainable HIV/AIDS prevention and treatment programmes. The results of this study represent the first of several formative research projects in support of these two goals.

The overall objective was to gain insight into diverse family perspectives on the feasibility and acceptability of a family-based adolescent HIV prevention programme for rural Indian families. The proposed intervention is distinct from previous prevention approaches in that parents will be targeted as agents of change who can provide their adolescents with the guidance, information and strategies necessary to reduce their risk of HIV infection.

To date, we know of no family-based adolescent HIV-prevention programmes for rural Indian youth. The majority of adolescent prevention programmes have tended to target adolescents via peer models or school-based programmes [7-9], or have focused predominantly on urban areas. As a result, relatively little is known about the familial and contextual factors that might promote or hinder the success of a family-based HIV prevention intervention for rural youth.

This study focused on adolescents aged 14 to 18 years old and their families who reside in a rural community near Mumbai and Pune in Maharashtra. Rural adolescents in Maharashtra were targeted for several reasons. First, Maharashtra continues to bear a disproportionately high burden of HIV cases in India [2]. In addition, research with rural youth in Maharashtra suggests that HIV knowledge is low. For example, in a study with rural Maharashtran girls and women aged 15 to 24 years old, only 49% indicated that they were aware of AIDS and only 60% reported that AIDS could be avoided [10].

Sexual behaviour remains the leading cause of HIV infection in India [11], and complex factors underlie rural youth’s vulnerability to HIV. In Maharashtra, many rural young men migrate to cities, particularly Mumbai, in search of economic opportunities. While they are in urban areas, young men may have sexual relationships with women, including sex workers [12]. When male migrants return to their rural homes to marry and begin families, this migration creates a bridge for HIV infection. In addition, studies have also documented high rates of unprotected anal intercourse among rural men who have sex with men [13].

Although male adolescents report higher rates of sexual activity than females, female adolescents are also vulnerable to HIV. A complex combination of factors related to increased biological susceptibility, low levels of education, poverty and gender inequality heighten vulnerability for many females [8]. Many young women in Maharashtra do not complete secondary school. Some young women enter early marriages or commercial sex work, and gender inequality creates power differences that create formidable barriers to consistent condom use. Among young people aged 15 to 24 years, the number of women with HIV/AIDS is estimated to be almost twice that of young men [14]. Taken together, these factors suggest that rural adolescents are a vulnerable group of young people.

A growing body of research conducted with young people in developing contexts indicates that parents can influence the sexual decision making of their adolescent children [15-17]. These findings are consistent with the large body of literature from the US, which has found that parents can influence an adolescent’s sexual debut [18], condom use [19] and acquisition of STIs [20]. Additionally, a number of parent-based interventions evaluated in the US show that parents can reduce adolescent sexual risk behaviour when given appropriate information and parenting strategies [21-23].