Development of a Framework to Identify Research Priorities for Mitigating the Impact of Climate Change on HIV Response in India: A Scoping Review coupled with Modified Delphi

Development of a Framework to Identify Research Priorities for Mitigating the Impact of Climate Change on HIV Response in India: A Scoping Review coupled with Modified Delphi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of a Framework to Identify Research Priorities for Mitigating the Impact of Climate Change on HIV Response in India: A Scoping Review coupled with Modified Delphi Mihir Bhatta, Gautam Kumar Ghosh, Debjit Chakraborty, Falguni Debnath, and 20 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6819162/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Climate Change and extreme weather events are recognized as the critical threat to public health, with severe effects on vulnerable populations in low- and middle-income countries. In India, these climatic stressors may further undermine the HIV response by disrupting services, exacerbating vulnerabilities, augmenting transmission and straining health systems. However, the evidence based on how climate change intersects with HIV responses remains limited and fragmented. Present study aimed to develop a comprehensive framework for identifying research priorities aimed at mitigating the impact of climate change on the HIV response in India. Methods Present work was carried out through the scoping review followed by a modified Delphi. Scoping review included peer-reviewed articles and grey literatures published between 2000 to 2023 following PRISMA guidelines. The database search comprises of PubMed, Scopus, Web of Science, and regional sources, focusing on studies that explore the interface of climate and HIV-related health outcomes, service delivery, and system resilience. The data was extracted from the selected articles, then analysed to identify the lessons of contextual relevance. Building on the findings of the scoping review a Modified Delphi Consensus method was used in three interactive rounds to develop a research framework and finalise major priorities. Results An initial pool of 88,292 records and 55 additional grey literature sources was narrowed down to 119 documents (83 academic papers and 36 reports) after screening for relevance and eligibility. Most of the included studies focused on climate migration, health service disruptions. though a large proportion were narrative reviews with limited high-quality evidences. The Evidence Gap Map revealed significant research deficiencies, especially in areas such as food insecurity, co-infections, and policy-level responses. Using a modified Delphi method, the research team identified four major researchable domains namely food insecurity, migration, health system disruption, and co-infections. Conclusion This was a first of its kind endeavour in Indian setting to direct investments in cross cutting areas of Climate Change & HIV programs. The conceptual framework suggested that climate change affects the HIV response through interconnected pathways. The final research priorities aimed to guide evidence generation for policy action and resilient health systems. Climate change HIV response key populations food insecurity migration health system disruption co-infections Figures Figure 1 Figure 2 1. Introduction In general climate change and the HIV epidemic are independent to each other ( 1 ). But a recent publication ( 2 ), has evidence on anthropogenic activities and how these will increase ambient temperatures in the next 50 years compare to previous 6000 years. Altogether these will cause extreme weather events such as heavy rainfalls, droughts, floods, landslides which will modify coastlines, and without fast adoption of robust mitigation and adaptation techniques, these collectively will may disrupt regular access to food, potable water, and dependable shelters( 1 , 3 – 5 ). According to the World Bank, these consequences will cause an extra 5 million deaths, in between 2030 and 2050, mostly through starvation, malaria, and diarrhoeal diseases and will drive over 100 million more people into extreme poverty ( 1 , 6 ). The climate crisis is expected to have serious health repercussions for third world countries. While the routes that connect climate change to other diseases are well understood, but the relationship between climate change and HIV has yet to be recognised ( 7 ). The intersection of climate change and HIV is critical for global public health, especially because both disproportionately affect vulnerable regions like Sub-Saharan Africa (SSA) and Southeast Asia (SEA), which are strongly impacted by both HIV and climate change ( 1 ). PLHIV are at increased risk due to climate variability, which includes rising temperatures, unpredictable rainfall patterns, and frequent floods. These factors also interfere with access to antiretroviral therapy (ART), change healthcare delivery systems, and increase exposure to vector-borne illnesses ( 8 , 9 ). These interrelated variables make HIV therapy and prevention more difficult by increasing opportunistic infections and worsening health care outcomes ( 10 ). The need of resolving social and environmental injustices including women empowerments is highlighted by the disproportionate effects of climate change on marginalised people. People who are displaced as a result of natural disasters are frequently cut off from necessary medical care, which exacerbates inequities in health care services including HIV treatment ( 9 , 11 ). India has a longer coastline. of 7516.6-kilometer, which are divided into nine states ( 12 , 13 ) along with this, drought-prone regions of India have grown approximately more than 55% form 1997 ( 14 ) similarly more than 10% of its landform is vulnerable to hydro-geological jeopardies ( 15 ). Studies in Indonesia have shown that people in coastal regions are more vulnerable to HIV during and/or immediately following natural disasters ( 16 – 19 ); in many drought-prone locations, floods pose serious challenges to PLHIVs, exacerbating their health conditions ( 20 ). About 0.42 million square kilometres of countries land mass, is vulnerable to landslides ( 21 ), and 4% of the country's forest canopy is under the threat of wild forest fires ( 22 ). Vulnerable populations, especially PLHIVs, are directly impacted by the aftermath of these occurrences in terms of their access to a range of healthcare services ( 23 , 24 ). Studies on the relationship between climate change and health have been conducted worldwide. However, there is no such study specifically address how it affects HIV in terms of prevention, care, and treatment. So, it is difficult for Policymakers and other stakeholders to address these issues without having identified a list of priorities and their possible solutions. Hence this study was conducted to prepare a comprehensive framework to find out research priorities aimed at mitigating the effect of climate change on HIV response in India. 2. Materials and methods This study comprises of two methods: A) Scoping Review to map the available evidence and followed by B) Modified Delphi method involving domain experts to conceptualize the framework to find out research priorities aimed at mitigating the effect of climate change on HIV response in India. 2.1. Scoping Review This scoping review was carried out in order to methodically find and compile data about how climate change affects HIV responses in India. The technique ensured a thorough and transparent approach by following the principles (25,26). 2.1.1. Establishing the Research Question Using the relevant search criteria, a scoping review of published literature, and reports was conducted using the e-databases PubMed and Google Scholar. The PECOS (population, exposure, comparison, outcome and study design) approach were used to determine which published publications were included. Exclusion criteria include publications written in languages other than English, from nations other than India, about homes that are not impacted by the environment, and about non-socioecological effects. In order to mitigate the influence of extreme weather events on HIV in India, the review sought to address the following primary research question: What are the research gaps and priorities? The following sub-questions were addressed: What is the impact of climate change on HIV care, treatment, and prevention in India? Which particular vulnerabilities are made worse by climate change for persons living with HIV (PLHIV)? What kinds of interventions have been suggested to deal with these issues? 2.1.2. Eligibility Criteria: The following were the criteria for inclusion and exclusion: 2.1.2.1. Inclusion criteria: PECOS approach criteria were used for defining review questions. Published articles form peer-reviewed journals, and published reports or documents by the government or reputed nongovernmental agencies were included from January 2003 to December 2023. 2.1.2.2. Population: According to National AIDS Control Organisation (NACO), India, key populations include injecting drug users, transgender people, men who have sex with men, and female sex workers as high-risk groups for HIV transmission (27). 2.1.2.3. Exposure: Climate related direct (drought; landslides, flood/river bank erosion, air pollution) and indirect events (food insecurity/ agriculture, fisheries), 2.1.2.4. Comparison Group: Not relevant to this study 2.1.2.5. Outcome: Association between climate factors with HIV response and health services through diverse intermediate factors. 2.1.2.6. Study Design: Data are extracted through a previously prepared data extraction form which includes different levels of data accumulation to obtain a general picture among FSW, MSM, H/TG and IDU. 2.1.2.7. Exclusion criteria: Articles published other than English language, describing countries other than low- and middle-income countries, articles published and describing non-environmentally affected households, and articles with non-socioecological influences. 2.1.3. Search Strategy The following databases were thoroughly searched: PubMed Scopus Google Scholar Web of Science's Combinations of the following were included as the search terms, with appropriate Boolean operators: "Climate change" AND "HIV response" "HIV/AIDS" AND "environmental stressors" AND "India" "Climate change" AND "vulnerable populations" Additional grey literature was obtained from the websites of important organisations, such as the National AIDS Control Organisation (NACO), UNAIDS, and the World Health Organisation (WHO). The lists of reference were searched to find further sources. 2.1.4. Study Selection There were two steps in the selecting process: Screening of Titles and Abstracts: Two impartial reviewers checked abstracts and titles for eligibility. Full-Text Screening: Relevance was evaluated for full-text articles that satisfied the inclusion requirements. Consensus or discussion with a third reviewer were used to settle disagreements 2.1.5. Data Extraction A standardised data extraction form was used to extract pertinent information, and it contained the following: Study objectives, methods, and key findings. Population features and geographic focus. Gaps, difficulties, and suggested solutions were noted. 2.1.6. Data Synthesis Two investigators independently reviewed the papers and then a consensus was reached for the final list of papers to be included in this study. Extracted data from the articles were entered in the predesigned data abstraction form. Based on the findings of the selected study it was categorized thematically into socioenvironmental determinants, health service problems, and policy frameworks to describe the effect of extreme weather events and HIV and mitigating the influence ofthe same on HIV response. 2.2. Application of modified Delphi method: Building on the findings of the scoping review a modified Delphi consensus method was used in three interactive rounds to methodically develop a research framework and finalise major priorities. The modified Delphi consensus process was applied to find out research prioritisation on extreme weather events on HIV response in India. In this study we invited experts such as HIV specialists, Program officials, Climate experts, Economists, Gender empowerment specialists, Social science experts and Statisticians as these disciplines are interlinked and could find out the research priorities and the factors those influence the pathways of effect of extreme climate events towards HIV responses in India (25). The Modified Delphi Consensus Process offers a transparent, evidence-based, and expert-validated approach to research prioritisation (26). By including interdisciplinary perspectives, we ensured that the final research output was scientifically rigorous, contextually relevant, and actionable. 3. Results In order to investigate the relationship between climate change and HIV/AIDS outcomes, the study carried out an extensive review. 88,292 documents were first found via database searches, and 55 further reports were obtained from NGOs and national and international organisations. A total of 2,397 records were tested for eligibility after 55,146 duplicate records and 35,543 data irrelevant to climate change were eliminated. 1,842 records were eliminated during screening because they lacked HIV information. A total of 555 publications were selected for either full-text or abstract review. However, 295 articles (abstract only) could not be retrieved because of insufficient information. 260 articles were assessed for eligibility following additional evaluation. Among these, 177 papers were removed because they had no relevant information on HIV response routes or climate change consequences. The final systematic review comprised 83 papers and 36 reports (Figure 1). The generated evidence gap map illustrated the current research landscape. The majority of research examined the influence of direct climate disasters (such as floods, droughts, cyclones, and tsunamis) and migratory patterns on HIV/AIDS outcomes. The majority of papers were narrative reviews and primary research, with only a handful being systematic reviews, protocols, or randomised controlled trials (Figure 2). Significant research gaps were identified in numerous areas: There had been few researches investigating the relationship between food insecurity and HIV/AIDS. There was less data on the impact of vector-borne and sexually transmitted illnesses associated to climate change. There was a shortage of high-quality research, such as systematic reviews, meta-analyses, and randomised controlled trials. There were few policy recommendations available to address HIV response options under climate change scenario. Despite some evidence linking HIV/AIDS to climate-related migration and extreme weather events, there is still an obvious need for additional rigorous, systematic, and intervention-focused research, particularly in the areas of food security and emerging infectious illnesses. 3.1. Result comes out through modified Delphi 3.1.1. First Round Identifying Broad Research Areas: The core research team initiate the process by presenting results from the scoping review and the Evidence Gap Map (EGM). These findings identified current knowledge gaps and research needs at the intersection of climate change and HIV in India. Experts were encouraged to remark on these findings and recommend prospective research areas for further investigation. Structured conversations, individual reflections, and a collaborative feedback process were used to suggest broad research areas. These topics focused on how climate change affects HIV transmission, treatment access, health system resilience, and socioeconomic determinants of health(27–29). 3.1.2. Second Round Thematic Consolidation: In this round, an extensive analysis was done with the findings from the first round and consolidated four significant theme areas that emerged as critical linkages between extreme climate events and HIV responses, which are as follows: Food Insecurity : Evaluating the impact of climate-induced food scarcity, malnutrition, and nutritional deficiencies along with immunological health, and ART adherence among PLHIV (People Living with HIV)(30,31). Migration: Investigating the effect of climate-related displacement and migration in raising HIV vulnerability, reducing healthcare access, and increasing risk behaviours. Health Service disruption and governance : Investigating how climate-related catastrophes and environmental changes affect HIV treatment services, supply chains, health infrastructure, and governance policies(32). Infectious illnesses and co-infections: Investigating the relationship between climate-sensitive infectious illnesses (including vector-borne and waterborne diseases) and HIV disease progression, co-infections, and health outcomes(33). Each subject was thoroughly validated and refined via expert talks to guarantee relevance, feasibility, and possible impact in the Indian healthcare and policy context. 3.1.3. Final Round Priority and Ranking : The third and last stage centred on refining, ranking, and prioritising research questions for each of the four theme areas. Experts ranked research priorities using a structured grading system, considering the criteria as follows: Urgency and Public Health Implications : How important is the issue in India's present HIV and climate change context(34)? Research Implementation Feasibility : Can research be performed effectively given the existing resources and methodologies(35)? Policy and Intervention Potential : Are the findings likely to influence national HIV policy and climate adaption strategies(36)? Relevance for Vulnerable Populations : Is the research addressing significant concerns faced by marginalised groups such as PLHIV, women, and climate migrants(37)? 3.2. Identified research priorities achieved through consensus of the interdisciplinary team: The conceptual study framework is based on the understanding that climate change impacts HIV response in India through multiple interconnected pathways. The primary pathway is food insecurity, driven by deficits in crop yields, livestock, fisheries, and forestry products, further exacerbated by mental health and gender-related issues. This pathway is linearly linked to displacement and climate-induced migration. The second key pathway is climate migration triggered by extreme weather events, where mental health challenges and gender disparities further influence HIV outcomes. Health system disruptions caused by climate-related disasters represent a distinct pathway, affecting the effectiveness of state-specific HIV prevention strategies and the continuity of care during emergencies, with mental health and gender factors acting as mediators, and also influencing patterns of displacement and migration. Additionally, the interaction between climate change and other infectious diseases, accelerated by immunosuppression and shaped by social and structural determinants, forms a sub-pathway that further influences HIV response in India (7). 3.2.1. Impact of Food Insecurity Amidst Climate Change on HIV Transmission One of the identified research goals was to gain a better understanding of how food insecurity affects HIV transmission and health outcomes across diverse populations. Under this broad heading the major areas were to focus particularly on the mother-to-child transmission (MTCT), and analysing the effect of food aid and income production initiatives in mitigating transmission risks, particularly among women. The research study would also need to look into the establishment of food security screenings through India's National AIDS Control Program (NACP) and compared that to the ART results between patients who would have adequate food availability and inadequate food availability. It would also look at the effects of climate change on food insecurity and HIV, as well as the nutritional benefits of indigenous foods in helping persons with HIV improve their immune function. Longitudinal data would be utilised to better understand the gender disparities if any and the causal mechanisms that link food insecurity and HIV transmission, as well as to find the effective nutrition interventions(38–42). 3.2.2. Migration and HIV: Addressing Climate-Induced Migration and Prevention Strategy This research priority was established to explore migration as a consequence of environmental changes and its association with increased HIV risks. The research team would focus into Mapping the movement hotspots, incorporating those corridors, exploring the sexual networks, and researching MTCT in high-migration states are all important areas of focus. It would also evaluates the viability of NACP programs for migrant communities(43,44). 3.2.3. The Effects of Climate Change on Health Infrastructure and HIV Response Under this broad heading the sub research area would be the impact of natural disasters on public health facilities, gender disparities worsened by climate-related disruptions, and the incorporation of climate-resilient practices if any in the healthcare. Through this research priority the idea is also to look into the NACP responses to emergencies, including breakthroughs in ART, opioid substitution treatment, as well as gaps in disaster risk mitigation and emergency supply chain management for HIV programs(45,46). 3.2.4. Climate change, Infectious diseases and HIV: Investigating the syndemic impacts This research priority would investigate the combined effect of extreme weather events, infectious illnesses, and HIV, focussing on the idea of a "syndemic" in which climate-induced changes exacerbate the burden of numerous health disorders. It focused on how rising temperatures and climatic events speed up the spread of infectious diseases such as tuberculosis, hepatitis, and vector-borne infections, disproportionately harming people living with HIV (PLHIV). The study also investigates delays in healthcare services induced by natural catastrophes, which can lead to interruptions in ART and vital drugs, further jeopardising viral suppression. Furthermore, the study looks at the influence of food poverty, malnutrition, and displacement in increasing vulnerability to illnesses, particularly among marginalised communities. The study emphasises the importance of coordinated health strategies to meet the interrelated issues faced by climate change and HIV(48,49). 4. Discussion The findings of the present study provide a crucial understanding of the complex interplay between extreme climate events with HIV responses in India, with the use of modified Delphi approach, four key thematic areas are emerged as critical research priorities, such as inadequate food supply, extream weather induced displacement, disturbance of health infrastructure and infectious diseases. Evidently, India's overall development is closely associated with climate risks, which disproportionately affect communities vulnerable to HIV infection as well as those people living with HIV. Adaptive capacity across the country varies significantly by state, region, and socioeconomic status. Effective management of climate-related risks on HIV response in India necessitates a deeper understanding of the key drivers of hazards, the exposure levels of different regions and populations, the sensitivity of these regions, and their resulting vulnerabilities. Moreover, it is crucial to comprehend the complex interactions among these factors, including the dominant pathways that shape their impact (34). Food insecurity has been well-documented as both a driver and consequence of HIV, influencing both transmission and treatment outcomes. The findings of this study highlight that climate-induced food scarcity and malnutrition significantly impact ART adherence, immunological health, and overall well-being of PLHIV. These results are consistent with previous studies that link food insecurity to increased HIV risk behaviours, including transactional sex and power imbalances in sexual relationships, particularly among women. Similarly, migration or displacement as one of the other major pathways, which is linking with climate change to increased HIV risk. Forced migration due to climate-induced disasters, such as floods and droughts, exposes individuals to mental health stressors, augmented risk of sexual abuse, and gender-related violence (38). These observations are aligning with global findings showing that displaced populations face higher HIV vulnerability due to unstable living conditions, reduced healthcare access, and risky survival behaviours. Moreover, rising temperatures and altered precipitation patterns are linked to an increase in vector-borne diseases such as malaria and dengue, which can further compromise the health of PLHIV. The climate-induced health service disruptions disproportionately impact PLHIV, leading to treatment interruptions, decreased access to life-saving medications, and an increased burden on already strained healthcare infrastructure (42). As climate disasters damage health facilities and disrupt supply chains, maintaining ART continuity becomes a challenge. Present study also reveals that strengthening healthcare infrastructure and adopting climate-resilient policies are essential to ensuring uninterrupted HIV care. Future research should focus on food system resilience and nutritional interventions tailored for PLHIV. Further investigations are also needed to develop adaptive healthcare models that incorporate climate forecasting into HIV response planning (48). Despite its significant findings, this study has some limitations. First, the research relies on expert opinions and existing literature, which may introduce bias in priority setting and thematic categorization. The modified Delphi technique, while effective for consensus-building, inherently reflects the perspectives of selected experts and may not fully capture the views of all stakeholders, including affected communities. Second, the study focuses on India, limiting the generalizability of findings to other regions. While climate change and HIV interactions share commonalities globally, specific socio-political and economic contexts may shape different impacts and responses in other countries. Third, the study does not include primary data collection from PLHIV or healthcare providers, which could have provided more nuanced insights into real-world challenges and coping mechanisms. Future studies should incorporate qualitative interviews and longitudinal data to strengthen evidence-based recommendations. Finally, while the study explores broad themes of climate change and HIV response, some variables, such as mental health impacts and policy effectiveness, require further in-depth analysis. Future research should focus on quantifying the direct and indirect effects of climate change on HIV outcomes through epidemiological and intervention-based studies. Declarations Contribution MB did the study design, methodology, writing, review, edit. GKG did the study design, writing, review, edit. DC did the study design, methodology, supervision, writing, review, edit. FD did the methodology, writing, review. AJ did the study design, methodology, writing. SM did the methodology, writing. SB did the methodology, writing. SS did the methodology, expert consultation, writing, review. MS did the methodology, expert consultation, review. AM did the methodology, supervision, review. SG did the methodology, expert consultation, review. MAK did the methodology, expert consultation, review. PR did the methodology, expert consultation, review. SH did the methodology, expert consultation, review. VV did the methodology, expert consultation, review. RA did the methodology, expert consultation, review. DNG did the methodology, expert consultation, review. SCS did the methodology, expert consultation, review. GSS did the methodology, expert consultation, review. SSR did the methodology, expert consultation. RSA did the methodology, expert consultation, writing, review. CB did the methodology, expert consultation, review. AKD did the methodology, supervision, writing, review, edit. SD did the supervision, review, edit. Conflict of Interest Authors are declaring no conflict of interest. Fund This work is financially supported by United Nations Development Programme, Project Number: 01001966. 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Understanding Hepatitis and HIV transmission amongst undocumented Pakistani migrants and asylum seekers in a Parisian suburb. Anthropol Med. 2020 Dec;27(4):395–411. Friel S, Berry H, Dinh H, O’Brien L, Walls HL. The impact of drought on the association between food security and mental health in a nationally representative Australian sample. BMC Public Health. 2014 Oct 24;14:1102. McKay FH, Sims A, van der Pligt P. Measuring Food Insecurity in India: A Systematic Review of the Current Evidence. Curr Nutr Rep. 2023;12(2):358–67. Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food Insecurity is Associated with Incomplete HIV RNA Suppression Among Homeless and Marginally Housed HIV-infected Individuals in San Francisco. J Gen Intern Med. 2009 Jan;24(1):14–20. Brookings [Internet]. [cited 2025 Mar 18]. Natural Disasters, Conflict, and Human Rights: Tracing the Connections. Available from: https://www.brookings.edu/articles/natural-disasters-conflict-and-human-rights-tracing-the-connections/ McLeman R, Smit B. Migration as an Adaptation to Climate Change. Clim Change. 2006 May 1;76(1):31–53. Walia A, Sharma P, Nusrat N. Kerala Floods 2018: Impacts and Lessons Drawn. In: Singh A, editor. International Handbook of Disaster Research [Internet]. Singapore: Springer Nature; 2022 [cited 2025 Mar 18]. p. 1–17. Available from: https://doi.org/10.1007/978-981-16-8800-3_188-1 Pandya A, Redcay A. Impact of COVID-19 on Transgender Women and Hijra: Insights from Gujarat, India. J Hum Rights Soc Work. 2022;7(2):148–57. Glynn TR, Safren SA, Carrico AW, Mendez NA, Duthely LM, Dale SK, et al. High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic. AIDS Behav. 2019 Nov;23(11):2956–65. Mwatelah R, McKinnon LR, Baxter C, Abdool Karim Q, Abdool Karim SS. Mechanisms of sexually transmitted infection‐induced inflammation in women: implications for HIV risk. J Int AIDS Soc. 2019 Aug 30;22(Suppl Suppl 6):e25346. UNAIDS_FactSheet_en.pdf [Internet]. [cited 2025 Mar 3]. Available from: https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6819162","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":474752550,"identity":"4ab64718-6234-43a1-9db7-a33f9abe897d","order_by":0,"name":"Mihir Bhatta","email":"","orcid":"","institution":"ICMR - National Institute for Research in Bacterial Infections","correspondingAuthor":false,"prefix":"","firstName":"Mihir","middleName":"","lastName":"Bhatta","suffix":""},{"id":474752551,"identity":"21b9a2d3-54e0-4736-b92b-4ccc854ebf36","order_by":1,"name":"Gautam Kumar Ghosh","email":"","orcid":"","institution":"ICMR - National Institute for Research in Bacterial Infections","correspondingAuthor":false,"prefix":"","firstName":"Gautam","middleName":"Kumar","lastName":"Ghosh","suffix":""},{"id":474752552,"identity":"bab1d069-a5f7-4eed-af71-9c8fdb079be0","order_by":2,"name":"Debjit Chakraborty","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDCCAwwGzAw8EkAWY+MDIMnDR6wWoB7GZgOQFjbitDAwgKxhAxEMBLXw3T688XGBjEUdv3RzW+XXHDsZNgbmh49u4NEieS6t2HgG0GGScw623Zbdlgx0GJuxcQ4eLQZneMykeYBaDG4ktt2W3MYM1MLDJk1Ai/lvkBZ7oJZiyW31RGkxYwbbIpHYxvhx22HCWiTPsBVLA/0iOePOwWZpxm3HediYCfiF7wzzxs+FPXX8/LPbH378ua3anp+9+eFjfFrAgLGHARwzzDwgHjMh5WDwA6KF8QdRqkfBKBgFo2CkAQD4JEExm5d9nAAAAABJRU5ErkJggg==","orcid":"","institution":"ICMR - 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S. Srinivasan","email":"","orcid":"","institution":"Program for Appropriate Technology in Health","correspondingAuthor":false,"prefix":"","firstName":"G.","middleName":"S.","lastName":"Srinivasan","suffix":""},{"id":474752569,"identity":"d176932c-e08f-4ecd-9290-89fa4bf9abce","order_by":19,"name":"Saikat Sinha Roy","email":"","orcid":"","institution":"Jadavpur University","correspondingAuthor":false,"prefix":"","firstName":"Saikat","middleName":"Sinha","lastName":"Roy","suffix":""},{"id":474752570,"identity":"f5d0c3f2-e2cb-40f2-bc81-8eb021e7469e","order_by":20,"name":"Rajatashuvra Adhikary","email":"","orcid":"","institution":"World Health Organization - India","correspondingAuthor":false,"prefix":"","firstName":"Rajatashuvra","middleName":"","lastName":"Adhikary","suffix":""},{"id":474752571,"identity":"04482481-f8cc-49e0-94f7-fdc43ce1fc5e","order_by":21,"name":"Chiranjeev Bhattacharjya","email":"","orcid":"","institution":"United Nations Development Programme","correspondingAuthor":false,"prefix":"","firstName":"Chiranjeev","middleName":"","lastName":"Bhattacharjya","suffix":""},{"id":474752572,"identity":"357390f9-e659-4a0f-8ea2-0256504177a0","order_by":22,"name":"Alok Kumar Deb","email":"","orcid":"","institution":"ICMR - National Institute for Research in Bacterial Infections","correspondingAuthor":false,"prefix":"","firstName":"Alok","middleName":"Kumar","lastName":"Deb","suffix":""},{"id":474752573,"identity":"c98f6ce3-2215-45b5-8ad5-4a07297b6add","order_by":23,"name":"Shanta Dutta","email":"","orcid":"","institution":"ICMR - National Institute for Research in Bacterial Infections","correspondingAuthor":false,"prefix":"","firstName":"Shanta","middleName":"","lastName":"Dutta","suffix":""}],"badges":[],"createdAt":"2025-06-04 10:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6819162/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6819162/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85218336,"identity":"1a3d3e7c-d059-4b9b-be94-bb8476bdd14b","added_by":"auto","created_at":"2025-06-23 13:48:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":242806,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6819162/v1/151176ee3b107b8792720b24.png"},{"id":85219598,"identity":"5a2cfdcc-b770-45bd-8dde-89e46a6dfd3c","added_by":"auto","created_at":"2025-06-23 13:56:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":325828,"visible":true,"origin":"","legend":"\u003cp\u003eEvidence Gap Map\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6819162/v1/202b4302c4699ffddca03535.png"},{"id":91527337,"identity":"e1a58523-d799-4a42-84b3-39eb7388f631","added_by":"auto","created_at":"2025-09-17 11:17:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1552783,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6819162/v1/047ed1fb-69a3-4528-a626-ae0d57554be6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of a Framework to Identify Research Priorities for Mitigating the Impact of Climate Change on HIV Response in India: A Scoping Review coupled with Modified Delphi","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn general climate change and the HIV epidemic are independent to each other (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). But a recent publication (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), has evidence on anthropogenic activities and how these will increase ambient temperatures in the next 50 years compare to previous 6000 years. Altogether these will cause extreme weather events such as heavy rainfalls, droughts, floods, landslides which will modify coastlines, and without fast adoption of robust mitigation and adaptation techniques, these collectively will may disrupt regular access to food, potable water, and dependable shelters(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). According to the World Bank, these consequences will cause an extra 5\u0026nbsp;million deaths, in between 2030 and 2050, mostly through starvation, malaria, and diarrhoeal diseases and will drive over 100\u0026nbsp;million more people into extreme poverty (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The climate crisis is expected to have serious health repercussions for third world countries. While the routes that connect climate change to other diseases are well understood, but the relationship between climate change and HIV has yet to be recognised (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The intersection of climate change and HIV is critical for global public health, especially because both disproportionately affect vulnerable regions like Sub-Saharan Africa (SSA) and Southeast Asia (SEA), which are strongly impacted by both HIV and climate change (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). PLHIV are at increased risk due to climate variability, which includes rising temperatures, unpredictable rainfall patterns, and frequent floods. These factors also interfere with access to antiretroviral therapy (ART), change healthcare delivery systems, and increase exposure to vector-borne illnesses (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These interrelated variables make HIV therapy and prevention more difficult by increasing opportunistic infections and worsening health care outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The need of resolving social and environmental injustices including women empowerments is highlighted by the disproportionate effects of climate change on marginalised people. People who are displaced as a result of natural disasters are frequently cut off from necessary medical care, which exacerbates inequities in health care services including HIV treatment (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndia has a longer coastline. of 7516.6-kilometer, which are divided into nine states (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) along with this, drought-prone regions of India have grown approximately more than 55% form 1997 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) similarly more than 10% of its landform is vulnerable to hydro-geological jeopardies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Studies in Indonesia have shown that people in coastal regions are more vulnerable to HIV during and/or immediately following natural disasters (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e); in many drought-prone locations, floods pose serious challenges to PLHIVs, exacerbating their health conditions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). About 0.42\u0026nbsp;million square kilometres of countries land mass, is vulnerable to landslides (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and 4% of the country's forest canopy is under the threat of wild forest fires (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Vulnerable populations, especially PLHIVs, are directly impacted by the aftermath of these occurrences in terms of their access to a range of healthcare services (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies on the relationship between climate change and health have been conducted worldwide. However, there is no such study specifically address how it affects HIV in terms of prevention, care, and treatment. So, it is difficult for Policymakers and other stakeholders to address these issues without having identified a list of priorities and their possible solutions. Hence this study was conducted to prepare a comprehensive framework to find out research priorities aimed at mitigating the effect of climate change on HIV response in India.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003eThis study comprises of two methods:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA) Scoping Review to map the available evidence and followed by\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eB) Modified Delphi method involving domain experts to conceptualize the framework to find out research priorities aimed at mitigating the effect of climate change on HIV response in India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1. Scoping Review\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis scoping review was carried out in order to methodically find and compile data about how climate change affects HIV responses in India. The technique ensured a thorough and transparent approach by following the principles (25,26).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.1. Establishing the Research Question\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the relevant search criteria, a scoping review of published literature, and reports was conducted using the e-databases PubMed and Google Scholar. The PECOS (population, exposure, comparison, outcome and study design) approach were used to determine which published publications were included. Exclusion criteria include publications written in languages other than English, from nations other than India, about homes that are not impacted by the environment, and about non-socioecological effects. In order to mitigate the influence of extreme weather events on HIV in India, the review sought to address the following primary research question:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhat are the research gaps and priorities?\u003c/li\u003e\n \u003cli\u003eThe following sub-questions were addressed:\u003c/li\u003e\n \u003cli\u003eWhat is the impact of climate change on HIV care, treatment, and prevention in India?\u003c/li\u003e\n \u003cli\u003eWhich particular vulnerabilities are made worse by climate change for persons living with HIV (PLHIV)?\u003c/li\u003e\n \u003cli\u003eWhat kinds of interventions have been suggested to deal with these issues?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2. Eligibility Criteria:\u0026nbsp;\u003c/strong\u003eThe following were the criteria for inclusion and exclusion:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.1. Inclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePECOS approach criteria were used for defining review questions. Published articles form peer-reviewed journals, and published reports or documents by the government or reputed nongovernmental agencies were included from January 2003 to December 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.2. Population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to National AIDS Control Organisation (NACO), India, key populations include injecting drug users, transgender people, men who have sex with men, and female sex workers as high-risk groups for HIV transmission (27).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.3. Exposure:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClimate related direct (drought; landslides, flood/river bank erosion, air pollution) and indirect events (food insecurity/ agriculture, fisheries),\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.4. Comparison Group:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot relevant to this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.5. Outcome:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAssociation between climate factors with HIV response and health services through diverse intermediate factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.6. Study Design:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are extracted through a previously prepared data extraction form which includes different levels of data accumulation to obtain a general picture among FSW, MSM, H/TG and IDU.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2.7. Exclusion criteria:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArticles published other than English language, describing countries other than low- and middle-income countries, articles published and describing non-environmentally affected households, and articles with non-socioecological influences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.3. Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following databases were thoroughly searched:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003ePubMed\u003c/li\u003e\n \u003cli\u003eScopus\u003c/li\u003e\n \u003cli\u003eGoogle Scholar\u003c/li\u003e\n \u003cli\u003eWeb of Science\u0026apos;s\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eCombinations of the following were included as the search terms, with appropriate Boolean operators:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u0026quot;Climate change\u0026quot; AND \u0026quot;HIV response\u0026quot;\u003c/li\u003e\n \u003cli\u003e\u0026quot;HIV/AIDS\u0026quot; AND \u0026quot;environmental stressors\u0026quot; AND \u0026quot;India\u0026quot;\u003c/li\u003e\n \u003cli\u003e\u0026quot;Climate change\u0026quot; AND \u0026quot;vulnerable populations\u0026quot;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAdditional grey literature was obtained from the websites of important organisations, such as the National AIDS Control Organisation (NACO), UNAIDS, and the World Health Organisation (WHO). The lists of reference were searched to find further sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.4. Study Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were two steps in the selecting process:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eScreening of Titles and Abstracts:\u003c/em\u003e Two impartial reviewers checked abstracts and titles for eligibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFull-Text Screening:\u003c/em\u003e Relevance was evaluated for full-text articles that satisfied the inclusion requirements. Consensus or discussion with a third reviewer were used to settle disagreements\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.5. Data Extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA standardised data extraction form was used to extract pertinent information, and it contained the following:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003eStudy objectives, methods, and key findings.\u003c/li\u003e\n \u003cli\u003ePopulation features and geographic focus.\u003c/li\u003e\n \u003cli\u003eGaps, difficulties, and suggested solutions were noted.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.6. Data Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo investigators independently reviewed the papers and then a consensus was reached for the final list of papers to be included in this study. Extracted data from the articles were entered in the predesigned data abstraction form. Based on the findings of the selected study it was categorized thematically into socioenvironmental determinants, health service problems, and policy frameworks to describe the effect of extreme weather events and HIV and mitigating the influence ofthe same on HIV response.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Application of modified Delphi method:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBuilding on the findings of the scoping review a modified Delphi consensus method was used in three interactive rounds to methodically develop a research framework and finalise major priorities. The modified Delphi consensus process was applied to find out research prioritisation on extreme weather events on HIV response in India. In this study we invited experts such as HIV specialists, Program officials, Climate experts, Economists, Gender empowerment specialists, Social science experts and Statisticians as these disciplines are interlinked and could find out the research priorities and the factors those influence the pathways of effect of extreme climate events towards HIV responses in India (25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Modified Delphi Consensus Process offers a transparent, evidence-based, and expert-validated approach to research prioritisation (26). By including interdisciplinary perspectives, we ensured that the final research output was scientifically rigorous, contextually relevant, and actionable.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn order to investigate the relationship between climate change and HIV/AIDS outcomes, the study carried out an extensive review. 88,292 documents were first found via database searches, and 55 further reports were obtained from NGOs and national and international organisations. A total of 2,397 records were tested for eligibility after 55,146 duplicate records and 35,543 data irrelevant to climate change were eliminated. 1,842 records were eliminated during screening because they lacked HIV information. A total of 555 publications were selected for either full-text or abstract review. However, 295 articles (abstract only) could not be retrieved because of insufficient information. 260 articles were assessed for eligibility following additional evaluation. Among these, 177 papers were removed because they had no relevant information on HIV response routes or climate change consequences. The final systematic review comprised 83 papers and 36 reports (Figure 1).\u003c/p\u003e\n\u003cp\u003eThe generated evidence gap map illustrated the current research landscape. The majority of research examined the influence of direct climate disasters (such as floods, droughts, cyclones, and tsunamis) and migratory patterns on HIV/AIDS outcomes. The majority of papers were narrative reviews and primary research, with only a handful being systematic reviews, protocols, or randomised controlled trials (Figure 2).\u003c/p\u003e\n\u003cp\u003eSignificant research gaps were identified in numerous areas:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThere had been few researches investigating the relationship between food insecurity and HIV/AIDS.\u003c/li\u003e\n \u003cli\u003eThere was less data on the impact of vector-borne and sexually transmitted illnesses associated to climate change.\u003c/li\u003e\n \u003cli\u003eThere was a shortage of high-quality research, such as systematic reviews, meta-analyses, and randomised controlled trials.\u003c/li\u003e\n \u003cli\u003eThere were few policy recommendations available to address HIV response options under climate change scenario.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDespite some evidence linking HIV/AIDS to climate-related migration and extreme weather events, there is still an obvious need for additional rigorous, systematic, and intervention-focused research, particularly in the areas of food security and emerging infectious illnesses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1. Result comes out through modified Delphi\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.1. First Round\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentifying Broad Research Areas:\u0026nbsp;\u003c/strong\u003eThe core research team initiate the process by presenting results from the scoping review and the Evidence Gap Map (EGM). These findings identified current knowledge gaps and research needs at the intersection of climate change and HIV in India. Experts were encouraged to remark on these findings and recommend prospective research areas for further investigation. Structured conversations, individual reflections, and a collaborative feedback process were used to suggest broad research areas. These topics focused on how climate change affects HIV transmission, treatment access, health system resilience, and socioeconomic determinants of health(27\u0026ndash;29).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.2. Second Round\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThematic Consolidation:\u0026nbsp;\u003c/strong\u003eIn this round, an extensive analysis was done with the findings from the first round and consolidated four significant theme areas that emerged as critical linkages between extreme climate events and HIV responses, which are as follows:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003e\u003cstrong\u003eFood Insecurity\u003c/strong\u003e: Evaluating the impact of climate-induced food scarcity, malnutrition, and nutritional deficiencies along with immunological health, and ART adherence among PLHIV (People Living with HIV)(30,31).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMigration:\u003c/strong\u003e Investigating the effect of climate-related displacement and migration in raising HIV vulnerability, reducing healthcare access, and increasing risk behaviours.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHealth Service disruption and governance\u003c/strong\u003e: Investigating how climate-related catastrophes and environmental changes affect HIV treatment services, supply chains, health infrastructure, and governance policies(32).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInfectious illnesses and co-infections:\u003c/strong\u003e Investigating the relationship between climate-sensitive infectious illnesses (including vector-borne and waterborne diseases) and HIV disease progression, co-infections, and health outcomes(33).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eEach subject was thoroughly validated and refined via expert talks to guarantee relevance, feasibility, and possible impact in the Indian healthcare and policy context.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.3. Final Round\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePriority and Ranking\u003c/strong\u003e: The third and last stage centred on refining, ranking, and prioritising research questions for each of the four theme areas. Experts ranked research priorities using a structured grading system, considering the criteria as follows:\u0026nbsp;\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003e\u003cstrong\u003eUrgency and Public Health Implications\u003c/strong\u003e: How important is the issue in India\u0026apos;s present HIV and climate change context(34)?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eResearch Implementation Feasibility\u003c/strong\u003e: Can research be performed effectively given the existing resources and methodologies(35)?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePolicy and Intervention Potential\u003c/strong\u003e: Are the findings likely to influence national HIV policy and climate adaption strategies(36)?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRelevance for Vulnerable Populations\u003c/strong\u003e: Is the research addressing significant concerns faced by marginalised groups such as PLHIV, women, and climate migrants(37)?\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. \u0026nbsp;Identified research priorities achieved through consensus of the interdisciplinary team:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe conceptual study framework is based on the understanding that climate change impacts HIV response in India through multiple interconnected pathways. The primary pathway is food insecurity, driven by deficits in crop yields, livestock, fisheries, and forestry products, further exacerbated by mental health and gender-related issues. This pathway is linearly linked to displacement and climate-induced migration. The second key pathway is climate migration triggered by extreme weather events, where mental health challenges and gender disparities further influence HIV outcomes. Health system disruptions caused by climate-related disasters represent a distinct pathway, affecting the effectiveness of state-specific HIV prevention strategies and the continuity of care during emergencies, with mental health and gender factors acting as mediators, and also influencing patterns of displacement and migration. Additionally, the interaction between climate change and other infectious diseases, accelerated by immunosuppression and shaped by social and structural determinants, forms a sub-pathway that further influences HIV response in India (7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eImpact of Food Insecurity Amidst Climate Change on HIV Transmission\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the identified research goals was to gain a better understanding of how food insecurity affects HIV transmission and health outcomes across diverse populations. Under this broad heading the major areas were to focus particularly on the mother-to-child transmission (MTCT), and analysing the effect of food aid and income production initiatives in mitigating transmission risks, particularly among women. The research study would also need to look into the establishment of food security screenings through India\u0026apos;s National AIDS Control Program (NACP) and compared that to the ART results between patients who would have adequate food availability and inadequate food availability. It would also look at the effects of climate change on food insecurity and HIV, as well as the nutritional benefits of indigenous foods in helping persons with HIV improve their immune function. Longitudinal data would be utilised to better understand the gender disparities if any and the causal mechanisms that link food insecurity and HIV transmission, as well as to find the effective nutrition interventions(38\u0026ndash;42).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2. Migration and HIV: Addressing Climate-Induced Migration and Prevention Strategy\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research priority was established to explore migration as a consequence of environmental changes and its association with increased HIV risks. The research team would focus into Mapping the movement hotspots, incorporating those corridors, exploring the sexual networks, and researching MTCT in high-migration states are all important areas of focus. It would also evaluates the viability of NACP programs for migrant communities(43,44).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3. The Effects of Climate Change on Health Infrastructure and HIV Response\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder this broad heading the sub research area would be the impact of natural disasters on public health facilities, gender disparities worsened by climate-related disruptions, and the incorporation of climate-resilient practices if any in the healthcare. Through this research priority the idea is also to look into the NACP responses to emergencies, including breakthroughs in ART, opioid substitution treatment, as well as gaps in disaster risk mitigation and emergency supply chain management for HIV programs(45,46).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4. Climate change, Infectious diseases and HIV: Investigating the syndemic impacts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research priority would investigate the combined effect of extreme weather events, infectious illnesses, and HIV, focussing on the idea of a \u0026quot;syndemic\u0026quot; in which climate-induced changes exacerbate the burden of numerous health disorders. It focused on how rising temperatures and climatic events speed up the spread of infectious diseases such as tuberculosis, hepatitis, and vector-borne infections, disproportionately harming people living with HIV (PLHIV). The study also investigates delays in healthcare services induced by natural catastrophes, which can lead to interruptions in ART and vital drugs, further jeopardising viral suppression. Furthermore, the study looks at the influence of food poverty, malnutrition, and displacement in increasing vulnerability to illnesses, particularly among marginalised communities. The study emphasises the importance of coordinated health strategies to meet the interrelated issues faced by climate change and HIV(48,49).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe findings of the present study provide a crucial understanding of the complex interplay between extreme climate events with HIV responses in India, with the use of modified Delphi approach, four key thematic areas are emerged as critical research priorities, such as inadequate food supply, extream weather induced displacement, disturbance of health infrastructure and infectious diseases. Evidently, India's overall development is closely associated with climate risks, which disproportionately affect communities vulnerable to HIV infection as well as those people living with HIV. Adaptive capacity across the country varies significantly by state, region, and socioeconomic status. Effective management of climate-related risks on HIV response in India necessitates a deeper understanding of the key drivers of hazards, the exposure levels of different regions and populations, the sensitivity of these regions, and their resulting vulnerabilities. Moreover, it is crucial to comprehend the complex interactions among these factors, including the dominant pathways that shape their impact (34).\u003c/p\u003e\n\u003cp\u003eFood insecurity has been well-documented as both a driver and consequence of HIV, influencing both transmission and treatment outcomes. The findings of this study highlight that climate-induced food scarcity and malnutrition significantly impact ART adherence, immunological health, and overall well-being of PLHIV. These results are consistent with previous studies that link food insecurity to increased HIV risk behaviours, including transactional sex and power imbalances in sexual relationships, particularly among women. Similarly, migration or displacement as one of the other major pathways, which is linking with climate change to increased HIV risk. Forced migration due to climate-induced disasters, such as floods and droughts, exposes individuals to mental health stressors, augmented risk of sexual abuse, and gender-related violence (38). These observations are aligning with global findings showing that displaced populations face higher HIV vulnerability due to unstable living conditions, reduced healthcare access, and risky survival behaviours. Moreover, rising temperatures and altered precipitation patterns are linked to an increase in vector-borne diseases such as malaria and dengue, which can further compromise the health of PLHIV. The climate-induced health service disruptions disproportionately impact PLHIV, leading to treatment interruptions, decreased access to life-saving medications, and an increased burden on already strained healthcare infrastructure (42). As climate disasters damage health facilities and disrupt supply chains, maintaining ART continuity becomes a challenge. Present study also reveals that strengthening healthcare infrastructure and adopting climate-resilient policies are essential to ensuring uninterrupted HIV care. Future research should focus on food system resilience and nutritional interventions tailored for PLHIV. Further investigations are also needed to develop adaptive healthcare models that incorporate climate forecasting into HIV response planning (48).\u003c/p\u003e\n\u003cp\u003eDespite its significant findings, this study has some limitations. First, the research relies on expert opinions and existing literature, which may introduce bias in priority setting and thematic categorization. The modified Delphi technique, while effective for consensus-building, inherently reflects the perspectives of selected experts and may not fully capture the views of all stakeholders, including affected communities.\u003c/p\u003e\n\u003cp\u003eSecond, the study focuses on India, limiting the generalizability of findings to other regions. While climate change and HIV interactions share commonalities globally, specific socio-political and economic contexts may shape different impacts and responses in other countries.\u003c/p\u003e\n\u003cp\u003eThird, the study does not include primary data collection from PLHIV or healthcare providers, which could have provided more nuanced insights into real-world challenges and coping mechanisms. Future studies should incorporate qualitative interviews and longitudinal data to strengthen evidence-based recommendations.\u003c/p\u003e\n\u003cp\u003eFinally, while the study explores broad themes of climate change and HIV response, some variables, such as mental health impacts and policy effectiveness, require further in-depth analysis. Future research should focus on quantifying the direct and indirect effects of climate change on HIV outcomes through epidemiological and intervention-based studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMB did the study design, methodology, writing, review, edit. GKG did the study design, writing, review, edit. DC did the study design, methodology, supervision, writing, review, edit. FD did the methodology, writing, review. AJ did the study design, methodology, writing. SM did the methodology, writing. SB did the methodology, writing. SS did the methodology, expert consultation, writing, review. MS did the methodology, expert consultation, review. AM did the methodology, supervision, review. SG did the methodology, expert consultation, review. MAK did the methodology, expert consultation, review. PR did the methodology, expert consultation, review. SH did the methodology, expert consultation, review. VV did the methodology, expert consultation, review. RA did the methodology, expert consultation, review. DNG did the methodology, expert consultation, review. SCS did the methodology, expert consultation, review. GSS did the methodology, expert consultation, review. SSR did the methodology, expert consultation. RSA did the methodology, expert consultation, writing, review. CB did the methodology, expert consultation, review. AKD did the methodology, supervision, writing, review, edit. SD did the supervision, review, edit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors are declaring no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFund\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work is financially supported by United Nations Development Programme, Project Number: 01001966.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLieber M, Chin-Hong P, Whittle HJ, Hogg R, Weiser SD. The Synergistic Relationship Between Climate Change and the HIV/AIDS Epidemic: A Conceptual Framework. AIDS Behav. 2021 Jul 1;25(7):2266\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eXu C, Kohler TA, Lenton TM, Svenning JC, Scheffer M. Future of the human climate niche. Proc Natl Acad Sci. 2020 May 26;117(21):11350\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eWarner K, Hamza M, Oliver-Smith A, Renaud F, Julca A. 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Sex Transm Dis. 2000 Jul;27(6):327. \u003c/li\u003e\n\u003cli\u003eArksey H, O\u0026rsquo;Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005 Feb 1;8(1):19\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eLevac D, Colquhoun H, O\u0026rsquo;Brien KK. Scoping studies: advancing the methodology. Implement Sci IS. 2010 Sep 20;5:69. \u003c/li\u003e\n\u003cli\u003epopulation definition as per naco - Google Search [Internet]. [cited 2025 May 1]. 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Effect of malaria on HIV/AIDS transmission and progression. Parasit Vectors. 2013 Jan 17;6:18. \u003c/li\u003e\n\u003cli\u003eMcLeman RA. Climate and human migration : past experiences, future challenges [Internet]. New York : Cambridge University Press; 2014 [cited 2025 Mar 18]. 322 p. Available from: http://archive.org/details/climatehumanmigr0000mcle\u003c/li\u003e\n\u003cli\u003eRao ASRS, Thomas K, Sudhakar K, Maini PK. HIV/AIDS epidemic in India and predicting the impact of the national response: mathematical modeling and analysis. Math Biosci Eng MBE. 2009 Oct;6(4):779\u0026ndash;813. \u003c/li\u003e\n\u003cli\u003eGhosh DG. COVID-19 in India: Health Implications and Treatment Needs of People Who Use Drugs (PWUD) and Patients with Substance Use Disorders (SUD) [Internet]. Rochester, NY: Social Science Research Network; 2020 [cited 2025 Mar 18]. 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BMC Public Health. 2014 Oct 24;14:1102. \u003c/li\u003e\n\u003cli\u003eMcKay FH, Sims A, van der Pligt P. Measuring Food Insecurity in India: A Systematic Review of the Current Evidence. Curr Nutr Rep. 2023;12(2):358\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eWeiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food Insecurity is Associated with Incomplete HIV RNA Suppression Among Homeless and Marginally Housed HIV-infected Individuals in San Francisco. J Gen Intern Med. 2009 Jan;24(1):14\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eBrookings [Internet]. [cited 2025 Mar 18]. Natural Disasters, Conflict, and Human Rights: Tracing the Connections. Available from: https://www.brookings.edu/articles/natural-disasters-conflict-and-human-rights-tracing-the-connections/\u003c/li\u003e\n\u003cli\u003eMcLeman R, Smit B. Migration as an Adaptation to Climate Change. Clim Change. 2006 May 1;76(1):31\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eWalia A, Sharma P, Nusrat N. Kerala Floods 2018: Impacts and Lessons Drawn. In: Singh A, editor. International Handbook of Disaster Research [Internet]. Singapore: Springer Nature; 2022 [cited 2025 Mar 18]. p. 1\u0026ndash;17. Available from: https://doi.org/10.1007/978-981-16-8800-3_188-1\u003c/li\u003e\n\u003cli\u003ePandya A, Redcay A. Impact of COVID-19 on Transgender Women and Hijra: Insights from Gujarat, India. J Hum Rights Soc Work. 2022;7(2):148\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eGlynn TR, Safren SA, Carrico AW, Mendez NA, Duthely LM, Dale SK, et al. High Levels of Syndemics and Their Association with Adherence, Viral Non-suppression, and Biobehavioral Transmission Risk in Miami, a U.S. City with an HIV/AIDS Epidemic. AIDS Behav. 2019 Nov;23(11):2956\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eMwatelah R, McKinnon LR, Baxter C, Abdool Karim Q, Abdool Karim SS. Mechanisms of sexually transmitted infection‐induced inflammation in women: implications for HIV risk. J Int AIDS Soc. 2019 Aug 30;22(Suppl Suppl 6):e25346. \u003c/li\u003e\n\u003cli\u003eUNAIDS_FactSheet_en.pdf [Internet]. [cited 2025 Mar 3]. Available from: https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Climate change, HIV response, key populations, food insecurity, migration, health system disruption, co-infections","lastPublishedDoi":"10.21203/rs.3.rs-6819162/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6819162/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClimate Change and extreme weather events are recognized as the critical threat to public health, with severe effects on vulnerable populations in low- and middle-income countries. In India, these climatic stressors may further undermine the HIV response by disrupting services, exacerbating vulnerabilities, augmenting transmission and straining health systems. However, the evidence based on how climate change intersects with HIV responses remains limited and fragmented. Present study aimed to develop a comprehensive framework for identifying research priorities aimed at mitigating the impact of climate change on the HIV response in India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePresent work was carried out through the scoping review followed by a modified Delphi. Scoping review included peer-reviewed articles and grey literatures published between 2000 to 2023 following PRISMA guidelines. The database search comprises of PubMed, Scopus, Web of Science, and regional sources, focusing on studies that explore the interface of climate and HIV-related health outcomes, service delivery, and system resilience. The data was extracted from the selected articles, then analysed to identify the lessons of contextual relevance. Building on the findings of the scoping review a Modified Delphi Consensus method was used in three interactive rounds to develop a research framework and finalise major priorities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn initial pool of 88,292 records and 55 additional grey literature sources was narrowed down to 119 documents (83 academic papers and 36 reports) after screening for relevance and eligibility. Most of the included studies focused on climate migration, health service disruptions. though a large proportion were narrative reviews with limited high-quality evidences. The Evidence Gap Map revealed significant research deficiencies, especially in areas such as food insecurity, co-infections, and policy-level responses. Using a modified Delphi method, the research team identified four major researchable domains namely food insecurity, migration, health system disruption, and co-infections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a first of its kind endeavour in Indian setting to direct investments in cross cutting areas of Climate Change \u0026amp; HIV programs. The conceptual framework suggested that climate change affects the HIV response through interconnected pathways. The final research priorities aimed to guide evidence generation for policy action and resilient health systems.\u003c/p\u003e","manuscriptTitle":"Development of a Framework to Identify Research Priorities for Mitigating the Impact of Climate Change on HIV Response in India: A Scoping Review coupled with Modified Delphi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 13:48:06","doi":"10.21203/rs.3.rs-6819162/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80980eb1-af84-4e73-99f9-118917463cbf","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-17T11:08:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 13:48:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6819162","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6819162","identity":"rs-6819162","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}