A Retrospective Study of Characteristics of HIV Infected Individuals Opting Out from Antiretroviral Treatment under National Programme

Background: Retention in care is important for optimal treatment outcomes and effective positive prevention. Reports from India and other countries have mentioned various factors affecting retention but the data on 'opting out' from Antiretroviral Treatment (ART) under the National AIDS Control Programme are scanty. Aim and Objectives: To estimate prevalence and predictors for opting out from Antiretroviral Treatment among HIV infected individuals attending ART center at ICMR-National AIDS Research Institute, Pune. Material and Methods: In this retrospective study, records of individuals taking ART between January 2006 and May 2017 were reviewed. An individual who no longer wished to continue treatment with the national programme because of his/her personal choice and stopped visiting the centre was reported as being 'opted out' from the programme. Results: Of the total 3842 individuals ever initiated on ART, 115 (3%) individuals opted out. The possibility of opting out from ART was 4.9 [95% CI: 1.78-13.6, (p=0.002)] times more in individuals who showed declining trend in their CD4 counts and 8.8 [95% CI: 3.33-23.27, (p<0.001)] times more in individuals who received treatment for less than a year. Sixty four (56%) opted out individuals could not be contacted telephonically. Of the 51 (44%) ndividuals that were contacted, 16 replied that they will visit the clinic as per their convenience. The reasons for opting out from RTin remaining 35 patients were inconvenience for coming to the clinic in terms of distance or financial issues (13), taking treatment from private sector (10), side effects of the drugs (5), death (4) and taking treatment from other government programme clinics (3). Conclusion: Efforts should be taken to address the issues of individuals not willing to continue ART from the programme clinics (opted out). The counseling should be strengthened to prevent the individuals opting out from the treatment. The national operational guidelines for ART services need to address the issues of these individuals so that they can be brought back into the programme.

HIV drug-resistance early-warning indicators and quality care in India: preliminary findings from a pilot study in Pune city.

Background: India has rapidly scaled up its programme for antiretroviral therapy (ART). There is high potential for the emergence of HIV drug resistance (HIVDR), with an increasing number of patients on ART. It is not feasible to perform testing for HIVDR using laboratory genotyping, owing to economic constraints. This study piloted World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR, and quality-of-care indicators (QCIs), in four ART clinics in Pune city. Methods: A retrospective study was conducted in 2015, among four ART clinics in Pune city, India. The data on four standardized EWIs (EWI 1: On-time pill pickup, EWI 2: Retention of patients in ART care at 12 months after initiation, EWI 3: Pharmacy stock-out, EWI 4: Pharmacy dispensing practices) and three QCIs (QCI 1: Regularity in CD4 testing in patients taking ART, QCI 2: Percentage of patients initiating ART within 30 days of medical eligibility, QCI 3: Percentage of patients initiating ART within 30 days of initiation of anti-tuberculosis therapy) were abstracted into WHO Excel HIV data abstractor tools, from the patient records from April 2013 to March 2014. Results: All four ART clinics met the EWI 4 target (100%) for ART dispensing practices. The target for EWIs on-time pill-pick (EWI 1 >90%) and pharmacy stockouts (EWI 3: no stock-outs, 100%) were achieved in one clinic. None of the clinics met the EWI 2 target for retention in care at 12 months (>90%) and the overall retention was 76% (95% confidence interval: 73% to 79%). The targets for QCI 1 and QCI 2 (>90% each) were achieved in one and two clinics respectively. None of the clinics achieved the target for QCI 3 (>90%). Conclusion: ART dispensing practices (EWI 4) were excellent in all clinics. Efforts are required to strengthen retention in care and timely pill pick-up and ensure continuity of clinic-level drug supply among the programme clinics in Pune city. The clinics should focus on regularity in testing CD4 count and timely initiation of ART.

Use of first line antiretroviral therapy from a free ART programme clinic in Pune, India - A preliminary report.

Background & objectives: The treatment outcomes under national antiretroviral therapy (ART) programme are being evaluated in some ART centres in the country. We carried out this study to analyze the impact of first line antiretroviral therapy in HIV infected patients attending a free ART roll out national programme clinic in Pune, India. Methods: Antiretroviral naive HIV infected patients attending the clinic between December 2005 and April 2008 and followed up till March 31, 2011 were included in the analysis. The enrolment and follow up of these patients were done as per the national guidelines. Viral load estimations were done in a subset of patients. Results: One hundred and forty two patients with median CD4 count of 109 cells/μl (IQR: 60-160) were initiated on treatment. The median follow up was 44 months (IQR: 37-53.3 months). Survival analysis showed that the probability of being alive at the end of 5 years was 85 per cent. Overall increase in the median CD4 count was statistically significant (P<0.001). It was significant in patients with >95 per cent adherence (P<0.001). In 14 per cent patients, the absolute CD4 count did not increase by 100 or more cells/μl at the end of 12 months. Viral load estimation in a subset of 68 patients showed undetectable levels in 61 (89.7%) patients after a median duration of 46 months (IQR: 38.3-54.8). Interpretation & conclusions: The first line treatment was effective in patients attending the programme clinic. The adherence level influenced immunological and virological outcomes of patients.

Incident HIV infection among men attending STD clinics in Pune, India: pathways to disparity and interventions to enhance equity.

Systematic disparities in rates of HIV incidence by socioeconomic status were assessed among men attending three sexually transmitted disease (STD) clinics in Pune, India, to identify key policy-intervention points to increase health equity. Measures of socioeconomic status included level of education, family income, and occupation. From 1993 to 2000, 2,260 HIV-uninfected men who consented to participate in the study were followed on a quarterly basis. Proportional hazards regression analysis of incident HIV infection identified a statistically significant interaction between level of education and genital ulcer disease. Compared to the lowest-risk men without genital ulcer disease who completed high school, the relative risk (RR) for acquisition of HIV was 7.02 (p < 0.001) for illiterate men with genital ulcer disease, 3.62 (p < 0.001) for men with some education and genital ulcer disease, and 3.02 (p < 0.001) for men who completed high school and had genital ulcer disease. For men with no genital ulcer disease and those with no education RR was 1.09 (p = 0.84), and for men with primary/middle school it was 1.70 (p = 0.03). The study provides evidence that by enhancing access to treatment and interventions that include counselling, education, and provision of condoms for prevention of STDs, especially genital ulcer disease, among disadvantaged men, the disparity in rates of HIV incidence could be lessened considerably. Nevertheless, given the same level of knowledge on AIDS, the same level of risk behaviour, and the same level of biological co-factors, the most disadvantaged men still have higher rates of HIV incidence.