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Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India a

a

a

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Ritu Parchure , Vinay Kulkarni , Sanjeevani Kulkarni & Raman Gangakhedkar a

Prayas, Pune, India

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National AIDS Research Institute, Pune, India Published online: 06 Jan 2015.

Click for updates To cite this article: Ritu Parchure, Vinay Kulkarni, Sanjeevani Kulkarni & Raman Gangakhedkar (2015) Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 27:6, 716-722, DOI: 10.1080/09540121.2014.996518 To link to this article: http://dx.doi.org/10.1080/09540121.2014.996518

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AIDS Care, 2015 Vol. 27, No. 6, 716–722, http://dx.doi.org/10.1080/09540121.2014.996518

Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India Ritu Parchurea*, Vinay Kulkarnia, Sanjeevani Kulkarnia and Raman Gangakhedkarb a

Prayas, Pune, India; bNational AIDS Research Institute, Pune, India

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(Received 1 July 2014; accepted 3 December 2014) Continued engagement throughout the HIV care continuum, from HIV diagnosis through retention on antiretroviral therapy (ART), is crucial for enhancing impact of HIV care programs. We assessed linkage and retention in HIV care among people living with HIV (PLHIV) enrolled at a private HIV care clinic in Pune, India. Of 1220 patients, 28% delayed linkage after HIV diagnosis with a median delay of 24 months (IQR = 8–43). Younger people, women, low socioeconomic status, and those diagnosed at facilities other than the study clinic were more likely to delay linkage. Those with advanced HIV disease at diagnosis and testing for HIV due to HIV-related illness were linked to care immediately. Of a total of 629 patients eligible for ART at first CD4 count, 68% initiated ART within 3 months. Among those not eligible for ART, only 46% of patients sought subsequent CD4 count in time. Multivariate logistic regression analysis revealed that patients with initial CD4 count of 350–500 cells/cu mm (OR: 2, 95% CI: 1.1–3.5) and >500 cells/cu mm (OR: 2.1, 95% CI: 1.2–3.7) were less likely to do subsequent CD4 test on time as compared to those with CD4 < 50 cells/cu mm. Among patients not eligible for ART, those having >12 years of education (OR: 0.4, 95% CI: 0.2–0.9) were more likely to have timely uptake of subsequent CD4 count. Among ART eligible patients, being an unskilled laborer (OR: 2.2, 95% CI: 1.1–4.2) predicted lower uptake. The study highlights a long delay from HIV diagnosis to linkage and further attrition during pre-ART and ART phases. It identifies need for newer approaches aimed at timely linkage and continued retention for patients with low education, unskilled laborers, and importantly, asymptomatic patients. Keywords: HIV/AIDS; India; linkage to HIV care; retention in HIV care; uptake of CD4 counts

Background Timely initiation and adherence to antiretroviral therapy (ART) decreases morbidity and mortality among people living with HIV/AIDS (PLHIV; Fox et al., 2010; Hoffmann et al., 2013). Early diagnosis of HIV, immediate linkage, and retention in care are crucial components of HIV care continuum; however loss to follow-up (LFU) remains a major challenge (Rosen & Fox, 2011). In India, over 1.73 million PLHIV were ever registered at ART centers by 2012 (Department of AIDS control (NACO), 2012–2013). Significant attrition has been observed at each stage of continuum of care. A 20% dropout was reported from diagnosis at integrated counseling and testing center to linkage to ART center (Shastri et al., 2013). A retention rate of 84% was seen in government ART centers at 2 years of ART (Bachani et al., 2010). A private clinic from Andhra Pradesh reported 31% retention throughout HIV care continuum (Alvarez-Uria, Pakam, Midde, & Naik, 2013). The national program monitors HIV disease progression with 6 monthly CD4 counts to determine ART eligibility during pre-ART phase and then to monitor response to ART. In the current study, we reviewed linkage

*Corresponding author. Email: [email protected] © 2015 Taylor & Francis

and retention in HIV care in a cohort of PLHIV using timely uptake of CD4 counts as an outcome indicator.

Methods Study setting The study clinic is run by a nonprofit organization from Pune, India. It provides outpatient clinical, counseling, laboratory services, and ART to PLHIV at cost subsidized to their level of earning. National guidelines are followed for HIV diagnosis and management during preART and after ART initiation. Study population and design This retrospective study was done among PLHIV enrolled at the study clinic during 2008 to 2012. Deidentified data of enrolled patients were exported to a Microsoft ACCESS database. Inclusion criteria and definitions Antiretroviral (ARV) naive adult patients (age > 18 years), enrolled at the clinic between 1 January 2008 and

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Results A total of 1220 individuals were included for the analysis (Figure 1). Linkage to HIV care

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Figure 1. Cases included in the final analysis.

31 December 2012, and diagnosed with HIV after 2004 were included in the analysis (Figure 1). “Timely linkage to HIV care services” was defined as immunological staging (CD4 count) done within three months of HIV diagnosis. “Timely uptake of subsequent scheduled CD4 count” was defined as second CD4 count done within 9 months of first immunological staging. A window of 3 months after the scheduled 6 monthly CD4 test was factored in defining timely uptake. Eligibility for ART was assessed as per contemporary immunological criteria – CD4 cut-off of 3 months 500/cu mm

1 1.15 0.77 0.88 1 0.93 1 0.84 0.89 1 1.06 0.68 1 1.65 1.22 1.37 1.33 1 1.13 1 0.88 0.92 1 1.18 1 1.34 1.48 2.03 1.88

OR, Odds ratio; aOR, adjusted odds ratio; CI, confidence interval; S/E status, socioeconomic status.

95% CI

p value

(0.73–1.79) (0.49–1.2) (0.55–1.42)

0.55 0.25 0.61

(0.74–1.17)

0.55

(0.62–1.13) (0.54–1.46)

0.25 0.65

(0.79–1.44) (0.44–1.04)

0.69 0.07

(1.11–2.47) (0.83–1.78) (0.79–2.39) (0.91–1.95)

0.01 0.31 0.26 0.14

(0.89–1.43)

0.33

(0.58–1.32) (0.65–1.28)

0.52 0.61

(0.91–1.51) (0.88–2.03) (0.96–2.28) (1.28–3.22) (1.2–2.95)

aOR

95% CI

p value

(0.7–2.11) (0.43–1.35) (0.54–1.79)

0.48 0.35 0.94

(0.51–1.1) – – –

0.14 – – –

1 1.22 0.76 0.98 1 0.75 – – – 1 0.95 0.61 1 1.61 1.21 1.35 1.25 – – –

(0.68–1.34) (0.37–1)

0.79 0.05

(1.01–2.58) (0.72–2.05) (0.71–2.57) (0.81–1.93) – – –

0.05 0.47 0.36 0.32 – – –

0.21

– – –

– – –

– – –

0.17 0.07 3 months

1 1.72 1.12 1.63 1 1.1 0.84 1 2.24 0.84 1.08 1.73 – –

(0.7–1.72) (0.41–1.7)

(0.42–7.04) (0.28–4.51) (0.4–6.75)

0.69 0.62

0.45 0.87 0.5

p value

References

95% CI aOR Category Variable

Eligible for ART

Table 3. Predictors of not undertaking timely subsequent scheduled CD4 testing, stratified by ART eligibility status at first immunological staging, among HIV-infected patients enrolled at study clinic during 2008–2012.

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Alvarez-Uria, G., Pakam, R., Midde, M., & Naik, P. K. (2013). Entry, retention, and virological suppression in an HIV cohort study in India: Description of the cascade of care and implications for reducing HIV-related mortality in low- and middle-income countries. Interdisciplinary Perspectives on Infectious Diseases, 2013, Article ID 384805. doi:10.1155/2013/384805 Bachani, D., Garg, R., Rewari, B. B., Hegg, L., Rajasekaran, S., Deshpande, A., … Rao, K. S. (2010). Two-year treatment outcomes of patients enrolled in India’s national first-line antiretroviral therapy programme. The National Medical Journal of India, 23(1), 7–12. Banandur, P., Ramanaik, S., Manhart, L. E., Buzdugan, R., Mahapatra, B., Isac, S., … Blanchard, J. F. (2012). Understanding out-migration among female sex workers in South India. Sexually Transmitted Diseases, 39, 776– 783. doi:10.1097/OLQ.0b013e3182641d90 Bursac, Z., Gauss, C. H., Williams, D. K., & Hosmer, D. W. (2008). Purposeful selection of variables in logistic regression. Source Code Biology Medicine, 3, 17. doi:10.1186/ 1751-0473-3-17 Department of AIDS control (NACO). (2012–2013). Annual report. New Delhi: Author. Fox, M. P., Sanne, I. M., Conradie, F., Zeinecker, J., Orrell, C., Ive, P., … Wood, R. (2010). Initiating patients on antiretroviral therapy at CD4 cell counts above 200 cells/microl is associated with improved treatment outcomes in South Africa. AIDS, 24, 2041–2050. doi:10.1097/QAD. 0b013e32833c703e Gangakhedkar, R. R., Bentley, M. E., Divekar, A. D., Gadkari, D., Mehendale, S. M., Shepherd, M. E., … Quinn, T. C. (1997). Spread of HIV infection in married monogamous women in India. JAMA, 278, 2090–2092. doi:10.1001/ jama.1997.03550230066039 Hoffmann, C. J., Lewis, J. J., Dowdy, D. W., Fielding, K. L., Grant, A. D., Martinson, N. A., … Chaisson, R. E. (2013). Mortality associated with delays between clinic entry and ART initiation in resource-limited settings: Results of a transition-state model. Journal of Acquired Immune Deficiency Syndromes, 63(1), 105–111. doi:10.1097/QAI. 0b013e3182893fb4 Lessells, R. J., Mutevedzi, P. C., Cooke, G. S., & Newell, M. L. (2011). Retention in HIV care for individuals not yet eligible for antiretroviral therapy: Rural KwaZulu-Natal, South

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Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India.

Continued engagement throughout the HIV care continuum, from HIV diagnosis through retention on antiretroviral therapy (ART), is crucial for enhancing...
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