Attitudes and acceptability of children, caregivers, and healthcare providers about using telemedicine for pediatric HIV care in a resource-limited setting.

BACKGROUND: The Pediatric HIV Telemedicine Initiative is a video-linked delivery of expert services, designed to reach those previously unable to access expert HIV care. The present qualitative study was designed to understand the acceptability of telemedicine [TM] by patients, their caregivers and health care providers in the anti-retroviral therapy (ART) centers in Maharashtra. METHODS: We conducted focus group discussions with caregivers at six ART centres (three linked with TM facilities and three not linked with TM). We also conducted in-depth interviews with medical officers, counselors, and pharmacists at each centre. The data from the interviews were transcribed and translated into English for analysis. The qualitative data were analyzed using thematic framework approach. RESULTS: Children and caregivers who had participated in telemedicine consultation through video conference found the process acceptable, were comfortable communicating during these sessions, and did not have any specific problem to report. The advantages of TM were: consultation without having to travel to other cities; economic advantage; and prompt consultation. The total time spent during the process and technical difficulties during the TM sessions were some of the challenges. The medical officers had the opportunity to discuss difficult cases with the expert during the TM session. Some sessions were also considered a 'group counseling' session, wherein several children and caregivers were able to interact and learn from each other and motivate each other. The health care providers at the three centers that did not currently have TM facilities expressed a desire to have these services at their centers as well. According to them, these facilities will help them address complicated and difficult pediatric HIV cases. Currently, they send their patients to referral centers or other hospitals. Since, many of these referral hospitals are situated in bigger cities, less than 50% of patients access care at these centers This is mostly due to the time constraints and finances (travel/stay) required for accessing these centres. DISCUSSION: TM was a feasible, acceptable, and desired approach for care of children living with HIV/AIDS. It provides support to their caregivers as well as their care providers. The ART staff from the telemedicine-linked peripheral centers were supportive of the use of TM and wanted these services to be initiated in the non-linked centers.

Successful integration of HIV pre-exposure prophylaxis into a community-based HIV prevention program for female sex workers in Kolkata, India.

We assessed the impact of pre-exposure prophylaxis (PrEP) in the context of a community-based HIV program among female sex workers (FSWs) in Kolkata, India. This was an open-label, uncontrolled demonstration trial. HIV seronegative FSWs over 18 years were eligible. Participants were administered daily tenofovir/emtricitabine (TDF-FTC) with follow-up visits at months 1, 3, 6, 9, 12, and 15. Drug adherence was monitored by self-report, and a random subset of participants underwent plasma TDF testing. 843 women were screened and 678 enrolled and started on PrEP. Seventy-nine women (11%) did not complete all scheduled visits: four women died of reasons unrelated to PrEP and 75 withdrew, for a 15-month retention rate of 89%. Self-reported daily adherence was over 70%. Among those tested for TDF, the percentage of women whose level reached ≥40 ng/mL was 65% by their final visit. There were no HIV seroconversions, and no evidence of significant changes in sexual behavior. This study demonstrated the feasibility and effectiveness of PrEP for FSWs in Kolkata, with very high levels of adherence to PrEP and no HIV seroconversions. The integration of PrEP into an existing community-based HIV prevention program ensured community support and facilitated adherence.

Reaching the Unreached: Providing Quality Care to HIV-Infected Children through Telemedicine-An Innovative Pilot Initiative from Maharashtra, India.

BACKGROUND: The National AIDS Control Organization (NACO) of India created the Regional Pediatric Antiretroviral Therapy (ART) Center; this was subsequently upgraded to seven Pediatric Centers of Excellence (PCoEs) to strengthen the quality of treatment and care of children living with HIV/AIDS (CLHAs). In October 2013, the pediatric HIV telemedicine initiative, an e-decentralized (care provided by local healthcare providers and support provided by a central agency through telemedicine facilities) model of expert pediatric HIV care and referral services, was established as a pilot project at the Pediatric Center of Excellence for HIV Care in Maharashtra. We designed the present study to compare management, compliance to ART, and mortality in children in the ART centers linked to the PCoE through telemedicine versus those that are not linked to the PCoE. METHODS: It was a retrospective cross-sectional study of secondary data from CLHAs from October 2013 through August 2015 in the ART centers to document the intermediate outcomes and to determine if the initiative has improved the quality of care for the CLHAs enrolled in the linked ART centers with nonlinked ART centers. The centers in which the telemedicine sessions were conducted regularly were called linked-regular centers and in whom it was conducted irregularly (less than the median of 12 videoconference cases), it was called a linked-irregular center. Data from 2803 children in 31 linked (1365 in irregular and 1438 in regular centers) and 2608 children in 28 nonlinked centers were analyzed. The outcomes in children in the pre-ART group (ART naïve) were (1) alive on pre-ART, (2) lost to follow-up on pre-ART, (3) death during the pre-ART period, (4) eligible but not initiated on ART, and (5) missing baseline and latest CD4 counts. The outcomes of children on ART were (1) alive on ART, (2) lost to follow-up on ART, (3) death on ART, and (4) missing baseline and latest CD4 counts. RESULTS: We found that a higher proportion of children in the linked-regular centers (79% vs. 70%, p < 0.001) and linked-irregular centers (76% vs. 70%, p = 0.04) was alive compared with that in the nonlinked centers in the pre-ART group. In this group, the proportion of children with missing baseline CD4 counts and latest CD4 counts was significantly low in linked (regular centers) centers. In the ART group, we found that a higher proportion of children in the linked-regular centers was alive compared with that in the linked-irregular centers (77% vs. 69%, p < 0.001); the proportion was not significantly different in nonlinked centers (77% vs. 78%, p = 0.56). In this group, the proportion of missing baseline CD4 counts was significantly lower in the linked-regular centers (3% vs 13%, p<0.001) and linked-irregular centers (1% vs. 13%, p < 0.001) compared with that in the nonlinked centers. Furthermore, the latest CD4 counts were missing in a significantly lower proportion of children in the linked-regular centers compared with those in the linked-irregular centers (6% vs. 18%, p < 0.001) and nonlinked centers (6% vs. 18%, p < 0.001). CONCLUSION: Our study shows that the centers linked through telemedicine performed better in terms of patient care and treatment, with a lesser loss to follow-up and lesser deaths in CLHA. Overall, this pilot project of telemedicine for pediatric HIV has been proven to be acceptable, feasible, and effective in improving the quality of care for children living with HIV across the state of Maharashtra.

Prevalence of HBV and HCV infections, Bhutan, 2017: Progress and next steps.

BACKGROUND: Bhutan is committed to eliminating hepatitis B and hepatitis C, though recent baseline estimates of disease burden in the general population are unknown. In 2017, we carried out a biomarker survey in the general population to estimate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) biomarkers to evaluate the impact of immunization and guide further efforts. METHODS: In 2017, a cross-sectional, population-based, three-stage cluster survey was undertaken of the general population (1-17 and 20+ years of age). We visited households, collected blood specimens and administered a standard questionnaire. Specimens were collected for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We calculated prevalence of infection and selected characteristics, along with confidence intervals (CIs). RESULTS: Of 1372 individuals approached, 1358 (99%) participated. Of those, 1321 (97%) had a specimen tested for HBsAg, and among 1173 enrolled individuals 5 years of age or older, 1150 (98%) individuals were tested for anti-HCV. The prevalence of HBsAg was 2.0% in 775 persons 20 years of age or older (95% CI: 1.0-4.0) and 0.5% in 546 persons 1-17 years of age (95% CI: 0.1-1.8). The prevalence of anti-HCV was 0.3% (95% CI: 0.1-0.8) among persons ≥5 years. CONCLUSIONS: Universal hepatitis B immunization of infants has resulted in a low prevalence of chronic HBV infection in persons 1-17 years of age and the prevalence of anti-HCV is low among persons aged ≥5 years. Efforts should continue to reach high coverage of the timely birth dose along with completion of the hepatitis B vaccine series. To reduce the chronic liver disease burden among adults, HBV and HCV testing and treatment as indicated might be restricted to pregnant women, blood donors, individuals with chronic liver diseases, and other groups with history of high-risk exposures.

HIV-1 pol gene diversity and molecular dating of subtype C from Sri Lanka.

BACKGROUND: The first case of HIV infection in Sri Lanka was reported in 1987 and at the end of 2018 there were 3500 people living with HIV. There have been commendable efforts made towards the detection, treatment, and prevention of HIV in the country. Even though the genetic diversity of HIV has been shown to affect the parameters ranging from detection to vaccine development, there is no data available with respect to the molecular epidemiology of HIV-1 in Sri Lanka. METHODS: In this report we have performed the ancillary analysis of pol gene region sequences (n = 85) obtained primarily for the purpose of HIV-1 drug resistance genotyping. Briefly, dried blood spot specimens (DBS) collected from HIV-1 infected individuals between December 2015 and August 2018 were subjected to pol gene amplification and sequencing. These pol gene sequences were used to interpret the drug resistance mutation profiles. Further, sequences were subjected to HIV-1 subtyping using REGA 3.0, COMET, jPHMM and, RIP online subtyping tools. Moreover, Bayesian phylogenetic analysis was employed to estimate the evolutionary history of HIV-1 subtype C in Sri Lanka. RESULTS: Our analysis revealed that the majority (51.8%) of pol gene sequences were subtype C. Other than subtype C, there were sequences categorized as subtypes A1, B, D and G. In addition to pure subtypes there were sequences which were observed to be circulating recombinant forms (CRFs) and a few of the recombinants were identified as potential unique recombinants (URFs). We also observed the presence of drug resistance mutations in 56 (65.9%) out of 85 sequences. Estimates of the Bayesian evolutionary analysis suggested that the HIV-1 subtype C was introduced to Sri Lanka during the early 1970s (1972.8). CONCLUSION: The findings presented here indicate the presence of multiple HIV-1 subtypes and the prevalence of drug resistance mutations in Sri Lanka. The majority of the sequences were subtype C, having their most recent common ancestor traced back to the early 1970s. Continuous molecular surveillance of HIV-1 molecular epidemiology will be crucial to keep track of drug resistance, genetic diversity, and evolutionary history of HIV-1 in Sri Lanka.

Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage.

BACKGROUND: Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy. METHODS: Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role. RESULTS: We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps. CONCLUSIONS: Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

The Ashodaya PrEP project: Lessons and implications for scaling up PrEP from a community-led demonstration project among female sex workers in Mysore, India.

To inform PrEP roll out, Ashodaya Samithi, a sex workers' collective, conducted a community-led prospective demonstration project among female sex workers in Mysore and Mandya, India. Following a community preparedness phase and pre-screening, participants were recruited for clinical screening and enrolment, provided PrEP as part of combination HIV prevention, and followed for 16 months. Adherence was measured by self-reported pill intake and by tenofovir blood level testing among a subset of participants. Of the 647 participants enrolled, 640 completed follow-up. Condom use remained stable and no HIV seroconversions occurred. Self-reported daily PrEP intake over the last month was 97.97% at the end of the study. Tenofovir blood levels >40 ng/mL (consistent with steady state dosing) were detected among 80% (n = 68/85) and 90.48% (n = 76/84) of participants at month 3 and 6, respectively. Our study holds important insights for rolling out PrEP in community settings as part of targeted HIV prevention interventions.

Effectiveness of isoniazid preventive therapy on incidence of tuberculosis among HIV-infected adults in programme setting.

BACKGROUND & OBJECTIVES: As India and other developing countries are scaling up isoniazid preventive therapy (IPT) for people living with HIV (PLHIV) in their national programmes, we studied the feasibility and performance of IPT in terms of treatment adherence, outcome and post-treatment effect when given under programmatic settings. METHODS: A multicentre, prospective pilot study was initiated among adults living with HIV on isoniazid 300 mg with pyridoxine 50 mg after ruling out active tuberculosis (TB). Symptom review and counselling were done monthly during IPT and for six-month post-IPT. The TB incidence rate was calculated and risk factors were identified. RESULTS: Among 4528 adults living with HIV who initiated IPT, 4015 (89%) successfully completed IPT. IPT was terminated in 121 adults (3%) due to grade 2 or above adverse events. Twenty five PLHIVs developed TB while on IPT. The incidence of TB while on IPT was 1.17/100 person-years (p-y) [95% confidence interval (CI) 0.8-1.73] as compared to TB incidence of 2.42/100 p-y (95% CI 1.90-3.10) during the pre-IPT period at these centres (P=0.017). The incidence of TB post-IPT was 0.64/100 p-y (95% CI 0.04-1.12). No single factor was significantly associated with the development of TB. INTERPRETATION & CONCLUSIONS: Under programmatic settings, completion of IPT treatment was high, adverse events minimal with good post-treatment protection. After ruling out TB, IPT should be offered to all PLHIVs, irrespective of their antiretroviral therapy (ART) status. Scaling-up of IPT services including active case finding, periodic counselling on adherence and re-training of ART staff should be prioritized to reduce the TB burden in this community.

Tuberculosis infection control measures at health care facilities offering HIV and tuberculosis services in India: A baseline assessment.

BACKGROUND: Tuberculosis (TB) is one of world's oldest infectious disease and ranks alongside HIV as leading infectious killer. Tuberculosis infection control especially in HIV and TB care facilities has warranted attention after the recent health care-associated outbreaks in South Africa. The aim of this study was to describe the tuberculosis infection control measures implemented by HIV and TB care facilities in five high HIV burden provinces in India. METHODS: Baseline assessment of 30 high burden Antiretroviral centers and TB facilities was conducted during Oct 2015-Dec 2015 by AIC trained staff using a structured format. RESULTS: Thirty HIV and TB care facilities in five high HIV burden provinces were enrolled. Facility infrastructure and airborne infection control practices were highly varied between facilities. TB screening and fast tracking at ART centers is happening at majority of centers however inadequate TB infection control training, poor compliance to administrative and personal protective measures and lack of mechanism for health care workers surveillance need attention. CONCLUSIONS: Local specific TB infection control interventions to be designed and implemented at HIV and TB care facilities including implementation of administrative, environmental and use of personal protective equipment's with the training of staff members. Health care workers surveillance needs to be prioritized considering the rising instances of tuberculosis among Health care workers.

Metabolic syndrome and cardiovascular disease risk assessment among human immunodeficiency virus-infected individuals on antiretroviral therapy.

BACKGROUND: The association of cardiovascular risk with first-line antiretroviral therapy (ART) in Indians has been a matter of concern with the background of a high risk in South Asians. AIMS: This study aimed to compare metabolic syndrome and its components, dyslipidemia, insulin resistance, and cardiovascular risk among patients on first-line ART (Group 1) with age-matched, ART-naïve human immunodeficiency virus (HIV)-infected patients (Group 2) and normal controls (Group 3). METHODS: Patients attending a tertiary care center in Mysore were enrolled in the study after obtaining informed consent and controls were chosen from relatives of patients. RESULTS: The total number of patients enrolled in the study was 217 (males 111; females 106), and the mean age of these patients was 34.1 ± 7.4 years. The number of patients in Group 1 (HIV+, ART experienced) was 76; in Group 2 (HIV+, ART naïve) was 71, and in Group 3 (HIV-) was 70. There was no statistically significant difference in the prevalence of metabolic syndrome between the three groups. On comparing the components of metabolic syndrome, serum triglycerides (mg/dl) were significantly higher in the ART group (Group 1: 149.5 [interquartile range (IQR): 84-187], Group 2: 108 [IQR: 74-152], and Group 3: 141.5 [IQR: 89-192]; P = 0.014) and serum high-density lipoprotein cholesterol was higher in HIV-uninfected individuals (Group 1: 37.5 ± 11.83, Group 2: 31.5 ± 12.23, and Group 3: 40.1 ± 12.09; P = 0.0002). There was no association between metabolic syndrome, duration of HIV, and type of first-line ART. Total and low-density lipoprotein (LDL) cholesterol were significantly higher in the ART group. Homeostatic model assessment and Framingham scores did not reveal any significant difference across the three groups. CONCLUSION: HIV-infected individuals on ART had higher levels of triglycerides, LDL, and total cholesterol, but no increased cardiovascular risk compared to other groups.

Pattern of paediatric HIV status disclosure in coastal Karnataka.

Background & objectives: Karnataka is a high HIV prevalent State in India. Although benefits have been shown by disclosing the HIV status to the child, information regarding HIV status disclosure in Karnataka is limited. Hence, this study was conducted to estimate the proportion of children who had been disclosed of their HIV status and its pattern among those who visited the district antiretroviral therapy (ART) centre in coastal Karnataka. Methods: A cross-sectional study was conducted in an ART centre in a district hospital in coastal Karnataka between October 2014 and July 2015. Caregivers of paediatric HIV patients were approached and willing participants were administered a pre-formed, pre-tested semi-structured questionnaire developed for the study. Results: A total of 185 caregivers of the HIV-positive children were interviewed. Mean age of the children was 11±4 years. Only 107 (57.8%) children were aware of their HIV status. Of these, 95 were disclosed fully. Counsellors in rehabilitation centres were the most probable person to disclose and planned events. Children were told of their HIV status for their knowledge and were more likely to be disclosed if they were around 11-15 yr of age and staying in rehabilitation centres. Interpretation & conclusions: Older children were more likely to be disclosed of their HIV status by counsellors. Steps need to be taken to counsel and encourage caregivers to fully disclose the HIV status to the children at least when they attain the age more than 11 years.

Loss to follow-up and mortality among HIV-infected adolescents receiving antiretroviral therapy in Pune, India.

OBJECTIVES: India has the highest number of HIV-infected adolescents in Asia, but little is known about their treatment outcomes. We assessed rates and factors associated with loss to follow-up (LTFU) and mortality among Indian adolescents. METHODS: The analysis included adolescents (10-19 years old) starting antiretroviral therapy (ART) between 2005 and 2014 at BJ Government Medical College, Pune, India. LTFU was defined as missing more than three consecutive monthly visits. The competing-risks method was used to calculate subdistribution hazard ratios (SHRs) of predictors for LTFU, with death as the competing risk. Cox proportional hazard models were used to identify predictors of mortality. RESULTS: Of 717 adolescents starting ART, 402 with complete data were included in the analysis. Of these, 61% were male and 80% were perinatally infected, and the median baseline CD4 count was 174 cells/µL. LTFU and mortality rates were 4.4 and 4.9/100-person years, respectively. Cumulative LTFU incidence increased from 6% to 15% over 6 years. Age ≥ 15 years [adjusted SHR (aSHR) 2.44; 95% confidence interval (CI) 1.18-5.02] was a risk factor for LTFU. Cumulative mortality increased from 9.5% to 17.9% over 6 years. World Health Organization (WHO) stages III and IV [adjusted hazard ratio (aHR) 2.26; 95% CI: 1.14-4.48] and an increase in CD4 count by 100 cells/µL (aHR: 0.59; 95% CI: 0.43-0.83) were associated with mortality. CONCLUSIONS: A third of adolescents had been lost to follow-up or died by follow-up year 6. Older age was a risk factor for LTFU and advanced clinical disease for death. Strategies to improve retention counselling for older adolescents and closer clinical monitoring of all adolescents must be considered.

'M-TRACK' (mobile phone reminders and electronic tracking tool) cuts the risk of pre-treatment loss to follow-up by 80% among people living with HIV under programme settings: a mixed-methods study from Gujarat, India.

BACKGROUND: In 2016, the National AIDS Control Programme (NACP) in Gujarat, India implemented an innovative intervention called 'M-TRACK' (mobile phone reminders once every week for four weeks after diagnosis and electronic patient tracking tool) to reduce pre-treatment loss to follow-up (LFU) among people living with HIV (PLHIV) in Vadodara district while other districts received standard of care. OBJECTIVES: To assess the effectiveness of M-TRACK in reducing pre-treatment LFU (proportion of diagnosed PLHIV not registering for HIV care by four weeks after diagnosis) and to explore the implementation enablers and challenges from health care providers' and PLHIV perspective. METHODS: An explanatory mixed-methods study design was used wherein the quantitative phase (cohort study with two groups: Vadodara district exposed to M-TRACK and Rajkot district as unexposed) was followed by a qualitative phase (descriptive study involving group interview with 16 health care providers, personal interviews with two programme managers and telephonic interviews with 16 PLHIV). Data were collected during October 2016 to February 2017. RESULTS: During the pre-M-TRACK period (July-September 2016), the LFU proportion was similar [13% (25/191) in Vadodara; 15% (21/141) in Rajkot (p = 0.8)]. During the M-TRACK period (October-December 2016), LFU decreased to 4% (9/209) in Vadodara (exposed), whereas it remained similar at 16% (18/113) in Rajkot (unexposed) district (p = 0.02). PLHIV exposed to M-TRACK had an 80% lower risk of LFU (aRR 0.2; 95% CI: 0.1-0.5) compared with standard care, after adjusting for socio-demographics, time and clustering at district level. During interviews, M-TRACK was welcomed by both PLHIV and the counsellors. The latter felt it saved time by obviating the need for home visits and helped in documentation. Inconvenience of using landline phone available at the health facility, lack of budgets for reimbursement of mobile call expenses and internet connectivity problems were the key implementation challenges. CONCLUSION: M-TRACK was highly effective in reducing the gap between diagnosis and treatment. It may be considered for scale-up after addressing the challenges noted.

Why are HIV-infected people not started on antiretroviral therapy? A mixed-methods study from Gujarat, India.

Setting: Five purposively selected antiretroviral therapy (ART) centres in Gujarat, India. Objectives: To assess the proportion of ART-eligible people living with the human immunodeficiency virus (PLHIV) who were not initiated on ART within 2 months of being recorded as eligible, to identify factors associated with non-initiation and to explore reasons from the provider's perspective. Design: We used a mixed-methods design (triangulation) of 1) a quantitative phase involving record reviews and cohort analysis (Poisson regression) of PLHIV registered during April 2014-March 2015, and 2) a qualitative phase involving one-to-one interviews with 25 providers. Results: Of 2079 ART-eligible PLHIV, 339 (16%) were not started on ART within 2 months. PLHIV with CD4 counts of <350 cells/µl and patients who were labourers, hospitalised, bedridden or registered with certain ART centres were more likely not to be initiated on ART. Qualitative results were categorised into two broad themes: government health system- and patient-related challenges, which validated and complemented the quantitative findings. Conclusion: Several patient subgroups at greater risk of ART non-initiation were identified, along with reasons for risk; this has important programme implications for achieving the UNAIDS 90-90-90 goal, and particularly the second 90 component of having 90% of diagnosed PLHIV start ART.

Contexte : Cinq centres du TAR (traitement antirétroviral) sélectionnés dans ce but dans l'état de Gujarat, Inde.Objectifs : Evaluer la proportion de personnes vivant avec le virus de l'immunodéficience humaine (PVVIH) éligibles pour le TAR non mis sous TAR dans les 2 mois de leur éligibilité, identifier les facteurs associés à la non initiation et explorer les raisons vues par les prestataires de soins.Schéma: Nous avons eu recours à un mélange de méthodes (triangulation) : 1) une phase quantitative impliquant une revue des dossiers et une analyse de la cohorte (régression de Poisson) des PVVIH enregistrés entre avril 2014 et mars 2015, et 2) une phase qualitative impliquant des entretiens individuels avec 25 prestataires de soins.Résultats : Sur 2079 PVVIH éligibles au TAR, 339 (16%) n'ont pas été mis sous traitement dans les 2 mois. Les PVVIH ayant un taux de CD4 <350 cellules/µl, les patients qui étaient des travailleurs journaliers, hospitalisés, alités ou suivis par certains centres du TAR ont été plus susceptibles de ne pas être mis sous TAR. Les résultats qualitatifs ont été classés en deux vastes catégories : système de santé du gouvernement et défis liés aux patients ; ceux-ci ont validé et complété les résultats quantitatifs.Conclusion : Plusieurs sous-groupes de patients ayant un risque plus élevé de non mise en route du TAR et les raisons de ce problème ont été identifiés ; ceci pourrait avoir des implications importantes pour le programme dans l'atteinte de l'objectif 90­90­90, surtout en ce qui concerne le deuxième 90, qui consiste à débuter le TAR chez 90% des PVVIH diagnostiqués.

Marco de referencia: Cinco centros de suministro del tratamiento antirretrovírico (TAR) de Gujarat en la India, escogidos por muestreo dirigido.Objetivos: Evaluar la proporción de personas positivas frente al virus de la inmunodeficiencia humana (PPVIH) aptas para recibir el TAR, que no habían iniciado el tratamiento 2 meses después de haberse considerado idóneas; determinar los factores asociados con la falta de iniciación del TAR; y analizar las razones desde la perspectiva de los profesionales de salud.Método: Se utilizó un diseño de métodos mixtos (triangulación), con una fase cuantitativa de análisis de las historias clínicas y de cohortes de PPVIH registradas de abril del 2014 a marzo del 2015 y una fase cualitativa con entrevistas personales a 25 profesionales de salud.Resultados: De las 2079 PPVIH aptas para recibir el TAR, 339 no lo habían iniciado en un lapso de 2 meses (16%). La probabilidad de no iniciar el TAR fue mayor en las PPVIH con cifras de linfocitos CD4 <350 células/µl, los pacientes que eran obreros, estaban hospitalizados, encamados o que acudían a determinados centros de suministro de TAR. Los resultados se clasificaron en dos amplias categorías, a saber: problemas relacionados con el sistema público de salud o atribuibles a los pacientes, con lo cual se validaron y complementaron los resultados cuantitativos.Conclusión: Varios subgrupos de pacientes presentaron un mayor riesgo de no iniciar el TAR y se determinaron las razones del riesgo; los resultados pueden tener repercusiones importantes en el programa y favorecer el progreso hacia el cumplimiento del triple objetivo 90­90­90, sobre todo de su segundo componente, según el cual el 90% de las PPVIH debe iniciar el TAR.

Are partners of HIV-infected people being tested for HIV? A mixed-methods research from Gujarat, India.

Setting: Four selected antiretroviral therapy (ART) centres of Gujarat State, India, which accounts for 8% of the human immunodeficiency virus (HIV) burden in India. Objectives: 1) To assess the proportion of people living with HIV (PLHIV) whose partners were not tested for HIV; 2) to assess sociodemographic and clinical characteristics of index cases associated with partner testing; and 3) to understand perceived facilitators and barriers to partner testing and make suggestions on how to improve testing from the perspective of the health-care provider. Design: A mixed-method design with a quantitative phase that involved reviewing the programme records of married PLHIV enrolled during 2011-2015, followed by a qualitative phase of key informant interviews. Results: Of 3884 married PLHIV, 1279 (33%) did not have their partners tested for HIV. Factors including index cases being male, illiterate, aged >25 years, belonging to key populations, substance use and being in advanced clinical stages were more likely to be associated with partner non-testing. Non-disclosure of HIV status (due to fear of marital discord) and lack of awareness and risk perception were the key barriers to testing. Conclusion: One third of PLHIV did not have their partners tested for HIV. Several factors were identified as being associated with the non-testing of partners, and solutions were explored that need to be implemented urgently if we are to achieve the 90-90-90 targets and end HIV.

Contexte : Quatre centres du traitement antirétroviral (TAR) sélectionnés de l'état de Gujarat, qui compte pour 8% du poids du virus de l'immunodéficience humaine (VIH) en Inde.Objective : Nous avons voulu 1) évaluer la proportion de personnes vivant avec le VIH (PVVIH) dont les partenaires n'ont pas été testés pour le VIH ; 2) évaluer les caractéristiques sociodémographiques et cliniques du cas index associées au test du partenaire ; et 3) comprendre les facilitateurs et les contraintes perçus au test du partenaire et faire des suggestions pour améliorer les tests du point de vue des prestataires de soins de santé.Schéma à plusieurs methods: La phase quantitative a impliqué de retrouver dans les archives du programme les PVVIH mariés enrôlés entre 2011 et 2015 ; la phase qualitative a ensuite consisté en entretiens avec des informateurs clés.Résultats: Sur 3884 PVVIH mariés, 1279 (33%) n'ont pas fait tester leurs partenaires pour le VIH. Les facteurs comme le fait que le cas index soit un homme, illettré, d'âge >25 ans, appartenant à des populations clés, utilisant des drogues, étant à un stade avancé de la maladie, ont été plus susceptibles d'être associés à l'absence de test du partenaire. Le non divulgation du statut VIH (due à la peur d'une discorde maritale) et le manque de connaissances et de perception des risques ont été les obstacles majeurs au test.Conclusion : Un tiers des PVVIH n'ont pas fait tester leurs partenaires pour le VIH. Plusieurs facteurs associés à l'absence de test des partenaires ont été identifiés et des solutions ont été recherchées. Elles doivent être mises en œuvre d'urgence si nous voulons atteindre les cibles de 90­90­90 et mettre fin au VIH.

Marco de referencia: Cuatro centros de tratamiento antirretrovírico (TAR) en el estado de Guyarat, que representa el 8% de la carga de morbilidad por el virus de la inmunodeficiencia humana (VIH) de la India.Objetivos: 1) Examinar la proporción de personas positivas frente al VIH cuyas parejas no cuentan con la prueba diagnóstica del VIH; 2) analizar las características socioeconómicas y clínicas del caso inicial que se relacionan con la práctica de la prueba diagnóstica en la pareja; y 3) comprender los elementos facilitadores y los obstáculos percibidos a la prueba del VIH en las parejas y las propuestas encaminadas a mejorar su utilización, desde el punto de vista de los profesionales de salud.Métodos: Se aplicó un modelo de métodos mixtos con una etapa inicial cuantitativa, que comportó el examen de los registros del programa de las personas positivas frente al VIH casadas inscritas del 2011 al 2015, seguida por una etapa cualitativa durante la cual se realizaron entrevistas a informantes clave.Resultados: De las 3884 personas positivas frente al VIH casadas, 1279 parejas no contaban con la prueba del VIH (33%). Las características del caso inicial que se asociaron con mayor frecuencia a la falta de prueba diagnóstica de la pareja fueron el sexo masculino, el analfabetismo, la edad más de 25 años, el hecho de pertenecer a una población clave, el consumo de sustancias psicoactivas y un estadio clínico avanzado de la enfermedad. Los principales obstáculos a la práctica de las pruebas fueron la negativa a divulgar su situación frente al VIH (por temor a una discordia conyugal) y la falta de sensibilización y percepción de los riesgos.Conclusión: En un tercio de las personas positivas frente al VIH, no se había practicado a su pareja la prueba diagnóstica de la infección. Se reconocieron diversos factores vinculados con esta situación y se analizaron las soluciones. La aplicación de estas medidas es urgente con el fin de cumplir con las metas 90­90­90 y eliminar la infección por el VIH.

Loss to follow-up among children in pre-ART care under the National AIDS Programme, Tamil Nadu, South India.

Setting: Children aged <15 years constitute 7% of all people living with the human immunodeficiency virus (HIV) in India. A previous study from an antiretroviral therapy (ART) centre in south India reported 82% loss to follow-up (LTFU) among children in pre-ART care (2006-2011). Objective: To assess the proportion of LTFU within 1 year of registration among HIV-infected children (aged < 15 years) registered in all 43 ART centres in the state of Tamil Nadu, India, during the year 2012. Design: This was a retrospective cohort study involving a review of programme records. Results: Of 656 children registered for HIV care, 20 (3%) were not assessed for ART eligibility. Of those remaining, 226 (36%) were not ART eligible and entered pre-ART care. Among these, at 1 year of registration, 50 (22%) were LTFU, 40 (18%) were transferred out and 136 (60%) were retained in care at the same centre. The child's age, sex, World Health Organization stage or occurrence of opportunistic infection were not associated with LTFU. Conclusion: One in five children registered under pre-ART care were lost to follow-up. Stronger measures to prevent LTFU and reinforce retrieval actions are necessary in the existing National HIV Programme.

Contexte: Les enfants âgés de <15 ans constituent 7% de toutes les personnes vivant avec le virus de l'immunodéficience humaine (VIH) en Inde. Une étude précédente émanant d'un centre de thérapie antirétrovirale (TAR) d'Inde du Sud a rapporté 82% de pertes de vue (LTFU) parmi les enfants en soin pré-ART (2006­2011).Objectif: Evaluer la proportion de LTFU dans l'année suivant l'enregistrement parmi les enfants (âgés de <15 ans) infectés par le VIH enregistrés dans les 43 centres du TAR de l'état du Tamil Nadu, Inde, pendant l'année 2012.Schéma: Une étude rétrospective de cohorte impliquant une revue des dossiers du programme.Résultats: Sur 656 enfants enregistrés pour une prise en charge du VIH, 20 (3%) n'ont pas été évalués pour leur éligibilité au TAR. Parmi les autres, 226 (36%) n'ont pas été éligibles au TAR et sont entrés en soins pré-TAR. Parmi eux, à une année de l'enregistrement, 50 (22%) ont été LTFU, 40 (18%) ont été transférés et 136 (60%) sont restés en soins dans le même centre. L'âge de l'enfant, le sexe, le stade de l'Organisation mondiale de la santé et la survenue d'infections opportunistes n'ont pas été associés avec le LTFU.Conclusion: Un enfant sur cinq enregistré en prise en charge pré-TAR a été LTFU. Les mesures de prévention des LTFU et les efforts de localisation doivent être renforcés au sein du programme national VIH existant.

Marco de referencia: Los niños < l5 años de edad representan el 7% de todas las personas positivas frente al virus de la inmunodeficiencia humana (VIH) en la India. En un estudio anterior realizado en un centro de tratamiento antirretrovírico (TAR) en el sur del país, se notificó una tasa de pérdida durante el seguimiento de 82% en los niños que acudían a la atención pre-TAR (del 2006 al 2011).Objetivo: Evaluar la proporción de pérdidas durante el seguimiento durante el primer año después del registro de los niños infectados por el VIH (<15 años de edad) en todos los 43 centros de suministro de TAR en el estado de Tamil Nadu, en la India, en el año 2012.Método: Un estudio retrospectivo de cohortes a partir de los registros del programa.Resultados: De los 656 niños registrados en la atención de la infección por el VIH, en 20 no se evaluó su aptitud para recibir el TAR (3%). De los niños restantes, 226 no cumplían los requisitos del TAR (36%) y se inscribieron en la atención pre-TAR. De este grupo, un año después del registro, 50 niños se habían perdido durante el seguimiento (22%), 40 se habían transferido a otro centro (18%) y 136 permanecían en la atención en el mismo centro (60%). La edad de los niños, el sexo, el estadio clínico de la enfermedad según la escala de la Organización Mundial de la Salud y la aparición de una infección oportunista no se asociaron con la pérdida durante el seguimiento.Conclusión: Uno de cada cinco niños registrados en la atención pre-TAR se perdió durante el seguimiento. Es preciso fortalecer las medidas que prevengan estas pérdidas y las intervenciones de recuperación de los pacientes en el programa nacional contra el VIH que existe en el país.

HIV-infected presumptive tuberculosis patients without tuberculosis: How many are eligible for antiretroviral therapy in Karnataka, India?

For certain subgroups within people living with the human immunodeficiency virus (HIV) [active tuberculosis (TB), pregnant women, children <5years old, and serodiscordant couples], the World Health Organization recommends antiretroviral therapy (ART) irrespective of CD4 count. Another subgroup which has received increased attention is "HIV-infected presumptive TB patients without TB". In this study, we assess the proportion of HIV-infected presumptive TB patients eligible for ART in Karnataka State (population 60million), India. This was a cross-sectional analysis of data of HIV-infected presumptive TB patients diagnosed in May 2015 abstracted from national TB and HIV program records. Of 42,585 presumptive TB patients, 28,964 (68%) were tested for HIV and 2262 (8%) were HIV positive. Of the latter, 377 (17%) had active TB. Of 1885 "presumptive TB patients without active TB", 1100 (58%) were already receiving ART. Of the remaining 785 who were not receiving ART, 617 (79%) were assessed for ART eligibility and of those, 548 (89%) were eligible for ART. About 90% of "HIV-infected presumptive TB patients without TB" were eligible for ART. This evidence supports a public health approach of starting all "HIV-infected presumptive TB patients without TB" on ART irrespective of CD4 count in line with global thinking about 'test and treat'.

Parental concerns on disclosure of HIV status to children living with HIV: children's perspective.

Disclosure is an important component of comprehensive management of children living with HIV infection (CLHIV). Many parental concerns are barriers for disclosure in children and only few studies addresses children's perspective on these concerns. Our study aims to understand children's perspective on parental concerns for disclosure and assess the knowledge of HIV. A questionnaire-based cross-sectional study involving CLHIV between 10 and 18 years attending HIV clinic in southern India, was conducted. Data were collected by directly interviewing only the children after obtaining consent from parents/caregivers. Initial open-ended questions were asked to assess the disclosure status and only fully disclosed children were included. Out of 362 enrolled eligible children, the prevalence of full and partial disclosure was 36.7% and 24%, respectively. The mean age of disclosure was 10.4 years (SD ± 2.6) and non-parental family members in an informal setting were the most common source of disclosure (38.3%). Forty-six percentages of parents were unaware of their child's disclosure status. Only 2% had disclosed their status to others who were not part of their care. Among disclosed children, 33.8% became upset or sad upon knowing their status, 12% faced discrimination and 41.4% had complete knowledge about their illness. Though the prevalence of disclosure among CLHIV was high, a majority of them had incomplete knowledge about HIV infection. The parental concerns as reported in literature like the child is too young to disclose, concerns about coping, fear of stigma and discrimination and child disclosing to others were not expressed by children.

Effectiveness of symptom screening and incidence of tuberculosis among adults and children living with HIV infection in India.

BACKGROUND: WHO recommends the use of a simplified symptom-based algorithm for screening for tuberculosis (TB) among people living with HIV (PLHIV). We assessed the feasibility and effectiveness of this algorithm and determined the prevalence and incidence of TB among PLHIV attending antiretroviral treatment (ART) centres in India. METHODS: We did a prospective multicentric implementation research study in four states of India. To rule out TB, we administered the WHO symptom-screen algorithm to all PLHIV every month for 6 months. If they were found to be symptomatic any time during this period, they were referred for investigations for TB. A case of TB diagnosed during the first month of screening was taken as a prevalent case while those detected TB in the subsequent 5 months were considered cases of incident TB. We calculated the incidence rate using the person-years method. Results . Between May 2012 and October 2013, a total of 6099 adults and 1662 children living with HIV were screened for TB at the ART centres of four states. Of the 6099 adult PLHIV, 1815 (30%) had at least one symptom suggestive of TB, of whom only 634 (35%) were referred for investigations of TB. Of those referred, 97 (15%) PLHIV were diagnosed with TB. Overall, the prevalence of undiagnosed TB was 0.84 person-years and in the subsequent period, the incidence of TB was 2.4/100 person-years (95% CI 1.90-3.10). Among 1662 children, 434 (26%) had at least one symptom suggestive of TB. But only 57 (13%) children were referred for investigations of TB and 13 (23%) of them were diagnosed with TB. The prevalence of TB among children was 0.5% and its incidence among them was 2.7/100 person-years (95% CI 1.60-4.30). CONCLUSION: Prevalence and incidence of TB is high among PLHIV attending ART centres. This emphasizes the need to strengthen regular screening for symptoms of TB and further referral of those symptomatic for diagnosis of TB.