Implementation of the Treat All Policy Among Persons with HIV Infection Enrolled in Care But Not on Antiretroviral Therapy - India, May 2017-June 2018.

Since September 2015, the World Health Organization has recommended antiretroviral therapy (ART) for all persons with human immunodeficiency virus (HIV) infection, regardless of clinical stage or CD4 count (1). This Treat All policy was based on evidence that ART initiation early in HIV infection as opposed to waiting for the CD4 count to decline to certain levels (e.g., <500 cells/mm3, per previous guidelines), was associated with reduced morbidity, mortality, and HIV transmission (2-4). Further, approximately half of persons enrolled in non-ART care that included monitoring for HIV disease progression (i.e., in pre-ART care) were lost to follow-up before becoming ART-eligible (5). India, the country with the third largest number of persons with HIV infection in the world (2.1 million), adopted the Treat All policy on April 28, 2017. This report describes implementation of Treat All during May 2017-June 2018, by India's National AIDS Control Organization (NACO) and partners, by facilitating ART initiation among persons previously in pre-ART care at 46 ART centers supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR)* in six districts in the states of Maharashtra and Andhra Pradesh. Partners supported these 46 ART centers in identifying and attempting to contact persons who were enrolled in pre-ART care during January 2014-April 2017, and educating those reached about Treat All. ART center-based records were used to monitor implementation indicators, including ART initiation. A total of 9,898 (39.6%) of 25,007 persons previously enrolled in pre-ART care initiated ART; among these 9,898 persons, 6,315 (63.8%) initiated ART after being reached during May 2017-June 2018, including 1,635 (16.5%) who had been lost to follow-up before ART initiation. NACO scaled up efforts nationwide to build ART centers' capacity to implement Treat All. Active tracking and tracing of persons with HIV infection enrolled in care but not on ART, combined with education about the benefits of early HIV treatment, can facilitate ART initiation.

Quality and effectiveness of counselling at antiretroviral therapy centres in India: capturing counsellor and beneficiary perspectives.

BACKGROUND: Ensuring the quality and effectiveness of counselling is imperative for enabling people living with HIV to cope with treatment adherence. Countrywide assessment of antiretroviral therapy (ART) centres was undertaken to assess the quality and effectiveness of counselling. The insights gained from the assessment are expected to build an improved understanding of the counselling aspect and contribute to informing decisions strengthening the counselling provided at ART centres. METHODS: Assessment of counselling at 357 ART centres entailed interviews with counsellors and beneficiaries using a structured questionnaire administered by trained technical experts. Two counsellors and five beneficiaries at each ART centre were interviewed to assess both the quality and effectiveness of counselling. Beneficiaries were selected from different risk groups to understand their varied concerns and experiences. RESULTS: During the assessment, 618 counsellors were interviewed (45% women); also, 1785 beneficiaries were interviewed, consisting of 892 (49.9%) men, 857 (48.1%) women and 36 (2.0%) transgender. Counsellors were found to be relatively well informed on topics pertaining to pre-ART, ART preparedness and positive healthy living, and the psychosocial support extended to patients. Counsellors surveyed were not aware of critical areas such as counselling of pregnant women (44.5%) , drug adherence (44.8%) and the use of information, education and communication material during counselling, and pill count. The majority of beneficiaries reported being informed on issues pertaining to retention; however, 30-40% of beneficiaries were not informed regarding the critical elements of adherence such as counselling on ART side effects (68.5%), pill count (62.8%) and information on access to social benefit schemes (25.7%). Factors such as client volume, the training of the counsellors and adequate space for counselling affected the quality of counselling. CONCLUSION: With concerted efforts in bridging the gaps in knowledge, infrastructure and information needs, India's national AIDS control programme (NACP) can enhance the counselling services at ART centres and improve the quality of services for patient retention.

Assessment of quality of antiretroviral therapy services in India, 2014-2015.

Background: Following a decade of provision of free antiretroviral therapy (ART) in India, a nationwide assessment of ART services was conducted to review quality of care at ART centers. This paper presents the methods and defines replicable model of undertaking large scale assessments. Methods: During the period January 2014-March 2015, 357 ART centers were reviewed under four domains, namely, operations, technical, monitoring and evaluation (M&E), and logistics. Mixed methods, comprising of desk review and on-site facility assessment; random sample of records, interviews with both health-care staff and people living with HIV (PLHIV) were used. Grading for each of the domain was done on a scale of 5, with 1 (Very poor) being the lowest and 5 (Excellent) as highest. Results: 1720 health-care staff and 1762 beneficiaries were interviewed; 34 600 patient cards were reviewed. Of the 357 centers assessed 60, 169 and 128 scored Excellent, Average and Poor, respectively, in operations domain; 147, 176, 34 in Technical domain; 215, 115, 27 in M&E domain; 263, 71, 23 centers in logistics domain scored Excellent, Average and Poor, respectively. About 95% (1698/1785) of PLHIV were satisfied with the care provided at ART centers. Conclusion: The methodology used for the assessment of ART centers in India yielded insights on the different domains that impact implementation and quality of service delivery. The design of this exercise may inform other researchers and managers planning similar large-scale assessments.

Metabolic syndrome among urban Indian young adults: prevalence and associated risk factors.

BACKGROUND: We estimated the prevalence of metabolic syndrome among urban Indian young adults (18-25 years) as defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), Internation Diabetes Federation (IDF), and Indian consensus statement criteria. METHOD: We included 473 urban young adults through simple random sampling methodology to estimate the prevalence and associated risk factors for metabolic syndrome. RESULTS: Prevalence of metabolic syndrome was estimated to be 3.6 [95% confidence interval (CI) 2.2-5.8], 6.6% (95% CI 4.6-9.1), and 8.7% (95% CI 6.4-11.6) using the NCEP ATP III, IDF, and Indian consensus statement criteria, respectively. Men had significantly higher waist circumference, systolic blood pressure, fasting blood glucose, and triglycerides, whereas mean concentrations of both high-density lipoprotein cholesterol (HDL-C) and total cholesterol were significantly higher among women. Low HDL-C (38.9%), high blood pressure (26%), and central obesity (16.1%) were the most common component risk factors. Although less than 4% of normal weight adults met the criteria for metabolic syndrome, rates increased in overweight individuals and reached a prevalence of 87% in the obese participants. In all, 61.3% of the total population had one or more risk factors for metabolic syndrome. CONCLUSION: The prevalence of metabolic syndrome is high among urban young adults in India, and it increased with increase in body mass index (BMI). Each component risk factor in isolated form-increased BMI, smoking, and history of hypertension--is an associated risk factor for metabolic syndrome. Although it is unclear whether metabolic syndrome screening in young Indians as a means to prevent adverse cardiovascular health outcomes is appropriate, healthy lifestyles should nevertheless be encouraged, and young adults should be considered as an important group for cardiovascular risk reduction programs.

Survival probability and predictors of mortality and retention in care among patients enrolled for first-line antiretroviral therapy, Andhra Pradesh, India, 2008-2011.

BACKGROUND: The national antiretroviral therapy (ART) initiative in India began in 2004. In order to better inform the national program, we estimated the mean cumulative survival probability and loss to follow-up (LFU) rate among patients initiated on ART. METHODS: We identified a cohort of people living with HIV (PLHIV) aged ≥15 years initiated on ART in two ART centres in Hyderabad city, Andhra Pradesh state, India between January 2008 and December 2008. The cohort was followed-up until 31 December 2011 and death and/or LFU were the primary endpoints. Death from any cause during the study period was considered to be the result of HIV infection. We used the Kaplan-Meier estimation method for survival probability and Cox proportional hazard model to identify the predictors. RESULTS: Of the 1690 patients initiated on ART, 259 (15.3%) were transferred out during the study period. Mortality rate was 7.6/100 person-years. Male gender, low CD4 count, history of tuberculosis before initiation of ART, and weight <48 kg were the predictors of mortality. Patients who were LFU were more likely to be males, unemployed, widowed, and had weight below 48 kg. CONCLUSION: Survival rates on ART were higher compared to other resource-limited settings. Delayed diagnosis and initiation of ART and co-infection with TB were important predictors for both mortality and retention in care.