Survival of Children Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Andhra Pradesh, India.

OBJECTIVE: To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India. METHODS: The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability. RESULTS: The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the <5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ≤ 200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ≥350/mm3. CONCLUSION: Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

Scorecard - An Innovative Simplified Tool to Supplement the Existing Monitoring Mechanism to Assess and Improve Performance of Antiretroviral Treatment Centers.

INTRODUCTION: All 26 antiretroviral treatment (ART) centers of Gujarat were monitored by Gujarat State AIDS Control Society under the National AIDS Control Program. A comprehensive tool is needed to identify gap in service delivery and to prioritize monitoring visits. OBJECTIVES: To supplement the existing monitoring system, identify strengths/weakness of ART centers, and give recommendations. METHODOLOGY: Scorecard was developed in spreadsheet format with 17 scoring indicators on monthly base from March 2014 onward. The centers were classified in three color zones: green (score ≥80%), yellow (score <80% and ≥50%), and red (score <50%). Visits were prioritized at centers with more indicators in yellow/red zone. The performance of centers was compared for March 2014 and March 2015. RESULTS: The statistically significant improvement was observed in indicator "ART initiation within 2 months of eligibility," while after removing red zone from analysis, four more indicators named "eligible patients transferred out before ART initiation, general clients started on ART, antenatal women started on ART, and pre-ART follow-up CD4 done" reflect statistically significant improvement. Quadrant analysis was done for some indicators, which provide insight that less number of eligible patients may be a reason for low initiation of ART at one center, and at four other centers, the possible reasons for low retention are high death rate and high lost to follow-up rate. Based on these findings, the recommendations were made to regular mentoring centers, improve coordination between ART center and care and support centers (CSCs), and conduct verbal autopsy. CONCLUSION: Scorecard is a simple and cost-effective tool for monitoring, and by highlighting low-performing indicators, it helps in improving quality of services provided at ART centers.

Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India.

OBJECTIVE: To assess whether customised mobile phone reminders would improve adherence to therapy and thus decrease virological failure among HIV infected patients starting antiretroviral treatment (ART). DESIGN: Randomised controlled trial among HIV infected patients initiating antiretroviral treatment. SETTING: Three diverse healthcare delivery settings in south India: two ambulatory clinics within the Indian national programme and one private HIV healthcare clinic. PARTICIPANTS: 631 HIV infected, ART naïve, adult patients eligible to initiate first line ART were randomly assigned to mobile phone intervention (n=315) or standard care (n=316) and followed for 96 weeks.. INTERVENTION: The intervention consisted of customised, interactive, automated voice reminders, and a pictorial message that were sent weekly to the patients' mobile phones for the duration of the study. MAIN OUTCOME MEASURES: The primary outcome was time to virological failure (viral load >400 copies/mL on two consecutive measurements). Secondary outcomes included ART adherence measured by pill count, death rate, and attrition rate. Suboptimal adherence was defined as mean adherence <95%. RESULTS: Using an intention-to-treat approach we found no observed difference in time to virological failure between the allocation groups: failures in the intervention and standard care arms were 49/315 (15.6%) and 49/316 (15.5%) respectively (unadjusted hazard ratio 0.98, 95% confidence interval 0.67 to 1.47, P=0.95). The rate of virological failure in the intervention and standard care groups were 10.52 and 10.73 per 100 person years respectively. Comparison of suboptimal adherence was similar between both groups (unadjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.65, P=0.14). Incidence proportion of patients with suboptimal adherence was 81/300 (27.0%) in the intervention arm and 65/299 (21.7%) in the standard care arm. The results of analyses adjusted for potential confounders were similar, indicating no significant difference between the allocation groups. Other secondary outcomes such as death and attrition rates, and subgroup analysis also showed comparable results across allocation groups. CONCLUSIONS: In this multicentre randomised controlled trial among ART naïve patients initiating first line ART within the Indian national programme, we found no significant effect of the mobile phone intervention on either time to virological failure or ART adherence at the end of two years of therapy.Trial registration Current Controlled Trials ISRCTN79261738.

Adherence to Antiretroviral Therapy and Its Effect on Survival of HIV-Infected Individuals in Jharkhand, India.

INTRODUCTION: Research in India has extensively examined the factors associated with non-adherence to antiretroviral therapy (ART) with limited focus on examining the relationship between adherence to ART regimen and survival status of HIV infected patients. This study examines the effect of optimal adherence to ART on survival status of HIV infected patients attending ART centers in Jharkhand, India. MATERIALS AND METHODS: Data from a cohort of 239 HIV infected individuals who were initiated ART in 2007 were compiled from medical records retrospectively for 36 months. Socio-demographic characteristics, CD4 T cell count, presence of opportunistic infections at the time of ART initiation and ART regimen intake and survival status was collected periodically. Optimal adherence was assessed using pill count methods; patients who took <95% of the specified regimens were identified as non-adherent. Cox-proportional hazard model was used to determine the relative hazards of mortality. RESULTS: More than three-fourths of the patients were male, on an average 34 year old and median CD4 T cell count was 118 cells/cmm at the time of ART registration. About 57% of the patients registered for ART were found to be adherent to ART. A total of 104 patients died in 358.5 patient-years of observation resulting in a mortality rate of 29 per 100 patient-years (95% confidence interval (CI): 23.9-35.2) and median survival time of 6.5 months (CI: 2.7-10.9). The mortality rate was higher among patients who were non-adherent to ART (64.5, CI: 50.5-82.4) than who were adherent (15.4, CI: 11.3-21.0). The risk of mortality was fourfold higher among individuals who were non-adherent to ART than who were adherent (Adjusted hazard ratio: 3.9, CI: 2.6-6.0). CONCLUSION: Adherence to ART is associated with a higher chance of survival of HIV infected patients, ascertaining the need for interventions to improve the ART adherence and early initiation of ART.