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

Gerardo Alvarez-Uria, Raghavakalyan Pakam, Manoranjan Midde, Praveen Kumar Naik, Gerardo Alvarez-Uria, Raghavakalyan Pakam, Manoranjan Midde, Praveen Kumar Naik

Abstract

HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression.

Figures

Figure 1
Figure 1
Flowchart of patients included in each stage of HIV care. ART, antiretroviral therapy; ∗ 46 patients having a first CD4 cell count μL were excluded because the CD4 count determination was performed after November 4th 2011.
Figure 2
Figure 2
Survival curves at different stages of HIV care. Kaplan-Meier survival curves by entry into care within 3 months (a), by retention in pre-ART care (b), by retention in pre-ART care of patients with initial CD4 count 250–350 (c), >350 (d), by ART initiation within 3 months of becoming eligible (e), by ART initiation within three months of patients with CD4 count >200 (f), 50–200 (g), μL; c/mL, copies/mL.
Figure 3
Figure 3
Cumulative retention of patients at each stage of care after HIV diagnosis.
Figure 4
Figure 4
Potential five-year mortality reduction of 1000 patients diagnosed with HIV infection (error  bars = standard  errors).

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