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
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. 1. Introduction By the end of 2011, more than 90% of the 34 million people infected with HIV worldwide were living in low- or middle-income countries [1]. 16.8$ billion was invested globally into HIV in 2011 and, in low- and middle-income countries, 89% of the investment was allocated to treatment care and support of HIV infected people [1]. One of the most important aims of the medical care of HIV patients is to initiate antiretroviral therapy (ART) before the development of HIV-related complications and to allow immunological recovery by maintaining long-term virological suppression. Despite important advances in the rollout of ART worldwide, 1.7 million people died of HIV-related pathologies in 2011 [1]. This high mortality could be explained by many factors including late presentation of HIV [2–5], poor engagement in medical care [6–9], poor retention in pre-ART care [10–12], late or no initiation of ART [13–15], high levels of attrition from care after ART initiation [16, 17], and poor virological suppression in patients on ART [18]. When designing programmes aimed at providing treatment, care, and support to people living with HIV, it is important to understand the contributions of these factors to the overall HIV mortality, in order to improve the efficiency of HIV
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