Integration of healthcare programs: A long-term policy perspective for a sustainable HIV program for India

With the Government of India′s initiative to ensure Universal Access to health through its flagship program of National Rural Health Mission, the debate on the economic efficiency and sustainability of a ′stand-alone′ over ′integrated′ programs has become extremely relevant. This study was conducted with the aim to establish opinion on the issue of sustainability of ′stand-alone′ HIV program in India. Experts working on health policy development and implementation at various were interviewed on this issue and majority of experts interviewed were of the opinion that a ′stand-alone′ HIV program is not sustainable in the long run because of inefficient use of resources. Integration of HIV program with the general health system is essential but it needs extensive planning. Areas like HIV testing centers, prevention of parent to child transmission and sexually transmitted infection diagnosis and treatment can be integrated with the general health system immediately

Scaling up antiretroviral treatment services in Karnataka, India: impact on CD4 counts of HIV-infected people.

SETTING: Twelve antiretroviral treatment centres under National AIDS Control Programme (NACP), Karnataka State, India. OBJECTIVE: For the period 2004-2011, to describe the trends in the numbers of people living with HIV (PLHIV) registered for care and their median baseline CD4 counts, disaggregated by age and sex. DESIGN: Descriptive study involving analysis of routinely captured data (year of registration, age, sex, baseline CD4 count) under NACP. RESULTS: 34,882 (97% of total eligible) PLHIV were included in analysis. The number registered for care has increased by over 12 times during 2004-11; with increasing numbers among females. The median baseline CD4 cell count rose from 125 in 2004 to 235 in 2011--the increase was greater among females as compared to males. However, about two-thirds still presented at CD4 cell counts less than 350. CONCLUSION: We found an increasing trend of median CD4 counts among PLHIV presenting to ART centres in Karnataka, an indicator of enhanced and early access to HIV care. Equal proportion of females and higher baseline CD4 counts among them allays any fear of differential access by gender. Despite this relative success, a substantial proportion still presented at low CD4 cell counts indicating possibly delayed HIV diagnosis and delayed linkage to HIV care. Universal HIV testing at health care facilities and strengthening early access to care are required to bridge the gap

The cost‐effectiveness and budgetary impact of a dolutegravir‐based regimen as first‐line treatment of HIV infection in India

Abstract Introduction: Dolutegravir (DTG)‐based antiretroviral therapy (ART) is recommended for first‐line HIV treatment in the US and Europe. Efavirenz (EFV)‐based regimens remain the standard of care (SOC) in India. We examined the clinical and economic impact of DTG‐based first‐line ART in the setting of India's recent guidelines change to treating all patients with HIV infection regardless of CD4 count. Methods: We used a microsimulation of HIV disease, the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐International model, to project outcomes in ART‐naive patients under two strategies: (1) SOC: EFV/tenofovir disoproxil fumarate (TDF)/lamivudine (3TC); and (2) DTG: DTG + TDF/3TC. Regimen‐specific inputs, including virologic suppression at 48 weeks (SOC: 82% vs. DTG: 90%) and annual costs ($98 vs.$102), were informed by clinical trial data and other sources and varied widely in sensitivity analysis. We compared incremental cost‐effectiveness ratios (ICERs), measured in $/year of life saved (YLS), to India's per capita gross domestic product ($1600 in 2015). We compared the budget impact and HIV transmission effects of the two strategies for the estimated 444,000 and 916,000 patients likely to initiate ART in India over the next 2 and 5 years. Results: Compared to SOC,DTG improved 5‐year survival from 76.7% to 83.0%, increased life expectancy from 22.0 to 24.8 years (14.0 to 15.5 years, discounted), averted 13,000 transmitted HIV infections over 5 years, increased discounted lifetime care costs from $3040 to$3240, and resulted in a lifetime ICER of $130/YLS, less than 10$180/year. Over a 2‐ or 5‐year horizon, total undiscounted outlays for HIV‐related care were virtually the same for both strategies. Conclusions: A generic DTG‐based regimen is likely to be cost‐effective and should be recommended for initial therapy of HIV infection in India

Decreasing cost of public sector first-line ART services in India from 2007-2008 to 2015-2016.

INTRODUCTION:India has scaled-up antiretroviral treatment (ART) in public sector facilities, but data to understand time trends of average cost of ART are limited. MATERIALS AND METHODS:Cost and output data were collected at all public sector ART centres in undivided Andhra Pradesh (high-HIV burden state) and Rajasthan (low-HIV burden state) in India from fiscal year 2007-2008 to 2012-2013. Average cost per patient for first-line ART, and its relation with scale of services, were assessed. Using data on scale of services, the average cost was estimated up to 2015-2016. Break-even point was estimated from average and marginal cost functions. Costs were adjusted to 2015 constant price. RESULTS:The average cost per patient alive and on ART in 2015-2016 was US$162 in undivided Andhra Pradesh and US$186 in Rajasthan, which was 51.4% and 35.8% lower than in 2007-2008, respectively. Average ART drug cost declined by 27.2% during this period, and was 70.9% and 61.5% of the total ART cost in the two states in 2015-2016. The average cost other than ART drugs declined by 73.1% and 45.7%, with the number of patients served increasing 7 and 14.2 times, respectively. Average cost other than ART drugs had a significant negative relation with scale (R2 = 86.4%-82.8%, p<0.001). Break-even analysis suggested that 47.5% and 58.8% of the ART centres in undivided Andhra Pradesh and Rajasthan, respectively, were functioning below optimal scale in 2015-2016. The estimated total economic cost of first-line ART services provided in the public sector in India in fiscal year 2015-2016 was US$151 million; it would be US$ 216.1 million to provide this to all eligible persons in India. CONCLUSION:The average cost of providing first-line ART has declined in India, and further reduction is possible if the optimal scale of services is achieved. These findings can inform resource requirement for the ART programme in India

Trends in number of HIV testing centres and ART centres established, year-wise in Karnataka, India, 2004-2011.

<div><p>HIV-Human immunodeficiency virus; ART-antiretroviral therapy.</p> <p>*The Y-axis is in the logarithmic scale.</p></div

Trends in the number of people tested for HIV and diagnosed HIV positive year-wise, in Karnataka, India, 2004-2011.

<div><p>HIV-Human immunodeficiency virus; ART-antiretroviral therapy.</p> <p>*The Y-axis is in the logarithmic scale.</p></div

Trends in median baseline CD4 counts of newly diagnosed HIV-infected individuals registered for HIV care at antiretroviral therapy centres, by sex, in Karnataka, India, 2004-2011.

<p>HIV-Human immunodeficiency virus; ART-antiretroviral therapy.</p

Antiretroviral resistance following immunological monitoring in a resource-limited setting of western India: A cross-sectional study

<div><p>Background</p><p>The free antiretroviral therapy (ART) program in India still relies on the clinico-immunological monitoring for diagnosis of treatment failure. As the nucleoside reverse transcriptase inhibitor (NRTI) backbone is shared in first- and second-line regimens, accumulation of drug resistant mutations (DRMs) can compromise the efficacy of NRTI. This study was undertaken to describe the pattern of HIV DRMs following immunological monitoring and investigate its impact on the cycling of NRTI between first- and second-line ART.</p><p>Methods and findings</p><p>This cross-sectional study was performed at a state-sponsored ART clinic of Pune city in western India between January and June 2016. Consecutive adults receiving first-line ART with immunological failure (IF) were recruited for plasma viral load (PVL) estimation. Randomly selected 80 participants with PVL >1000 copies/mL underwent HIV drug resistance genotyping. Of these, 75 plasma sample were successfully genotyped. The median CD4 count and duration of ART at the time of failure were 98 (IQR: 61.60–153.50) cells/μL and 4.62 (IQR: 3.17–6.15) years, respectively. The prevalence of NRTI, non-NRTI, and major protease inhibitor resistance mutations were 89.30%, 96%, and 1.33%, respectively. Following first-line failure, sequences from 56.67% of individuals indicated low- to high-level resistance to all available NRTI. The proportion of sequences with ≥2 thymidine analogue mutations (TAMs) and ≥3 TAMs were 62.12% and 39.39%, respectively. An average of 1.98 TAMs per sequence were observed following IF as compared to 0.37 TAMs per sequence following targeted PVL monitoring at 12 months of ART from a prior study; this difference was significant (p<0.001).</p><p>Conclusion</p><p>The option of cycling of NRTI analogues between first- and second-line regimens would no longer be effective if individuals are followed-up by immunological monitoring due to accumulation of mutations. Introduction of routine PVL monitoring is a priority for the long-term sustainability of free ART program in India.</p></div