High rates of adherence and treatment success in a public and public-private HIV clinic in India: potential benefits of standardized national care delivery systems

<p>Abstract</p> <p>Background</p> <p>The massive scale-up of antiretroviral treatment (ART) access worldwide has brought tremendous benefit to populations affected by HIV/AIDS. Optimising HIV care in countries with diverse medical systems is critical; however data on best practices for HIV healthcare delivery in resource-constrained settings are limited. This study aimed to understand patient characteristics and treatment outcomes from different HIV healthcare settings in Bangalore, India.</p> <p>Methods</p> <p>Participants from public, private and public-private HIV healthcare settings were recruited between 2007 and 2009 and were administered structured interviews by trained staff. Self-reported adherence was measured using the visual analogue scale to capture adherence over the past month, and a history of treatment interruptions (defined as having missed medications for more than 48 hours in the past three months). In addition, CD4 count and viral load (VL) were measured; genotyping for drug resistance-associated mutations was performed on those who were in virological failure (VL > 1000 copies/ml).</p> <p>Results</p> <p>A total of 471 individuals were included in the analysis (263 from the public facility, 149 from the public-private facility and 59 from the private center). Private facility patients were more likely to be male, with higher education levels and incomes. More participants reported ≥ 95% adherence among public and public-private groups compared to private participants (public 97%; private 88%; public-private 93%, p < 0.05). Treatment interruptions were lowest among public participants (1%, 10%, 5% respectively, p < 0.001). Although longer clinic waiting times were experienced by more public participants (48%, compared to private 27%, public-private 19%, p < 0.001), adherence barriers were highest among private (31%) compared with public (10%) and public-private (17%, p < 0.001) participants. Viral load was detectable in 13% public, 22% private and 9% public-private participants (p < 0.05) suggesting fewer treatment failures among public and public-private settings. Drug resistance mutations were found more frequently among private facility patients (20%) compared to those from the public (9%) or public-private facility (8%, p < 0.05).</p> <p>Conclusions</p> <p>Adherence and treatment success was significantly higher among patients from public and public-private settings compared with patients from private facilities. These results suggest a possible benefit of the standardized care delivery system established in public and public-private health facilities where counselling by a multi-disciplinary team of workers is integral to provision of ART. Strengthening and increasing public-private partnerships can enhance the success of national ART programs.</p

Blame, Symbolic Stigma and HIV Misconceptions are Associated with Support for Coercive Measures in Urban India

This study was designed to examine the prevalence of stigma and its underlying factors in two large Indian cities. Cross-sectional interview data were collected from 1,076 non-HIV patients in multiple healthcare settings in Mumbai and Bengaluru, India. The vast majority of participants supported mandatory testing for marginalized groups and coercive family policies for PLHA, stating that they “deserved” their infections and “didn’t care” about infecting others. Most participants did not want to be treated at the same clinic or use the same utensils as PLHA and transmission misconceptions were common. Multiple linear regression showed that blame, transmission misconceptions, symbolic stigma and negative feelings toward PLHA were significantly associated with both stigma and discrimination. The results indicate an urgent need for continued stigma reduction efforts to reduce the suffering of PLHA and barriers to prevention and treatment. Given the high levels of blame and endorsement of coercive policies, it is crucial that such programs are shaped within a human rights framework

Is self-reported adherence a valid measure of glycaemic control among people living with diabetes in rural India? A cross-sectional analysis.

BACKGROUND: Visual analogue scale (VAS) is one of the simplest to measure medication adherence. It has neither been widely used for Non communicable diseases (NCD) nor validated for in the Indian setting. We examined the validity of self-reported medication adherence measures in relation to HbA1C in a rural population with diabetes mellitus (DM). METHODS: Participants with DM was administered VAS, Diabetes Self-Management Questionnaire (DMSQ) and assessed for missed pills. Descriptive statistics and logistic regression analysis were done. RESULTS: We recruited 1347 participants and 84% of them reported being 100% adherent as per VAS and 83.8% stated that they did not miss any pills. However, 58.2% of participants who reported having 100% adherence had poor glycaemic control, as did 58.1% of those who did not miss any pills. None of the diabetic self-care measures was significantly associated with glycaemic control. CONCLUSION: We found a lack of association between self-reported adherence measures and glycaemic control in participants with DM suggesting that self-reported adherence scales may not be valid in this population

Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India.

BACKGROUND: Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India. METHODS: We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses. RESULTS: Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication. CONCLUSIONS: Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India

Correlates of social support in individuals with a diagnosis of common mental disorders and non communicable medical diseases in rural South India.

PurposeThe purpose of the study was to examine the association between socio-demographic and clinical characteristics and perceived social support among patients with a diagnosis of depression and/or anxiety and co-morbid medical conditions from rural south India.MethodsThe study was conducted in 49 PHCs in Ramanagara district, Karnataka, and included 2481 participants, who were 30&nbsp;years or older with co-morbid CMD (Common Mental Disorder) and hypertension, diabetes or ischemic heart disease. Socio-demographic characteristics of the participants were collected, and instrumental, emotional and total social support, quality of life, severity of disability, depression and anxiety were measured via face-to-face interviews using structured questionnaires.ResultsThe sample predominantly consisted of Hindu (98.5%) females (75%) in their middle to late adulthood. In multivariate models, age showed a significant curvilinear relation with all forms of social support (B = 0.001 and p &lt; 0.05), and emotional social support (B = -&nbsp;0.056, p = 0.004) was lower in employed than non-working participants. Household size was positively related to all forms of social support (B = 0.029 for instrumental, B = 0.022 for emotional, B = 0.025 for total social support, all p &lt; 0.001). Quality of life was positively associated with all forms of social support (B = 0.019 for instrumental, B = 0.016 for emotional, B = 0.018 for total social support, all p &lt; 0.001).ConclusionsFor this sample of outpatients diagnosed with both CMD and at least one comorbid medical condition in rural south India, greater household size was associated with better social support. The role of family in providing support can be utilized while designing interventions.Trial registration numberhttp://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018

Evaluation of WHO immunologic criteria for treatment failure: implications for detection of virologic failure, evolution of drug resistance and choice of second‐line therapy in India

IntroductionRoutine HIV viral load (VL) testing is not available in India. We compared test performance characteristics of immunologic failure (IF) against the gold standard of virologic failure (VF), examined evolution of drug resistance among those who stayed on a failing regimen because they did not meet criteria for IF and assessed implications for second-line therapy.MethodsParticipants on first-line highly active antiretroviral therapy (HAART) in Bangalore, India, were monitored for 24 months at six-month intervals, with CD4 count, VL and genotype, if VL&gt;1000 copies/ml. Standard WHO criteria were used to define IF; VF was defined as having two consecutive VL&gt;1000 copies/ml or one VL&gt;10,000 copies/ml. Resistance was assessed using standard International AIDS Society-USA (IAS-USA) recommendations.ResultsOf 522 participants (67.6% male, mean age of 37.5; 85.1% on nevirapine-based and 40.4% on d4T-containing regimens), 57 (10.9%) had VF, 38 (7.3%) had IF and 13 (2.5%) had both VF and IF. The sensitivity of immunologic criteria to detect VF was 22.8%, specificity was 94.6% and positive predictive value was 34.2%. Forty-four participants with VF only continued on their failing first-line regimen; by the end of the study period, 90.9% had M184V, 63.6% had thymidine analogue mutations (TAMs), 34.1% had resistance to tenofovir, and 63.6% had resistance to etravirine.ConclusionsWHO IF criteria have low sensitivity for detecting VF, and the presence of IF poorly predicts VF. Relying on CD4 counts leads to unnecessary switches to second-line HAART and continuation of failing regimens, jeopardizing future therapeutic options. Universal access to VL monitoring would avoid costly switches to second-line HAART and preserve future treatment options

Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions

IntroductionHIV stigma inflicts hardship and suffering on people living with HIV (PLHIV) and interferes with both prevention and treatment efforts. Health professionals are often named by PLHIV as an important source of stigma. This study was designed to examine rates and drivers of stigma and discrimination among doctors, nurses and ward staff in different urban healthcare settings in high HIV prevalence states in India.MethodsThis cross-sectional study enrolled 305 doctors, 369 nurses and 346 ward staff in both governmental and non-governmental healthcare settings in Mumbai and Bengaluru, India. The approximately one-hour long interviews focused on knowledge related to HIV transmission, personal and professional experiences with PLHIV, instrumental and symbolic stigma, endorsement of coercive policies, and intent to discriminate in professional and personal situations that involve high and low risk of fluid exposure.ResultsHigh levels of stigma were reported by all groups. This included a willingness to prohibit female PLHIV from having children (55 to 80%), endorsement of mandatory testing for female sex workers (94 to 97%) and surgery patients (90 to 99%), and stating that people who acquired HIV through sex or drugs "got what they deserved" (50 to 83%). In addition, 89% of doctors, 88% of nurses and 73% of ward staff stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure, and 57% doctors, 40% nurses and 71% ward staff stated that they would do so in low-risk situations as well. Significant and modifiable drivers of stigma and discrimination included having less frequent contact with PLHIV, and a greater number of transmission misconceptions, blame, instrumental and symbolic stigma. Participants in all three groups reported high rates of endorsement of coercive measures and intent to discriminate against PLHIV. Stigma and discrimination were associated with multiple modifiable drivers, which are consistent with previous research, and which need to be targeted in future interventions.ConclusionsStigma reduction intervention programmes targeting healthcare providers in urban India need to address fear of transmission, improve universal precaution skills, and involve PLHIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught

Examining engagement in care of women living with HIV in South India.

HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided

Elevated homocysteine and depression outcomes in patients with comorbid medical conditions in rural primary care.

We examined the association of elevated concentration of total homocysteine (tHcy) with the severity of depression in patients diagnosed with depression and comorbid chronic medical conditions in rural primary care settings in Karnataka. Participants were included from the control arm of a cluster-randomized controlled trial designed to evaluate the effects of using a collaborative care model to integrate screening and treatment of primary health center patients. tHcy was assayed at baseline, and depression severity scores were assessed using the Patient Health Questionnaire (PHQ-9) 6 months later. There was no difference in the mean PHQ-9 score between those with (mean PHQ = 7.4) and without (mean PHQ = 7.6) elevated tHcy levels (P = 0.67)