Dr. Sikhamani Rajasekaran1,
Dr. L. Jeyaseelan 2
, Mr. Patrick Nadol, MPH3, Dr. Meade Morgan4,
Dr. Dora Warren5 , Dr. Michael Friedman5,
Dr. C.
Chandrasekar1, Ms. Supriya Sahu6
Affiliations: 1.
Government Hospital of Thoracic Medicine (GHTM), Tambaram, India, 2.
CMC
Vellore, India , 3. International
Training & Education Center on HIV
(I-TECH), India, 4. Centers for Disease Control and Prevention, India,
5.
Centers for Disease
Control and Prevention, Atlanta GA, 6. Tamil Nadu State
HIV/AIDS Control Society (TANSACS)
Location of Project: India
Key words: anti-retroviral
scale-up, India
Background: India carries the
world’s second highest burden of
HIV with an estimated 5.2 million people (0.8% national
prevalence) living with
HIV/AIDS. India’s heterogeneous HIV
epidemic is concentrated in 6 (of 35) states and in high
risk populations (i.e.
sex workers, intravenous drug users). The Government of India, in its
recent HIV/AIDS
5-year plan,
has committed to expanding ART care to 300,000 eligible PLWHA’s.
There is an acute need for program data to better
inform the feasibility and
implementation of ART services in India.
Methods: The Government Hospital
of Thoracic Medicine at
Tambaram (GHTM) is India’s largest HIV/AIDS care and
treatment center. HIV-infected clients are
eligible for ART
with CD4 count < 200cells/mm3 or
a WHO Stage IV
defining condition. To
assess GHTM’s ART program effectiveness, we analyzed the ART scale-up
rate,
patient
outcomes, adherence, and treatment failure levels for registered
patients. Cox proportional hazards
model was used
to determine mortality risk factors.
Results: From
April
2004 to October 2006, 4098 (40% women, 7% children <15 years of age)
received first-line
ART at GHTM with an average 30% increase in ART clients
each quarter. Mean baseline CD4 was 113
(s.d.103)
cells/mm3. In adults
(n=3801), one and two year
survival rates were 90% and 87% respectively.
Of 310 total
deaths, the majority (68%) occurred within three months of
initiating ART. Average person-time of
follow up was
9.6 (s.d. 8.1) months.
Risk factors for adult
mortality
included (hazard ratio, 95% CI): being male(2.9, 1.9-4.3), living in an
urban
area
(1.7, 1.4-2.5), low weight(<40kg) and hemoglobin(<=9gm/dL) at
baseline(5.2, 3.6-7.5), and low CD4 values
(<50cell/mm3) at
baseline relative to patients with a higher baseline CD4 value
(>200cell/mm3)
(3.6, 2.3-5.5).
Other risk factors
were: no increase in absolute lymphocyte count (5.1, 3.2-8.0), and no
gain in
weight nor
hemoglobin from baseline to death, loss to follow-up, or analysis
end-point (16.3, 8.7-30.4). Treatment
adherence (>95%) was reported by 92.7% of clients. Treatment
failure,
(defined by WHO guidelines), was
estimated at 3.9%. The median CD4 cells/mm3
(IQR) increase at twelve (n=1218) and 24 months
(n=260) from baseline
were 244 (148-348), and 369 (204-507) respectively.
At twenty-four months,
96.9% of ART patients had a CD4 value at
least 10% greater than baseline with 52.7% of clients greater than
350 cells/mm3.
Conclusion: These
data compare favorably to those from
other countries and demonstrate the feasibility and
efficacy of a rapid ART
program scale-up in a high patient burden, diverse, and
resource-limited
setting in India.
They inform program
expansion by identifying risk factors for mortality and treatment
failure, and
show the potential
for high treatment adherence. These
finding also show the positive impact of ART and the need
to diagnose and
treat HIV patients earlier to potentially improve
outcomes.