Suchergebnisse

IntroductionRecent WHO guidance advocates for early antiretroviral therapy (ART) initiation at higher CD4 counts to improve survival and reduce HIV transmission. We sought to quantify how the cost‐effectiveness and epidemiological impact of early ART strategies in India are affected by attrition throughout the HIV care continuum.MethodsWe constructed a dynamic compartmental model replicating HIV transmission, disease progression and health system engagement among Indian adults. Our model of the Indian HIV epidemic compared implementation of early ART initiation (i.e. initiation above CD4 ≥350 cells/mm3) with delayed initiation at CD4 ≤350 cells/mm3; primary outcomes were incident cases, deaths, quality‐adjusted‐life‐years (QALYs) and costs over 20 years. We assessed how costs and effects of early ART initiation were impacted by suboptimal engagement at each stage in the HIV care continuum.ResultsAssuming "idealistic" engagement in HIV care, early ART initiation is highly cost‐effective ($442/QALY‐gained) compared to delayed initiation at CD4 ≤350 cells/mm3 and could reduce new HIV infections to <15,000 per year within 20 years. However, when accounting for realistic gaps in care, early ART initiation loses nearly half of potential epidemiological benefits and is less cost‐effective ($530/QALY‐gained). We project 1,285,000 new HIV infections and 973,000 AIDS‐related deaths with deferred ART initiation with current levels of care‐engagement in India. Early ART initiation in this continuum resulted in 1,050,000 new HIV infections and 883,000 AIDS‐related deaths, or 18% and 9% reductions (respectively), compared to current guidelines. Strengthening HIV screening increases benefits of earlier treatment modestly (1,001,000 new infections; 22% reduction), while improving retention in care has a larger modulatory impact (676,000 new infections; 47% reduction).ConclusionsEarly ART initiation is highly cost‐effective in India but only has modest epidemiological benefits at current levels of care‐engagement. Improved retention in care is needed to realize the full potential of earlier treatment.

Delayed presentation to care of perinatally infected children in India is a hindrance to achieving the "end pediatric HIV by 2020" goal. We describe the prevalence, risk factors and temporal trends of delayed presentation to care among them. Programmatic data of perinatally infected antiretroviral therapy (ART) - naïve children of Byramjee Jeejeebhoy Government Medical College (BJGMC) and Sassoon General Hospitals' (SGH) ART center, Pune, India from 2006 to 2016 was used. Children with WHO categories for moderate and severe immunodeficiency were classified as delayed presenters. Multivariable logistic regression was used to identify risk factors for delayed presentation. Of 269 children with available CD4 count registered for care, median age at presentation was 4 years (IQR: 3 – 6 years), 53% were male and 76% registered for care after 2009. Prevalence of delayed presentation was 52% (95% Confidence Interval 46% −58%). In multivariable models adjusted for age, sex and domicile distance, unit increase in age was inversely associated with delayed presentation (OR: 0.8, 95% CI: 0.7 – 0.9). Domicile distance ≥ 20km from the ART center was also associated with delayed presentation (OR: 2.2, 95% CI: 1.02 – 4.7). Median age at presentation increased over time (p<0.001), but proportion of children with delayed presentation remained unchanged (p=0.36). More than half of the children in our cohort presented late into care, with the age of delayed presentation increasing over time. Initiatives to improve linkage of these children at the earliest into the Indian HIV pediatric care continuum need to be identified.