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In India, under the National Tuberculosis Elimination Programme, the government provides free treatment for multidrug-resistant tuberculosis; however, many patients seek care elsewhere, which is costly. To determine those out-of-pocket expenses, we interviewed 40 presumptive patients and found that they spent more than their median annual income before registering for the government program.

Background: In India, challenges in pediatric TB contact screening and chemoprophylaxis initiation are still underexplored. Elucidating these challenges will help in better implementation of the programme at the grass-roots level thereby helping in early detection of pediatric cases and timely initiation of preventive therapy. This study aimed at exploring the challenges faced by the health care provider in contact screening and chemoprophylaxis initiation implementation of the pediatric household contacts. Methods: A qualitative study was conducted in the districts of Bengaluru and Udupi and in-depth interviews of key participants were adopted to explore the challenges. Qualitative data analysis was done after developing transcripts by generating themes and codes. Results: The key challenges were identified as stigma towards the disease, migrant patients with changing address, difficulty in sample collection, anxiety among parents due to long duration of the prophylactic treatment and adherence to IPT is not well documented, inadequate transportation from rural areas, and the ongoing COVID-19 pandemic. Conclusions: It is important for the National TB programme to address these challenges efficiently and effectively. Innovative solutions, feasible engagements, and massive efforts are to be taken by the programme to improve contact screening and isoniazid chemoprophylaxis implementation.

Due to limited availability of diagnostics and capacity, people with tuberculosis do not always undergo systematic assessment for severe illness (requiring inpatient care). In Karnataka (south India), para-medical programme staff used a screening tool to identify people at ‘high risk of severe illness’, defined using indicators of very severe undernutrition, abnormal vital signs and poor performance status (any one): (i) body mass index (BMI) ≤ 14.0 kg/m2 (ii) BMI ≤ 16.0 kg/m2 with bilateral leg swelling (iii) respiratory rate > 24/min (iv) oxygen saturation < 94% (v) inability to stand without support. Of 3020 adults notified from public facilities (15 October to 30 November 2020) in 16 districts, 1531 (51%) were screened (district-wise range: 13–90%) and of them, 538 (35%) were classified as ‘high risk of severe illness’. Short median delays in screening from notification (five days), and all five indicators being collected for 88% of patients, suggests the feasibility of using this tool in programme settings. However, districts with poor screening coverage require further attention. To end tuberculosis deaths, screening should be followed by referral to higher facilities for comprehensive clinical evaluation, to assess the need for inpatient care. Future studies should assess the validity (especially sensitivity in picking severely ill patients) of this screening tool.

Setting Dakshina Kannada District, coastal South India, under the Revised National Tuberculosis Control Programme (RNTCP). Objective To identify the potential and practices at primary health centres (PHCs) for the assessment of nutritional status of patients with tuberculosis (TB), the basic tools used to measure height and weight and the type of nutritional counselling provided. Design A cross-sectional study was conducted with physical verification of availability of height and weight measuring equipment. Information was collected on the method used by medical officers for assessing nutritional status in PHCs, action taken in case the patient is undernourished and any formal training in nutritional assessment and counselling. Results Of 37 PHCs assessed, weighing machines were available in all and stadiometers in 38%. Medical officers were not calculating body mass index for nutritional assessment even when height and weight were being uniformly measured. Nutritional classification was mostly based on the appearance and physique of the patient. Counselling included advice to take milk, eggs and protein powders with efforts to arrange funds from village health, sanitation and nutrition committees. Conclusion There is a need to equip the PHCs and their medical officers with necessary tools and training for nutritional assessment and counselling of patients with tuberculosis.

Background: The Tuberculosis (TB) disease has immense impact on physical, psychological, economic and social well-being of an individual. It is desired that the patient with any kind of TB disease should lead a respectable and happier life during their course of TB treatment. Currently, the quality of life (QOL) is an important indicator to assess the well-being of a person and there is paucity of such information among TB patients. Hence, we conducted to assess and compare the QOL of Revised National TB Control Programme registered Drug sensitive TB patients, Drug resistant TB patients and general population of Gadag district in Karnataka, India. Methods: A cross-sectional study was conducted in Gadag district, Karnataka from March 2017 through March 2018 among drug sensitive, drug resistant TB patients and general population. A Non-probability purposive sampling was adopted to select the samples that were matched for age, gender and ward. The select patients were administered WHO QOL-BREF questionnaire by trained personnel. Data were analyzed using SPSS version 12 analysis software. Results: The scores obtained for the four domains of QOL were (a) physical health: 69.62 + 18.29 (b) Psychological: 66.96 + 18.62 (c) Environment: 60.99 + 15.05 and (d) Social relationships: 53.5 + 19.93. Conclusions: The drug resistant TB patients have poor QOL when compared to drug sensitive and general population.

Background: India is a high TB (tuberculosis) burden country. The advent of HIV (Human immunodeficiency virus) and DR-TB (drug resistant TB) has worsened the ongoing TB control efforts. A study was conducted to (a) to determine the duration for developing drug resistant TB after diagnosis of HIV (b) to ascertain the patients status after one year of DR-TB treatment in Karnataka, India. Methods: It is a retrospective cross-sectional study involving review of records and reports at ART (Anti-retroviral treatment) centres and DR-TB centres in Karnataka during the period 2013-2014. Results: The median time from being known as HIV positive to being diagnosed as DR-TB was 1168 days (IQR: 571 - 1955). At the end of 14 months, nearly 39% of patients had died and 49% of patients were on treatment. Conclusion: The National Health programmes should prioritize monitoring of the HIV/TB patients and develop appropriate novel strategies for community involvement.

Background: Under the Revised National Tuberculosis control Programme (RNTCP) in India, the designated microscopy centres (DMCs) form the basic unit of smear positive TB case detection in a district. There is a need by the programme managers to estimate the mean and range of smear positive tuberculosis (TB) cases that can be detected at DMCs located in different type of health facilities to channelize their resources. Methods: It is a cross-sectional study conducted in the state of Karnataka, India during January 2014 to December 2014 based on the compiled reports from past five years received from all the 30 districts of the state. The prediction was made based on the performance of these DMCs in the last five years using a modeling technique. Results: The proportions of the DMCs located at health facilities are Primary Health Institutions/Centres (PHIs)—73%, Tuberculosis Units (TUs)—15%, Medical colleges (MC)—7%, District TB centres (DTC)—3% and Private Practitioners (PP)—2%. The maximum number of cases that can be detected at DTC is 3621 (SD 54), TU is 9224 (SD 90), PHI is 20,412 (SD 135), PP is 859 (SD 26) and MC is 8322 (SD 84). Conclusion: The predicted values will essentially serve as a tool for the programme managers of Karnataka to plan, strategize and monitor the performance of DMCs in the state.

For certain subgroups within people living with the human immunodeficiency virus (HIV) [active tuberculosis (TB), pregnant women, children

Background: In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India’s national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment. Objectives: To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India. Methods: This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients. Results: Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67–173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals). Conclusion: DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.

Background After the rapid scale-up of antiretroviral therapy (ART) in resource-limited settings, surveillance of primary drug resistance mutations (DRMs) among ART-naive individuals has important public health benefits. Although a highly successful national ART programme initiated by the Government of India exists, data on the prevalence of primary DRMs is scarce. The objective of the study is to estimate the prevalence, pattern and spectrum of population-based primary DRMs in therapy-naive HIV-1-infected individuals using clinical strains and database sequences from seven HIV prevalent states of India. Methods Drug resistance genotyping was performed on either plasma RNA or whole-blood genomic DNA using a validated in-house method on 170 HIV-1-positive therapy-naive individuals. An additional 679 database-derived sequences from four other states were included in the analysis. The WHO-recommended list of mutations (SDRM_2009) for nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) were used for interpretation of DRMs. Trends of primary DRMs before and after the ART rollout were studied. Results The overall prevalence of primary DRMs was 2.6% in the selected states of India when clinical isolates as well as database-derived sequences were combined. Common mutations included T69D and D67N (NRTI mutations), and L100I, K101E, K103N and Y181C (NNRTI mutations). There was a significant increase in NNRTI mutations over time. Conclusions The overall DRM prevalence in this study was low. However, an increasing trend in primary NNRTI resistance has been observed during the past decade. Establishment of HIV drug resistance threshold surveillance will be useful in understanding further trends of transmitted resistance.

India has an estimated 2.5 million HIV infections, most of which are heterosexually transmitted. Women comprise 40% of infected adults. In India, 90% of women between the ages of 15 and 45 years are married. Previous literature has suggested that sexual intercourse with an HIV-infected husband represents a married woman's greatest risk for being infected. However, a recent meta-analysis of discordant couples from sub-Saharan Africa reported that women were the index case in half of all couples. Similar data are not available from India. This cross-sectional study describes the epidemiology of 925 discordant couples from five districts in Karnataka province, one of the high HIV prevalence provinces in India. Men were the index case in 74% of couples. However, in young couples (where the index case was aged

In India, the contribution of medical colleges to the Revised National Tuberculosis Control Programme (RNTCP) in terms of tuberculosis (TB) case detection is exemplary.1 In 2013, about 15.2% of TB cases were detected in the 330 medical colleges across the country.2 The RNTCP extends support to medical colleges by providing human resources (a medical officer, TB health visitor and laboratory technician), the requisite logistics for microscopy activities and drugs for TB treatment.3 The infrastructure to establish this programme unit is provided by each medical college, and is often known as the ‘RNTCP cell’. The programme guidelines suggest that all TB cases detected in medical college clinical departments should be routed through the RNTCP cell, where patients are registered and initiated on anti-tuberculosis treatment. For programme monitoring and reporting, the medical college is considered as the peripheral health institute (PHI), and they submit monthly PHI report and quarterly case finding reports to the district TB control officer. We discuss an innovative approach to mainstreaming TB case detection and reporting by the academic sector. Missed TB cases are one of the main challenges to TB control today.4 The contribution to reducing ‘missed TB cases’—those who are either never diagnosed or are diagnosed in the laboratory but do not appear on the TB treatment register—is of paramount importance. As medical colleges are well resourced with diagnostic equipment and many more severe cases might end up there, there may be an impact on TB transmission and mortality which is of likely benefit to the new ‘End TB’ strategy. The issues prevailing in the current reporting mechanisms and ways of strengthening the recording and reporting at medical colleges are enumerated below. The medical college is a huge institution, with 18 departments, the majority of which (except anatomy and physiology) are involved directly or indirectly in screening, diagnosing, investigating, treating or managing a case of TB. The burden of TB cases detected for the first time at autopsy by the department of forensic medicine is also well recognised.5 In the current system, all presumptive TB cases screened for TB who are either smear-negative or extra-pulmonary are not captured. We believe it is crucial to record these data from all the departments, as there remains a high probability that some of these missed cases may later turn out positive.6 As tertiary health facilities, medical colleges are equipped with all types of equipment for investigating a case. The decreasing trend of nationwide smear-negative TB case detection augments the importance of capturing the data at subunit levels of a medical college. The majority of TB cases diagnosed at medical colleges are referred to the primary health centre nearest to the patient's residence for initiation of treatment. The programme depends entirely on referral forms, the postal service, short messaging service (SMS) using mobile phones and telephone to inform the primary health centre and district TB officer about the referral. However, this communication mechanism is tedious, often delayed and lacks promptness in providing feedback. This inefficient system also leads to interdistrict and interstate referral meetings that are usually less fruitful. It is thus imperative for the programme to develop a real-time web-based referral mechanism that is effective and prevents unnecessary loss of time for the programme staff. There is an urgent need to develop better recording and reporting systems in medical colleges. Mechanisms to capture all presumptive and diagnosed TB cases should be made operational through full involvement of the medical records department of the medical colleges. Strengthening the medical colleges will be a very helpful investment for the RNTCP in years to come.

Background: The association of cardiovascular risk with first-line antiretroviral therapy (ART) in Indians has been a matter of concern with the background of a high risk in South Asians. Aims: This study aimed to compare metabolic syndrome and its components, dyslipidemia, insulin resistance, and cardiovascular risk among patients on first-line ART (Group 1) with age-matched, ART-naïve human immunodeficiency virus (HIV)-infected patients (Group 2) and normal controls (Group 3). Methods: Patients attending a tertiary care center in Mysore were enrolled in the study after obtaining informed consent and controls were chosen from relatives of patients. Results: The total number of patients enrolled in the study was 217 (males 111; females 106), and the mean age of these patients was 34.1 ± 7.4 years. The number of patients in Group 1 (HIV+, ART experienced) was 76; in Group 2 (HIV+, ART naïve) was 71, and in Group 3 (HIV−) was 70. There was no statistically significant difference in the prevalence of metabolic syndrome between the three groups. On comparing the components of metabolic syndrome, serum triglycerides (mg/dl) were significantly higher in the ART group (Group 1: 149.5 [interquartile range (IQR): 84–187], Group 2: 108 [IQR: 74–152], and Group 3: 141.5 [IQR: 89–192]; P = 0.014) and serum high-density lipoprotein cholesterol was higher in HIV-uninfected individuals (Group 1: 37.5 ± 11.83, Group 2: 31.5 ± 12.23, and Group 3: 40.1 ± 12.09; P = 0.0002). There was no association between metabolic syndrome, duration of HIV, and type of first-line ART. Total and low-density lipoprotein (LDL) cholesterol were significantly higher in the ART group. Homeostatic model assessment and Framingham scores did not reveal any significant difference across the three groups. Conclusion: HIV-infected individuals on ART had higher levels of triglycerides, LDL, and total cholesterol, but no increased cardiovascular risk compared to other groups.

Objective Combination antiretroviral therapy (ART) has improved in efficacy, durability and tolerability. Virological efficacy studies in India are limited. We determined incidence and predictors of virological failure among patients initiating first-line ART and described virological resuppression after confirmed failure, with the goal of informing national policy. Methods Therapy-naive patients initiated on first-line ART as per national guidelines were monitored every 3 months for adherence and virological response over 2 years. Genotyping on baseline samples was performed to assess primary drug resistance. Multivariate Cox regression analysis was used to assess predictors of virological failure. Results Virological failure rate among 599 eligible patients was 10.7 failures per 100 person-years. Cumulative failure incidence was 13.2% in the first year and 16.5% over 2 years. Patients initiated on tenofovir had a significantly lower rate of virological failure than those on stavudine or zidovudine (6.7 vs. 11.9 failures per 100 person-years, P = 0.013). Virological failure was independently associated with age

Introduction: Given the chronic nature of HIV infection and the need for life-long antiretroviral therapy (ART), maintaining long-term optimal adherence is an important strategy for maximizing treatment success. In order to understand better the dynamic nature of adherence behaviors in India where complex cultural and logistic features prevail, we assessed the patterns, trajectories and time-dependent predictors of adherence levels in relation to virological failure among individuals initiating first-line ART in India. Methods: Between July 2010 and August 2013, eligible ART-naive HIV-infected individuals newly initiating first-line ART within the national program at three sites in southern India were enrolled and monitored for two years. ART included zidovudine/stavudine/tenofovir plus lamivudine plus nevirapine/efavirenz. Patients were assessed using clinical, laboratory and adherence parameters. Every three months, medication adherence was measured using pill count, and a structured questionnaire on adherence barriers was administered. Optimal adherence was defined as mean adherence ≥95%. Statistical analysis was performed using a bivariate and a multivariate model of all identified covariates. Adherence trends and determinants were modeled as rate ratios using generalized estimating equation analysis in a Poisson distribution. Results: A total of 599 eligible ART-naive patients participated in the study, and contributed a total of 921 person-years of observation time. Women constituted 43% and mean CD4 count prior to initiating ART was 192 cells/mm3. Overall mean adherence among all patients was 95.4%. The proportion of patients optimally adherent was 75.6%. Predictors of optimal adherence included older age (≥40 years), high school-level education and beyond, lower drug toxicity-related ART interruption, full disclosure, sense of satisfaction with one’s own health and patient’s perception of having good access to health-care services. Adherence was inversely proportional to virological failure (IRR 0.55, 95%CI 0.44-0.69 p

Background In India, TB and HIV co-infection remains as a serious public health problem. From 2006 onwards, the intensified TB-HIV collaborative activities are being jointly implemented by National AIDS Control Programme (NACP) and Revised National TB Control programme (RNTCP) at high HIV burden states. Objectives To determine (a) the predictors of outcome among a cohort of HIV-TB co-infected patients after two years after initiation of ART treatment. (b) prognostic significance of time difference between the initiation of ATT and ART in HIV-TB co-infected patients. Methods Patients registered at sixteen ART centres in Karnataka, from October through December 2009 formed the study cohort and were followed till December 2011. Results A total of 604 HIV-TB patients were registered. Follow-up (a) at the end of one year had shown 63.6% (377)patients with unfavorable TB treatment outcomes (b) at the end of second year, 55.6% (336)patients were alive on ART treatment. The variables male, smear negative TB, CD4 count less than 50cells per cumm and unfavorable TB outcome were significantly associated with unfavorable ART treatment outcome. Conclusions The programmes need to review the existing strategies and strengthen HIV-TB collaborative activities for timely treatment initiation with intensive monitoring of HIV-TB patients on treatment.

The therapeutic and preventive benefits of early initiation of antiretroviral therapy (ART) for HIV are now well established. Reflecting new research evidence, in 2015 the World Health Organization (WHO) recommended initiation of ART for all people living with HIV (PLHIV), irrespective of their clinical staging and CD4 cell count. The National AIDS Control Programme (NACP) in India is currently following the 2010 WHO ART guidelines for adults and the 2013 guidelines for pregnant women and children. This desk study assessed the number of people living with HIV who will additionally be eligible for ART on adoption of the 2015 WHO recommendations on ART. Data routinely recorded for all PLHIV registered under the NACP up to 31 December 2015 were analysed. Of the 250 865 individuals recorded in pre-ART care, an estimated 135 593 would be eligible under the WHO 2013 guidelines. A further 100 221 would be eligible under the WHO 2015 guidelines. Initiating treatment for all PLHIV in pre-ART care would raise the number on ART from 0.92 million to 1.17 million. In addition, nearly 0.07 million newly registered PLHIV will become eligible every year if the WHO 2015 guidelines are adopted, of which 0.028 million would be attributable to implementation of the WHO 2013 guidelines alone. In addition to drugs, there will be a need for additional CD4 tests and tests of viral load, as the numbers on ART will increase significantly. The outlay should be seen in the context of potential health-care savings due to early initiation of ART, in terms of the effect on disease progression, complications, deaths and new infections. While desirable, adoption of the new guidance will have significant programmatic and resource implications for India. The programme needs to plan and strengthen the service-delivery mechanism, with emphasis on newer and innovative approaches before implementation of these guidelines.

Competing domestic health priorities and shrinking financial support from external agencies necessitates that India's National AIDS Control Programme (NACP) brings in cost efficiencies to sustain the programme. In addition, current plans to expand the criteria for eligibility for antiretroviral therapy (ART) in India will have significant financial implications in the near future. ART centres in India provide comprehensive services to people living with HIV (PLHIV): those fulfilling national eligibility criteria and receiving ART and those on pre-ART care, i.e. not on ART. ART centres are financially supported (i) directly by the NACP; and (ii) indirectly by general health systems. This study was conducted to determine (i) the cost incurred per patient per year of pre-ART and ART services at ART centres; and (ii) the proportion of this cost incurred by the NACP and by general health systems. The study used national data from April 2013 to March 2014, on ART costs and non-ART costs (human resources, laboratory tests, training, prophylaxis and management of opportunistic infections, hospitalization, operational, and programme management). Data were extracted from procurement records and reports, statements of expenditure at national and state level, records and reports from ART centres, databases of the National AIDS Control Organisation, and reports on use of antiretroviral drugs. The analysis estimates the cost for ART services as US$ 133.89 (?8032) per patient per year, of which 66% (US$ 88.66, ?5320) is for antiretroviral drugs and 34% (US$ 45.23, ?2712) is for non-ART recurrent expenditure, while the cost for pre-ART care is US$ 33.05 (?1983) per patient per year. The low costs incurred for patients in ART and pre-ART care services can be attributed mainly to the low costs of generic drugs. However, further integration with general health systems may facilitate additional cost saving, such as in human resources.

‘Pre-antiretroviral treatment (pre-ART) care’ in the Indian context refers to all services provided to individuals with human immunodeficiency virus (HIV) infection between registering at an ART centre and receiving the first dose of ART medication.1 Pre-ART ‘retention’ is an important programme indicator, and is defined as the capacity of the health system to maintain patients on active follow-up before ART initiation. Maintaining HIV-infected persons in pre-ART care is important to provide effective management of opportunistic infections, to ensure ART initiation at the optimal time, and to promote prevention of HIV transmission in the community.2,3 Delays in ART initiation result in increased morbidity and mortality, which impact negatively on programme performance. India is currently facing a concentrated HIV epidemic, with an estimated 1.7–2.5 million people living with HIV.4 Of these, over 65% are considered eligible for ART,5 implying that about 35% should be retained in pre-ART care.6 Such individuals are required to be registered and maintained on follow-up care at ART centres countrywide. A systematic review by Rosen et al. showed that only a third of patients testing HIV-positive in sub-Saharan Africa are retained in care.7 India, like other ART programmes around the world, confines routine programme reporting to ‘on-treatment analysis’, which means that what happens before ART initiation is unknown. A previous study from Karnataka State, India, by Shastri et al. reported a 29% loss to follow-up between HIV testing, registration at ART centres and ART initiation among eligible individuals.8 However, retention among individuals who were not yet eligible for ART (pre-ART) was not assessed. Knowing the level of retention among pre-ART clients could have important programmatic and public health implications. In a cohort of HIV-infected persons who were registered in pre-ART care at an ART centre in the Tumkur district of Karnataka State, India, we aimed to 1) report on the proportion lost to follow-up within 1 year of registration and 2) determine socio-demographic and immunological variables associated with loss to follow-up.

OBJECTIVE: To compare the potential population-level impact of expanding antiretroviral treatment (ART) in HIV epidemics concentrated among female sex workers (FSWs) and clients, with and without existing condom-based FSW interventions. DESIGN: Mathematical model of heterosexual HIV transmission in south India. METHODS: We simulated HIV epidemics in three districts to assess the 10-year impact of existing ART programs (ART eligibility at CD4 cell count ≤350) beyond that achieved with high condom use, and the incremental benefit of expanding ART by either increasing ART eligibility, improving access to care, or prioritizing ART expansion to FSWs/clients. Impact was estimated in the total population (including FSWs and clients). RESULTS: In the presence of existing condom-based interventions, existing ART programs (medium-to-good coverage) were predicted to avert 11-28% of remaining HIV infections between 2014 and 2024. Increasing eligibility to all risk groups prevented an incremental 1-15% over existing ART programs, compared with 29-53% when maximizing access to all risk groups. If there was no condom-based intervention, and only poor ART coverage, then expanding ART prevented a larger absolute number but a smaller relative fraction of HIV infections for every additional person-year of ART. Across districts and baseline interventions, for every additional person-year of treatment, prioritizing access to FSWs was most efficient (and resource saving), followed by prioritizing access to FSWs and clients. CONCLUSION: The relative and absolute benefit of ART expansion depends on baseline condom use, ART coverage, and epidemic size. In south India, maximizing FSWs' access to care, followed by maximizing clients' access are the most efficient ways to expand ART for HIV prevention, across baseline intervention context.

Monitoring of HIV-infected individuals on antiretroviral treatment (ART) ideally requires periodic viral load measurements to ascertain adequate response to treatment. While plasma viral load monitoring is widely available in high-income settings, it is rarely used in resource-limited regions because of high cost and need for sophisticated sample transport. Dried blood spot (DBS) as source specimens for viral load measurement has shown promise as an alternative to plasma specimens and is likely to be a useful tool for Indian settings. The present study was undertaken to investigate the performance of DBS in HIV-1 RNA quantification against the standard plasma viral load assay.Between April-June 2011, 130 samples were collected from HIV-1-infected (n=125) and non-infected (n=5) individuals in two district clinics in southern India. HIV-1 RNA quantification was performed from DBS and plasma using Abbott m2000rt system after manual RNA extraction. Statistical analysis included correlation, regression and Bland-Altman analysis.The sensitivity of DBS viral load was 97 per cent with viral loads3.0 log 10 copies/ml. Measurable viral load (3.0 log 10 copies/ml) results obtained for the 74 paired plasma-DBS samples showed positive correlation between both the assays (r=0.96). For clinically acceptable viral load threshold values of5,000 copies/ml, Bland-Altman plots showed acceptable limits of agreement (-0.21 to +0.8 log 10 copies/ml). The mean difference was 0.29 log 10 copies/ml. The cost of DBS was $2.67 lower compared to conventional plasma viral load measurement in the setting.The significant positive correlation with standard plasma-based assay and lower cost of DBS viral load monitoring suggest that DBS sampling can be a feasible and economical means of viral load monitoring in HIV-infected individual in India and in other resource-limited settings globally.

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.

BACKGROUND: In March 2012, World Health Organization recommended that HIV testing should be offered to all patients with presumptive TB (previously called TB suspects). How this is best implemented and monitored in routine health care settings in India was not known. An operational research was conducted in Karnataka State (South India, population 64 million, accounts for 10% of India's HIV burden), to test processes and learn results and challenges of screening presumptive TB patients for HIV within routine health care settings. METHODS: In this cross-sectional study conducted between January-March 2012, all presumptive TB patients attending public sector sputum microscopy centres state-wide were offered HIV testing by the laboratory technician, and referred to the nearest public sector HIV counselling and testing services, usually within the same facility. The HIV status of the patients was recorded in the routine TB laboratory form and TB laboratory register. The laboratory register was compiled to obtain the number of presumptive TB patients whose HIV status was ascertained, and the number found HIV positive. Aggregate data on reasons for non-testing were compiled at district level. RESULTS: Overall, 115,308 patients with presumptive TB were examined for sputum smear microscopy at 645 microscopy centres state-wide. Of these, HIV status was ascertained for 62,847(55%) among whom 7,559(12%) were HIV-positive, and of these, 3,034(40%) were newly diagnosed. Reasons for non-testing were reported for 37,700(72%) of the 52,461 patients without HIV testing; non-availability of testing services at site of sputum collection was cited by health staff in 54% of respondents. Only 4% of patients opted out of HIV testing. CONCLUSION: Offering HIV testing routinely to presumptive TB patients detected large numbers of previously-undetected instances of HIV infection. Several operational challenges were noted which provide useful lessons for improving uptake of HIV testing in this important group.

Introduction One important operational challenge facing antiretroviral treatment (ART) programmes in low- and middle-income countries is the loss to follow-up between diagnosis of human immunodeficiency virus (HIV) and initiation of ART. This is a major obstacle to achieving universal access to ART. This study from Karnataka, India, tried to measure such losses by determining the number of HIV-positive individuals diagnosed, the number of them reaching ART centres, the number initiated on ART and the reasons for non-initiation of ART. Methods A review of records routinely maintained under the National AIDS Control Programme (NACP) was carried out in six districts of Karnataka. HIV-positive persons diagnosed during the months from January to June 2011 in 233 public HIV-testing sites were followed up until December 2011 based on the pre-ART registers. A chi-square test was used to assess statistical significance. Results Of 2291 HIV-positive persons diagnosed (52% male; mean age of 35 years), 1829 (80%) reached ART centres. Of the latter, 1166 (64%) were eligible for ART, and 959 (82%) were initiated on treatment. Overall losses (attrition) on the road between HIV diagnosis and ART initiation were 669 (29%). Deaths, migration and not willing to go to the ART centres were cited as the main known reasons for not reaching ART centres. For ART-eligible individuals who did not initiate ART, the most common known reasons for non-initiation included dying before initiation of ART and not being willing to start ART. Conclusions In a large state of India, eight in ten HIV-positive persons reached ART centres, and of those found ART eligible, 82% start treatment. Although this is an encouraging achievement, the programme needs to take further steps to improve the current performance by further reducing pre-ART attrition. We recommend online registering of diagnosed HIV-positive patients to track the patients more efficiently.

Methods A donor supported technical consultant was identified and located within the State AIDS Society. A logistic Management Information System is established to track procurement, distribution and supplies. Human resource recruitment, training and retention at the ART centres are decentralized to the district AIDS prevention and control units (DAPCU). Centralized classroom based training is complemented with field based onsite training and mentorship. A Google group is created for technical updates. DAPCU conducts coordination meetings to geographically distribute and allocate responsibility to all field level workers in HIV prevention and care programs to minimize loss to follow up.

Background Prior to 2007-08, ART services in Karnataka state, India were delivered through ART centres, located mainly in medical colleges, and tertiary and district hospitals. This led to high rates of defaults, increased travel time and cost and loss of working hours. To make treatment services more accessible to PLHIV, link ART centres (LACs) were developed at sub-district primary and secondary care levels, co-located with HIV voluntary counselling and testing centres.

Results Ninety-seven deaths occurred between January-September 2011. 55% of the deceased were males. The mean duration of survival on antiretroviral therapy was 36 weeks. Median age at time of death was 10 years (range 1-19) median CD4 count was 210 cells/μl (7-2500); 57% had CD4 cell count

Background 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. Methods 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). Results 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). Conclusions 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.

Background India accounts for 23% of the global incidence of TB cases; it also has an estimated 2.3 million HIV infections. Of the 2 million TB incident cases, 5% occurred in HIV infected persons. The country has large national TB and HIV control programs. This paper describes characteristics of TB-HIV co-infection cases registered under the program in Karnataka province, India. Treatment outcomes for coinfected patients are compared with those for TB patients in the province. Methods Program reports from the National AIDS Control program and the National TB control program for Karnataka province (a high HIV prevalence state, population 61 million) were analysed. Data from patients registered in each program in 2010–2011 was studied. Results Of the 6,480 adult co-infections, a third occurred in women; 78% of patients were initiated on ART. Among the cohort 73% had pulmonary TB, and 46% reported sputum positivity for acid fast bacilli. Treatment success among co-infected patients not on ART (54%) were significantly lower compared to those already on ART (80%); death and default rates were higher in the non-ART group. Treatment success proportions (75%) for the co-infected patients were similar to those for the 51,966 patients registered under the TB program. Death rates among co-infected patients (15%) were twice as high as for TB patients under the program, though default and failure rates were lower. Conclusion Co-infected patients already on ART demonstrated better TB outcomes in than those not on ART. Compared to those with TB only, co-infected patients had similar TB treatment success rates and lower rates of treatment default and failure. Integration of TB-HIV collaborative activities will strengthen our battle to control TB and HIV globally.

Background In south India, where intensive condom-based targeted interventions (TIs) for female sex workers (FSWs) have been successful, the potential impact of past, current, and proposed universal antiretroviral treatment (ART) eligibility criteria on concentrated HIV epidemics, remains unknown. Methods We developed a mathematical model of heterosexual HIV transmission to simulate the HIV epidemic in three south Indian districts, using district-specific epidemiological data. The model was calibrated to HIV prevalence by risk groups (low-risk, clients, FSWs), population size, and ART coverage. Assuming that condom-based TIs, HIV testing and treatment access, and retention in HIV-care are sustained at current levels, we compared the following scenarios against no ART: (a) continue with the previous eligibility criteria (CD4 ≤ 250 cells/μL) from the start of each district’s ART programme; (b) expand from previous to current eligibility (CD4 ≤ 350 cells/μL) after November 2011; and (c) expand to early ART at any CD4 cell count after January 2013. Results Without ART, the three districts achieve local elimination between the years 2040 and 2082, and by 2035–2063 under the current ART programme (eligibility criteria: CD4 ≤ 250 cells/μL prior to November 2011, CD4 ≤ 350 cells/μL thereafter). By January 2013, the current ART programme has potentially averted 7.8–11.0% of HIV infections, and saved 32–44 life-years per 100-person years on ART, in addition to gains achieved by local TIs. By 2023, the additional fraction of HIV infections averted by ART(compared to sustained TIs without ART) under scenarios A, B, and C are 21–42%, 33–57%, and 43–69%, respectively, and the incremental gains in life-years per 100-person years on ART are 120–140, 68–111, and 40–91, respectively. Conclusions In declining HIV epidemics with sustained TIs, current ART programmes and proposed ART expansion could provide additional epidemiological impact. The medium-term incremental gains become smaller as eligibility expands but access and retention in care remain constant.

BACKGROUND: In 2010, WHO expanded previously-recommended indications for anti-retroviral treatment to include all HIV-infected TB patients irrespective of CD4 count. India, however, still limits ART to those TB patients with CD4 counts

Introduction: ABO blood group system was the fi rst human blood group system to be discovered. Subsequent to the discovery of blood groups by Landsteiner and advancement in its study many workers tried to fi nd out associations between blood groups and the incidence of various diseases. The objective of the study was to create a blood group database which would probably help in transfusion services and fi nd out the distribution of blood groups in the seropositive population. Methodology: Blood groups were ascertained for 1809 patients who were HIV seropositive enrolled at ICTC in a tertiary care teaching hospital in Karnataka, India from April 2004 to January 2010 using the simple tile method. The results were compiles and statistically analyzed. Results: Blood grouping was done for 1809 patients, out of which 1749 (96.68%) were adults and 60(3.32%) were paediatric patients. O Rhesus positive was the most prevalent blood group in both adult (40.13%) and paediatric (43.33%) seropositives. B Rhesus positive was next commonest group in adults (26.12%) and A Rhesus positive in paediatric(30.0%). AB Rhesus negative (Adults-0.34% and Paediatric-0%) blood group was the least prevalent in the study population. Conclusion: It is important to create blood group database for the Indian seropositives population, to know any probable association between blood group and HIV infection. This study is an attempt to create a blood group database in a modestly large seropositive which would play a vital role in transfusion services and future research . Larger nation-wide studies would be required to substantiate any association between blood groups and HIV infection. DOI: http://dx.doi.org/10.3126/saarctb.v8i2.5901 SAARCTB 2011; 8(2): 42-45