title: 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.
abstract: 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.
authors: Department of Pediatrics, St John's National Academy of Health Sciences, Bangalore, India. anitashet@gmail.com
authors: Anita
authors: A
authors: Shet
authors: Ayesha
authors: A
authors: DeCosta
authors: Elsa
authors: E
authors: Heylen
authors: Suresh
authors: S
authors: Shastri
authors: Sara
authors: S
authors: Chandy
authors: Maria
authors: M
authors: Ekstrand
mesh_terms: D000328:Adult; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000628:therapy*; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D017149:Private Sector; D017150:Public Sector; D055818:Public-Private Sector Partnerships; D036301:Qualitative Research; D016896:Treatment Outcome; D016903:Drug Monitoring