title: The journey to antiretroviral therapy in Karnataka, India: who was lost on the road?
abstract: BACKGROUND
  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.
authors.affiliation: Karnataka State AIDS Prevention Society, Bangalore, India. susha007@gmail.com
authors.forename: Suresh
authors.initials: S
authors.lastname: Shastri
authors.forename: Srinath
authors.initials: S
authors.lastname: Sathyanarayna
authors.forename: Sharath Burugina
authors.initials: SB
authors.lastname: Nagaraja
authors.forename: Ajay Mv
authors.initials: AM
authors.lastname: Kumar
authors.forename: Bharat
authors.initials: B
authors.lastname: Rewari
authors.forename: Anthony D
authors.initials: AD
authors.lastname: Harries
authors.forename: Rony
authors.initials: R
authors.lastname: Zachariah
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D003430:Cross-Sectional Studies; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D055815:Young Adult
keywords: ART centres; India; loss to follow-up; operational research