title: Survival outcomes for first-line antiretroviral therapy in India's ART program.
abstract: Little is known about survival outcomes of HIV patients on first-line antiretroviral therapy (ART) on a large-scale in India, or facility level factors that influence patient survival to guide further improvements in the ART program in India. We examined factors at the facility level in addition to patient factors that influence survival of adult HIV patients on ART in the publicly-funded ART program in a high- and a low-HIV prevalence state.
  
  
  
  Retrospective chart review in public sector ART facilities in the combined states of Andhra Pradesh and Telangana (APT) before these were split in 2014 and in Rajasthan (RAJ), the high- and a low-HIV prevalence states, respectively. Records of adults initiating ART between 2007-12 and 2008-13 in APT and RAJ, respectively, were reviewed and facility-level information collected at all ART centres and a sample of link ART centres. Survival probability was estimated using Kaplan-Meier method, and determinants of mortality explored with facility and patient-level factors using Cox proportional hazard model.
  
  
  
  Based on data from 6581 patients, the survival probability of ART at 60 months was 76.3 % (95 % CI 73.0-79.2) in APT and 78.3 % (74.4-81.7) in RAJ. The facilities with cumulative ART patient load above the state average had lower mortality in APT (Hazard ratio [HR] 0.74, 0.57-0.95) but higher in RAJ (HR 1.37, 1.01-1.87). Facilities with higher proportion of lost to follow-up patients in APT had higher mortality (HR 1.47, 1.06-2.05), as did those with higher ART to pre-ART patient ratio in RAJ (HR 1.62, 1.14-2.29). In both states, there was higher hazard for mortality in patients with CD4 count 100 cells/mm3or less at ART initiation, males, and in patients with TB co-infection.
  
  
  
  These data from the majority of facilities in a high- and a low-HIV burden state of India over 5 years reveal reasonable and similar survival outcomes in the two states. The facilities with higher ART load in the longer established ART program in APT had better survival, but facilities with a higher ART load and a higher ratio of ART to pre-ART patients in the less experienced ART program in RAJ had poorer survival. These findings have important implications for India's ART program planning as it expands further.
authors.affiliation: Public Health Foundation of India, New Delhi, India. rakhi.dandona@phfi.org.
authors.forename: Rakhi
authors.initials: R
authors.lastname: Dandona
authors.affiliation: Department of AIDS Control, Ministry of Health and Family Welfare, Government of India, New Delhi, India.|World Health Organization Country Office for India, New Delhi, India.
authors.forename: Bharat B
authors.initials: BB
authors.lastname: Rewari
authors.affiliation: Public Health Foundation of India, New Delhi, India.
authors.forename: G Anil
authors.initials: GA
authors.lastname: Kumar
authors.affiliation: Public Health Foundation of India, New Delhi, India.|Department of AIDS Control, Ministry of Health and Family Welfare, Government of India, New Delhi, India.|World Health Organization Country Office for India, New Delhi, India.
authors.forename: Sukarma
authors.initials: S
authors.lastname: Tanwar
authors.affiliation: Public Health Foundation of India, New Delhi, India.
authors.forename: S G Prem
authors.initials: SG
authors.lastname: Kumar
authors.affiliation: Public Health Foundation of India, New Delhi, India.
authors.forename: Venkata S
authors.initials: VS
authors.lastname: Vishnumolakala
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.
authors.forename: Herbert C
authors.initials: HC
authors.lastname: Duber
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.
authors.forename: Emmanuela
authors.initials: E
authors.lastname: Gakidou
authors.affiliation: Public Health Foundation of India, New Delhi, India.|Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.
authors.forename: Lalit
authors.initials: L
authors.lastname: Dandona
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology / Q000401:mortality*; D006801:Humans; D007194:India / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: AIDS; ART; HIV; India; Mortality; Survival