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Open Access Why are HIV-infected people not started on antiretroviral therapy? A mixed-methods study from Gujarat, India

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Setting: Five purposively selected antiretroviral therapy (ART) centres in Gujarat, India.

Objectives: To assess the proportion of ART-eligible people living with the human immunodeficiency virus (PLHIV) who were not initiated on ART within 2 months of being recorded as eligible, to identify factors associated with non-initiation and to explore reasons from the provider's perspective.

Design: We used a mixed-methods design (triangulation) of 1) a quantitative phase involving record reviews and cohort analysis (Poisson regression) of PLHIV registered during April 2014–March 2015, and 2) a qualitative phase involving one-to-one interviews with 25 providers.

Results: Of 2079 ART-eligible PLHIV, 339 (16%) were not started on ART within 2 months. PLHIV with CD4 counts of <350 cells/μl and patients who were labourers, hospitalised, bedridden or registered with certain ART centres were more likely not to be initiated on ART. Qualitative results were categorised into two broad themes: government health system- and patient-related challenges, which validated and complemented the quantitative findings.

Conclusion: Several patient subgroups at greater risk of ART non-initiation were identified, along with reasons for risk; this has important programme implications for achieving the UNAIDS 90–90–90 goal, and particularly the second 90 component of having 90% of diagnosed PLHIV start ART.
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Keywords: 90–90–90; ART-eligible; National AIDS Control Programme; SORT IT; operational research

Document Type: Research Article

Affiliations: 1: Gujarat State AIDS Control Society, Health and Family Welfare Department, Government of Gujarat, Ahmedabad, India 2: Department of Community Medicine, Government Medical College and SSG Hospital, Vadodara, India 3: Department of Community Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, India 4: Department of Community Medicine, GMERS Medical College, Sola, Ahmedabad, India 5: World Health Organization India Country Office, New Delhi, India 6: Department of Medicine, BJ Medical College and Civil Hospital, Ahmedabad, India 7: Gujarat State AIDS Control Society, Health and Family Welfare Department, Government of Gujarat, Ahmedabad, India, Department of Community Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Gandhinagar, India 8: Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India 9: International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India, The Union, Paris, France

Publication date: September 21, 2017

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  • Public Health Action (PHA), The Union's quarterly open access on-line journal, provides a platform for its mission 'Health solutions for the poor'. PHA addresses the need for show-casing operational research that addresses issues in health systems and services. It publishes high-quality scientific research that provides new knowledge to improve access, equity, quality and efficiency of health systems and services.

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