Challenges in Retention of Patients in Continuum of HIV-Care in Delhi— Experience of a Decade & Way Ahead

Retention of the patients in HIV-care is critical for success of Anti Retroviral Treatment (ART) programme to reduce HIV-related morbidity & mortality and prevent emergence of drug resistance. In last decade in Delhi (April 2004 to March 2014), overall 24% HIV-positive patients were lost-to-follow-up (LTFU) at step-1 (testing to enrolment into HIV-care), 7.8% at step-2 (enrolment to ART eligibility), 23.7% at step-3 (eligibility to initiation of ART) and 16.6% at step-4 (initiation to lifelong ART) of retention cascade. About 2/3rd losses at step-4 were within 1st year and 80% within 2 years. The retention of the patients in pre-ART care was 3 times lower than those initiated ART. Only 27.4% patients were in active pre-ART care during 2013. The intensified LTFU tracking (ILT) undertaken during November, 2013 through March, 2014 was not successful in tracking 97% pre-ART LTFU clients due to incomplete addresses/or migration since address proof of patients on enrolment into HIV-care was not mandatory prior to 2009. Amongst patients tracked, 1.5% were alive, 0.24% had disengaged from care while 1.2% had died. After ILT overall “On ART” and “Pre-ART” LTFU rate in the last decade was 15.5% and 45.2%, respectively. The retention cascade of last year from April 2013 to March 2014 showed improvement through strategies adopted in Third Phase of National AIDS Control Programme (NACP-III; 2007-2013), and “On ART” and “Pre-ART” LTFU rates declined to 9.4% and 7.4%, respectively. However, desired at least 90% retention at various steps of the cascade could not be achieved. National Policy of delivering ART services through limited number of standalone ART centers in India, despite its significant success, has limitation of leaky treatment cascade and calls for policy makers to decentralize the programme by its appropriate integration with general health services and task shifting to improve continuum of care.