Knowledge, Attitudes, and Practices of Knowledge, Attitudes, and Practices of HIV Care and Antiretroviral Therapy HIV Care and Antiretroviral Therapy

Among HIV-Infected Adults Attending Among HIV-Infected Adults Attending Private and Public Clinics in IndiaPrivate and Public Clinics in India

THAB0204

Satish B Vaidya1, Suneil R Ramchandani2, Shruti H Mehta3, Dattatray G Saple4, Ved P Pandey5, Ravi Vadrevu6, Sikhamani Rajasekaran7, Vandana Bhatia8, Abhay

Chowdhary8, Robert C Bollinger3,9, and Amita Gupta9.

1. KJ Somaiya Medical College (Mumbai, India); 2. National Naval Medical Center, Bethesda, USA); 3. Johns Hopkins University School of Public Health (Baltimore,USA); 4 G.T Hospital, Grant Medical College (Mumbai, India); 5 M.Y. Hospital (Indore, India);

6 Sai Sudha Hospital (Kakinada, India); 7 Tambaram Sanitorium (Chennai, India)8 AIDS Research and Control Centre (Mumbai, India); 9 Johns Hopkins School of Medicine (Baltimore, USA)

HIV in IndiaHIV in India

• Estimated 5.2 – 5.7 million HIV-seropositive Estimated 5.2 – 5.7 million HIV-seropositive personspersons

• 70% of HIV infected found in high-prevalent 70% of HIV infected found in high-prevalent statesstates

• Approximately 550,000-700,000 Indians Approximately 550,000-700,000 Indians currently have AIDS currently have AIDS

Health Care in IndiaHealth Care in India• Public Health Care SectorPublic Health Care Sector

• Provides primary to tertiary care Provides primary to tertiary care • Free of cost Free of cost • Small percentage of all national health care expenditures. Small percentage of all national health care expenditures.

• Private Health Care SectorPrivate Health Care Sector• 70%70% of Indian patients receive care in the private sector. of Indian patients receive care in the private sector.• Provides fee-for-service care Provides fee-for-service care • Largely unregulated Largely unregulated • 80%80% of the national health care expenditure. of the national health care expenditure.

• Patients receiving Antiretroviral Treatment (ART) Patients receiving Antiretroviral Treatment (ART) predominantly seen in private facilities.predominantly seen in private facilities.

ObjectivesObjectives

• To understand HIV infected persons’ To understand HIV infected persons’ knowledge, attitudes and practices (KAP) knowledge, attitudes and practices (KAP) towards ART in public and private clinics towards ART in public and private clinics in India in India

Methods: Study DesignMethods: Study Design• Feb 2004 – Jul 2004: Cross-sectional survey Feb 2004 – Jul 2004: Cross-sectional survey

conducted at 3 public and 3 private clinics/hospitals in conducted at 3 public and 3 private clinics/hospitals in IndiaIndia

• Mumbai Mumbai • Public clinic Public clinic • Private clinic Private clinic

• ChennaiChennai• Public Hospital Public Hospital

• KakinadaKakinada• Private Hospital Private Hospital

• IndoreIndore• Public HospitalPublic Hospital• Private Clinic Private Clinic

Sites of Project

MethodsMethods• Inclusion criteriaInclusion criteria

• HIV-infected and knowledgeable of his/her HIV statusHIV-infected and knowledgeable of his/her HIV status• Seeking care at selected study siteSeeking care at selected study site• ≥ ≥ 18 years old18 years old• Deemed physically and mentally capable to complete Deemed physically and mentally capable to complete

the survey. the survey.

• Survey InstrumentSurvey Instrument• Administered by trained counselors in face-to-face Administered by trained counselors in face-to-face

interview in local languageinterview in local language• Questions included:Questions included:

• Sociodemographics Sociodemographics • HIV clinical history (including pattern of antiretroviral HIV clinical history (including pattern of antiretroviral

exposure)exposure)• HIV TreatmentHIV Treatment• Perceptions/knowledge of ART Perceptions/knowledge of ART

Data AnalysisData Analysis

• General characteristics of participants in General characteristics of participants in private vs. public were compared using chi-private vs. public were compared using chi-square tests for categorical variables and square tests for categorical variables and Mann-Whitney tests for continuous variables. Mann-Whitney tests for continuous variables.

• Univariate and multiple logistic regression Univariate and multiple logistic regression analysis was used to identify factors analysis was used to identify factors independently associated with being on independently associated with being on antiretroviral therapy. antiretroviral therapy.

Characteristics of Study Population Characteristics of Study Population n=1,667n=1,667

PublicPublic

n=789 (%)n=789 (%)

PrivatePrivate

n=878 (%)n=878 (%)p valuep value

MaleMale 501 (64)501 (64) 645 (74)645 (74) <0.0001<0.0001

Median age, yearsMedian age, years 3333 3434 0.230.23

Married/ live-in Married/ live-in partnerpartner 489 (62)489 (62) 691 (79)691 (79) <0.0001<0.0001

Less than high Less than high school educationschool education 508 (65)508 (65) 503 (58)503 (58) <0.0001<0.0001

EmployedEmployed 488 (62)488 (62) 597 (68)597 (68) 0.040.04

Characteristics of HIV HistoryCharacteristics of HIV Historyn=1,667n=1,667

PublicPublic

n=789 (%)n=789 (%)

PrivatePrivate

n=878 (%)n=878 (%)p valuep value

Site of DiagnosisSite of Diagnosis

Public HospitalPublic Hospital

Private ClinicPrivate Clinic

321 (41)321 (41)

458 (59)458 (59)

71 (8)71 (8)

801 (92)801 (92)

<0.0001<0.0001

Reason for HIV TestReason for HIV Test

Referred / SymptomaticReferred / Symptomatic

HIV Infected Spouse/ChildHIV Infected Spouse/Child

History of high-risk exposureHistory of high-risk exposure

Pre-operative / Medical Appt.Pre-operative / Medical Appt.

439 (59)439 (59)

126 (17)126 (17)

107 (14)107 (14)

50 (7)50 (7)

587 (70)587 (70)

126 (15)126 (15)

21 (3)21 (3)

82 (10)82 (10)

<0.0001<0.0001

Characteristics of HIV HistoryCharacteristics of HIV Historyn=1,667n=1,667

PublicPublic

n=789 (%)n=789 (%)

PrivatePrivate

n=878 (%)n=878 (%)

p valuep value

Heard of CD4 Cell CountHeard of CD4 Cell Count 247 (32)247 (32) 460 (53)460 (53) < 0.001< 0.001

Heard of HIV Viral LoadHeard of HIV Viral Load 99 (13)99 (13) 237 (27)237 (27) < 0.001< 0.001

Ever had CD4 Cell CountEver had CD4 Cell Count 149 (20) 149 (20) 374 (43)374 (43) < 0.001< 0.001

Ever had HIV Viral LoadEver had HIV Viral Load 37 (5)37 (5) 145 (17)145 (17) < 0.001< 0.001

Access to HIV Care Access to HIV Care n=1,667n=1,667

PublicPublic

n=789 (%)n=789 (%)

PrivatePrivate

n=878 (%)n=878 (%)p valuep value

Travel time to Primary Care SiteTravel time to Primary Care Site

< 1 hour< 1 hour

1 – 5 hours1 – 5 hours

> 5 hours> 5 hours

189 (24)189 (24)

270 (34)270 (34)

329 (42)329 (42)

225 (26) 225 (26)

498 (57)498 (57)

153 (18)153 (18)

<0.0001<0.0001

Barriers to CareBarriers to Care

Cannot Afford Loss of WagesCannot Afford Loss of Wages

Medical Care Site is too farMedical Care Site is too far

Family ResponsibilitiesFamily Responsibilities

234 (54)234 (54)

210 (49)210 (49)

370 (85)370 (85)

116 (34)116 (34)

147 (43)147 (43)

326 (94)326 (94)

<0.0001<0.0001

0.09 0.09

<0.0001<0.0001

ART KnowledgeART Knowledge n=604 n=604

PublicPublic

n=275 (%)n=275 (%)

PrivatePrivate

n=329 (%)n=329 (%)p valuep value

ART cannot cure HIVART cannot cure HIV 146 (53)146 (53) 157 (48)157 (48) 0.120.12

Traditional Healers do not Traditional Healers do not provide more effective provide more effective treatment than ARTtreatment than ART

230 (84)230 (84) 255 (78)255 (78) < 0.001< 0.001

ART does not cause side ART does not cause side effectseffects 93 (34) 93 (34) 190 (58)190 (58) < 0.001< 0.001

Must continue taking ART after Must continue taking ART after feeling betterfeeling better 225 (82)225 (82) 303 (92)303 (92) < 0.001< 0.001

Would share ART with familyWould share ART with family 62 (55)62 (55) 21 (14)21 (14) < 0.001< 0.001

Patients Taking ARTPatients Taking ART n=1,667 n=1,667

PublicPublic

n=789 (%)n=789 (%)

PrivatePrivate

n=878 (%)n=878 (%)p valuep value

Currently Taking ART (Physician)Currently Taking ART (Physician) 71 (9)71 (9) 311 (35)311 (35) <0.0001<0.0001

Currently Taking ART (Patient)Currently Taking ART (Patient)

Yes Yes

NoNo

Don’t KnowDon’t Know

86 (11)86 (11)

561 (72)561 (72)

125 (16)125 (16)

304 (35)304 (35)

269 (31)269 (31)

291 (34)291 (34)

<0.0001<0.0001

Patients not taking ART Patients not taking ART n=830n=830

PublicPublic

n=560 (%)n=560 (%)

PrivatePrivate

n=267 (%)n=267 (%)p valuep value

Reasons For Not Taking ARTReasons For Not Taking ART Cannot Afford the MedicationCannot Afford the Medication

Not aware of the MedicationsNot aware of the Medications

Doctor did not give medicationsDoctor did not give medications

Patient does not need medicationPatient does not need medication

224 (40)224 (40)

261 (47)261 (47)

157 (28)157 (28)

46 (8)46 (8)

48 (18)48 (18)

83 (31)83 (31)

106 (40)106 (40)

31 (12)31 (12)

<0.0001<0.0001

<0.0001<0.0001

<0.001<0.001

0.1160.116

Multivariate AnalysisMultivariate Analysis

CovariateCovariate Adjusted OR (95% CI)Adjusted OR (95% CI)

Private vs. Public CarePrivate vs. Public Care 4.88 (3.53 – 6.75)4.88 (3.53 – 6.75)

Had CD4 Cell CountHad CD4 Cell Count 3.69 (2.77 – 4.92)3.69 (2.77 – 4.92)

Heard of ARTHeard of ART

Yes vs. NoYes vs. No

Don’t Know vs. NoDon’t Know vs. No

2.78 (2.07 – 3.73)2.78 (2.07 – 3.73)

0.33 (0.14 – 0.79)0.33 (0.14 – 0.79)

Female GenderFemale Gender 0.73 (0.50 – 1.05)0.73 (0.50 – 1.05)

Distance from SiteDistance from Site

1 – 5 hrs vs. < 1 hr1 – 5 hrs vs. < 1 hr

> 5 hrs vs. < 1 hr> 5 hrs vs. < 1 hr

0.48 (0.34 – 0.66)0.48 (0.34 – 0.66)

0.49 (0.33 – 0.71)0.49 (0.33 – 0.71)

ConclusionsConclusions• HIV patients cared for in public health care facilities HIV patients cared for in public health care facilities

were less likely to be employed and had a were less likely to be employed and had a decreased income. decreased income.

• Knowledge and access to ART were greater for Knowledge and access to ART were greater for patients attending private clinics, but overall levels patients attending private clinics, but overall levels were low in both private and public settings.were low in both private and public settings.

• Overall Barriers to HIV care and ART use include:Overall Barriers to HIV care and ART use include:• Low awareness of ARTLow awareness of ART• Long travel times to clinic Long travel times to clinic • Financial constraintsFinancial constraints

ConclusionsConclusions

• Factors associated with ART use include:Factors associated with ART use include:• Obtaining care at a private clinicObtaining care at a private clinic• Being aware of ARTBeing aware of ART• Completed CD4 testCompleted CD4 test

• Factors associated with lack of ART use:Factors associated with lack of ART use:• Female gender (trend towards significance)Female gender (trend towards significance)• Longer travel times to health care site.Longer travel times to health care site.

LimitationsLimitations• Cross-sectional SurveyCross-sectional Survey

• Sites may not be representative of the broader Sites may not be representative of the broader population of HIV-infected individuals in Indiapopulation of HIV-infected individuals in India• Reflection of specific health-seeking HIV populations Reflection of specific health-seeking HIV populations • Selected, predominantly urban outpatient clinics in India. Selected, predominantly urban outpatient clinics in India.

• Overestimated levels of knowledge and access to ART. Overestimated levels of knowledge and access to ART.

• Some differences may have been driven by Some differences may have been driven by individual site differences. individual site differences.

ImplicationsImplications

• Further educational and programmatic Further educational and programmatic efforts are needed to improve treatment efforts are needed to improve treatment awareness and access for HIV-infected awareness and access for HIV-infected persons in both public and private settings in persons in both public and private settings in India.India.

• As India continues to develop its ART As India continues to develop its ART programs in the public domain, programs in the public domain, educational/social program development of educational/social program development of the private sector will be equally important.the private sector will be equally important.

AcknowledgmentsAcknowledgments

• We would like to acknowledge the study We would like to acknowledge the study participants and the staff at the following sites participants and the staff at the following sites for their contribution with this work:for their contribution with this work:• HHRF and ARCON, MumbaiHHRF and ARCON, Mumbai• Tambaram Sanitorium, ChennaiTambaram Sanitorium, Chennai• MY Hospital clinic, IndoreMY Hospital clinic, Indore• Sai Sudha, KakinadaSai Sudha, Kakinada• Yale University Office of Research Yale University Office of Research • Johns Hopkins Center for Clinical Global Health Johns Hopkins Center for Clinical Global Health

Education Education