The journey to antiretroviral therapy in Karnataka, India: who was lost on the road?

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.