Knowledge, Attitudes, and Practices of HIV Care and Antiretroviral Therapy Among HIV-Infected Adults Attending Private and Public Clinics in India THAB0204 Satish B Vaidya 1, Suneil R Ramchandani 2, Shruti H Mehta 3, Dattatray G Saple 4, Ved P Pandey 5, Ravi Vadrevu 6, Sikhamani Rajasekaran 7, Vandana Bhatia 8, Abhay Chowdhary 8, Robert C Bollinger 3,9, and Amita Gupta 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 India Estimated 5.2 – 5.7 million HIV-seropositive persons Estimated 5.2 – 5.7 million HIV-seropositive persons 70% of HIV infected found in high-prevalent states 70% of HIV infected found in high-prevalent states Approximately 550, ,000 Indians currently have AIDS Approximately 550, ,000 Indians currently have AIDS

Health Care in India Public Health Care Sector Public 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 Sector Private Health Care Sector 70% of Indian patients receive care in the private sector. 70% of Indian patients receive care in the private sector. Provides fee-for-service care Provides fee-for-service care Largely unregulated Largely unregulated 80% of the national health care expenditure. 80% of the national health care expenditure. Patients receiving Antiretroviral Treatment (ART) predominantly seen in private facilities. Patients receiving Antiretroviral Treatment (ART) predominantly seen in private facilities.

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

Methods: Study Design Feb 2004 – Jul 2004: Cross-sectional survey conducted at 3 public and 3 private clinics/hospitals in India Feb 2004 – Jul 2004: Cross-sectional survey conducted at 3 public and 3 private clinics/hospitals in India Mumbai Mumbai Public clinic Public clinic Private clinic Private clinic Chennai Chennai Public Hospital Public Hospital Kakinada Kakinada Private Hospital Private Hospital Indore Indore Public Hospital Public Hospital Private Clinic Private Clinic

Methods Inclusion criteria Inclusion criteria HIV-infected and knowledgeable of his/her HIV status HIV-infected and knowledgeable of his/her HIV status Seeking care at selected study site Seeking care at selected study site ≥ 18 years old ≥ 18 years old Deemed physically and mentally capable to complete the survey. Deemed physically and mentally capable to complete the survey. Survey Instrument Survey Instrument Administered by trained counselors in face-to-face interview in local language Administered by trained counselors in face-to-face interview in local language Questions included: Questions included: Sociodemographics Sociodemographics HIV clinical history (including pattern of antiretroviral exposure) HIV clinical history (including pattern of antiretroviral exposure) HIV Treatment HIV Treatment Perceptions/knowledge of ART Perceptions/knowledge of ART

Data Analysis General characteristics of participants in private vs. public were compared using chi- square tests for categorical variables and Mann-Whitney tests for continuous variables. General characteristics of participants in private vs. public were compared using chi- square tests for categorical variables and Mann-Whitney tests for continuous variables. Univariate and multiple logistic regression analysis was used to identify factors independently associated with being on antiretroviral therapy. Univariate and multiple logistic regression analysis was used to identify factors independently associated with being on antiretroviral therapy.

Characteristics of Study Population n=1,667 Public n=789 (%) Private n=878 (%) p value Male 501 (64) 645 (74) < Median age, years Married/ live-in partner 489 (62) 691 (79) < Less than high school education 508 (65) 503 (58) < Employed 488 (62) 597 (68) 0.04

Characteristics of HIV History n=1,667 Public n=789 (%) Private n=878 (%) p value Site of Diagnosis Public Hospital Public Hospital Private Clinic Private Clinic 321 (41) 458 (59) 71 (8) 801 (92) < Reason for HIV Test Referred / Symptomatic Referred / Symptomatic HIV Infected Spouse/Child HIV Infected Spouse/Child History of high-risk exposure History of high-risk exposure Pre-operative / Medical Appt. Pre-operative / Medical Appt. 439 (59) 126 (17) 107 (14) 50 (7) 587 (70) 126 (15) 21 (3) 82 (10) <0.0001

Characteristics of HIV History n=1,667 Public n=789 (%) Private n=878 (%) p value Heard of CD4 Cell Count 247 (32) 460 (53) < Heard of HIV Viral Load 99 (13) 237 (27) < Ever had CD4 Cell Count 149 (20) 374 (43) < Ever had HIV Viral Load 37 (5) 145 (17) < 0.001

Access to HIV Care n=1,667 Public n=789 (%) Private n=878 (%) p value Travel time to Primary Care Site < 1 hour < 1 hour 1 – 5 hours 1 – 5 hours > 5 hours > 5 hours 189 (24) 270 (34) 329 (42) 225 (26) 498 (57) 153 (18) < Barriers to Care Cannot Afford Loss of Wages Cannot Afford Loss of Wages Medical Care Site is too far Medical Care Site is too far Family Responsibilities Family Responsibilities 234 (54) 210 (49) 370 (85) 116 (34) 147 (43) 326 (94) < <0.0001

ART Knowledge n=604 Public n=275 (%) Private n=329 (%) p value ART cannot cure HIV 146 (53) 157 (48) 0.12 Traditional Healers do not provide more effective treatment than ART 230 (84) 255 (78) < ART does not cause side effects 93 (34) 190 (58) < Must continue taking ART after feeling better 225 (82) 303 (92) < Would share ART with family 62 (55) 21 (14) < 0.001

Patients Taking ART n=1,667 Public n=789 (%) Private n=878 (%) p value Currently Taking ART (Physician) 71 (9) 311 (35) < Currently Taking ART (Patient) Yes Yes No No Don’t Know Don’t Know 86 (11) 561 (72) 125 (16) 304 (35) 269 (31) 291 (34) <0.0001

Patients not taking ART n=830 Public n=560 (%) Private n=267 (%) p value Reasons For Not Taking ART Cannot Afford the Medication Cannot Afford the Medication Not aware of the Medications Not aware of the Medications Doctor did not give medications Doctor did not give medications Patient does not need medication Patient does not need medication 224 (40) 261 (47) 157 (28) 46 (8) 48 (18) 83 (31) 106 (40) 31 (12) <0.0001<0.0001<

Multivariate Analysis Covariate Adjusted OR (95% CI) Private vs. Public Care 4.88 (3.53 – 6.75) Had CD4 Cell Count 3.69 (2.77 – 4.92) Heard of ART Yes vs. No Yes vs. No Don’t Know vs. No Don’t Know vs. No 2.78 (2.07 – 3.73) 0.33 (0.14 – 0.79) Female Gender 0.73 (0.50 – 1.05) Distance from Site 1 – 5 hrs vs. < 1 hr > 5 hrs vs. 5 hrs vs. < 1 hr 0.48 (0.34 – 0.66) 0.49 (0.33 – 0.71)

Conclusions HIV patients cared for in public health care facilities were less likely to be employed and had a decreased income. HIV patients cared for in public health care facilities were less likely to be employed and had a decreased income. Knowledge and access to ART were greater for patients attending private clinics, but overall levels were low in both private and public settings. Knowledge and access to ART were greater for patients attending private clinics, but overall levels 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 ART Low awareness of ART Long travel times to clinic Long travel times to clinic Financial constraints Financial constraints

Conclusions Factors associated with ART use include: Factors associated with ART use include: Obtaining care at a private clinic Obtaining care at a private clinic Being aware of ART Being aware of ART Completed CD4 test Completed 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.

Limitations Cross-sectional Survey Cross-sectional Survey Sites may not be representative of the broader population of HIV-infected individuals in India Sites may not be representative of the broader population 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 individual site differences. Some differences may have been driven by individual site differences.

Implications Further educational and programmatic efforts are needed to improve treatment awareness and access for HIV-infected persons in both public and private settings in India. Further educational and programmatic efforts are needed to improve treatment awareness and access for HIV-infected persons in both public and private settings in India. As India continues to develop its ART programs in the public domain, educational/social program development of the private sector will be equally important. As India continues to develop its ART programs in the public domain, educational/social program development of the private sector will be equally important.

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