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Differentiated service delivery of treatment and laboratory services for people living with HIV in closed settings to avert treatment interruption and HIV transmission, Mizoram, India

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BACKGROUND: In 2019, Mizoram state had the highest estimated adult HIV prevalence (2.4%) and annual HIV incidence (0.94 per 1000 at risk) in India, with 21% HIV prevalence among prison inmates. People who inject drugs (PWID) are disproportionately impacted by HIV and if incarcerated or in other closed settings, PWID may have limited access to prevention and treatment services; this is the case with Mizoram's central prison and drug demand reduction centres (managed by non-profit organizations for rehabilitation of PWID).
DESCRIPTION: Delayed ART initiation, irregular clinical follow-up, non-adherence, and limited viral load (VL) testing were identified as major challenges in closed settings as a result of limited transportation between prisons and the ART centres, and limited bridge care upon prisoners' release. In November 2018, we implemented a differentiated service delivery model that included decentralized drug dispensation, VL specimen collection, and biweekly clinician visits at the closed setting facility to enhance rapid ART initiation, annual VL testing, and post discharge follow-up (continuation of care).
LESSONS LEARNED: During November 2018- December 2021, we served 1,013 PLHIV in closed settings. The majority of those served were males (840, 83.1%), 26-36 years (486, 48.2%), and with a substance-use disorder (795, 78.1%). By the end of 2021, 416 (41.1%) PLHIV were still retained in the closed setting; 4 (0.4%) died and 593 (58.5%) were referred to ART centres for post-release follow up. Among the 416 who stayed in the closed settings, 89.7% (373) were due for VL testing; 64.2% (239) received a VL test in the last 12 months, and 93.2% of those tested 222were virally suppressed. Among the 593 released from closed settings, 81.1% (480) were retained in ART care in the community.
CONCLUSIONS: Differentiated service delivery models are essential to decrease treatment interruption for PLHIV in closed settings and to ensure retention in care. We experienced some challenges post-discharge for 8% of patients due to COVID-19 when VL testing was disrupted. Despite this, decentralization of clinical and laboratory services with a coordinated post-release plan was key for higher rates of treatment engagement and VL testing access, leading to ongoing treatment engagement and high VL suppression.