This detailed comparison of the characteristics and behaviours of patients in different healthcare systems in HIV care in India gives us new insights into healthcare outcomes in relation to healthcare settings. We have found that despite having lower income and higher healthcare barriers such as prolonged clinic waiting times, patients in the public health care facility had significantly better adherence levels, higher viral suppression rates and lower drug resistance prevalence compared to patients accessing care in the private facility, suggesting superior treatment outcomes among patients in the public healthcare setting.
Previous analysis of the entire cohort of 552 participants at baseline demonstrated a strong association between suboptimal adherence, treatment failure and drug resistance . Adherence to ART is influenced by numerous factors, including state of health, travel or migration, adverse effects, stigmatization and financial constraints. Cost of ART has been identified as a barrier of adherence in several studies; in a study from Botswana, adherence was predicted to increase by 20% if cost were removed as a barrier . Among 150 subjects recruited in Tanzania poor adherence and virological failure appeared to be strongly correlated to self-funded ART . Cost of ART was found to be a significant correlate of self-reported adherence among patients attending private clinics in Mumbai , and was an important barrier of adherence discussed among a large majority of patients interviewed in Chennai . In the ART in Lower Income Countries study (ART-LINC), a strong relationship was found between receipt of ART and survival, with the greatest survival benefit being when ART was administered free of cost to patients in resource-limited areas . It is conceivable that the removal of cost as an adherence barrier among patients in the public and public-private healthcare systems has a strong role in the adherence and treatment outcomes seen in our study.
The value of an educational and counselling intervention in improving adherence has been well recognized . A Cochrane review concluded that patient support and educational interventions particularly those targeting coping skills, that are administered over the ART initiation period were indeed associated with improved adherence outcomes . Thus the system practised in the public and public-private settings where counselling is an integral part of HIV care is likely to have influenced the higher adherence rates noted in these settings. Although medical providers in private settings do offer adherence support, the lack of a standard counselling protocol often results in a wide range in the quality and impact of counselling support in private clinics.
The past decade has witnessed a massive scale-up of antiretroviral programs in Asia, particularly India. Today, there are 2.3 million persons in India living with HIV, equivalent to approximately 0.3 percent of the adult population, which is a 67% reduction from early prevalence reports in 2005-2006 . India is a large, diverse country with complex social issues which is a challenge to any national medical program. However the country has a well- articulated national strategy which is described in the National AIDS Control Program III (NACP III)  and is anchored in the principles of health promotion efforts while seeking to integrate prevention with care, support and treatment. The Program hence utilizes public, nongovernmental and private health institutions to carry out its functions of prevention, care and treatment. The supply chain management of anti-retroviral drugs is managed through a separate team that is responsible for maintaining a continuous supply of ARV drugs. Clearly articulated operational guidelines for ART centers lay the framework for the standard of care that is provided at these centers . Counseling for the patient is emphasized at every stage; from the initial health seeking visit, to diagnosis and evaluation of clinical stage, to initiation and maintenance on ART. ART centers are also linked to community care centres which are set up within the non-governmental organization (NGO) sector with the main objective of providing psycho-social support, ensuring drug adherence and providing home-based care . National data indicate that among all patients who have been initiated on ART so far, 11% have died, 0.65% have discontinued treatment, and only 9% patients are missing or lost-to-followup . Similar results were seen in a systematic study conducted at 3 government ART centers in India .
In order to widen their reach towards people from different socio-economic backgrounds, NACO has established several public-private partnerships in NGOs and private medical colleges structured such that both the government and the private institution have an equal role in maintaining the quality of care offered at these centres. It is increasingly believed that under such partnerships, public and private sectors can play innovative roles in financing and providing health care services, particularly in India [25–27]. In the public-private ART center model, the entire systems of counselling, encouragement of treatment supporters during the initial visits during the start of ART, multidisciplinary teamwork and patient flow, are maintained in a similar manner comparable to the system established within the public centers. Our data clearly show that health outcome as measured by adherence levels and virological suppression was clearly optimal in the public-private facility compared to the fully private setting.
Cost of antiretroviral drugs has been implicated as a major factor influencing adherence, although the literature is divided on this issue . An Indian study of HIV-infected patients from Pune and Delhi has shown that adherence was higher among patients paying out-of-pocket compared to those who were receiving free ART via an employee-insurance program; the investigators concluded that provision of free ART without adequate counselling and adherence support was likely to weaken treatment success . Our study also underscores the critical role played by the standardized national system of ensuring counselling and treatment support that is in-built into the ART clinics across the country.
There are several limitations with this study. The numbers studied were relatively small, and the patient numbers were dissimilar in the different settings. The public-private facility was newly begun and was reflected in the short duration of ART that the participants from this setting experienced. The relative youth of the center may have unduly influenced the lower proportion of those with detectable viral load although factors such as systematic counselling and better adherence may have also influenced the outcome. In addition, the private and public-private settings were located within the same institution, although it is important to note here that there was no overlap of patients or medical care providers, and the two settings were geographically separate in different locations. In contrast, the presence of both settings within the same institution may be seen as an advantage; the single geographical location may have minimized the heterogeneity of patients and lent more significance to the positive outcome noted in the public-private facility. It is also possible that these results may be indicative of the individual center and not the public-private or private category on the whole as only one such center each was included in the study. However the relative homogeneity of the organizational capacity of the public centers is assured by the National AIDS Control Program guidelines [21, 22], and it is likely that the public-private and private centers included in the study are also representative of other similar settings in the country. Additional research would be necessary to see if these findings can be replicated in other settings. It is noteworthy that since this is a cross-sectional study, no conclusions can be drawn regarding cause and effect. These limitations notwithstanding, the results of this study are strongly suggestive of the larger benefit of including strict standardized counselling guidelines and establishing a multi-faceted paradigm of medical care that is prevalent in the public and public-private HIV care facilities established under the National AIDS Control Program in India.