The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals.
TL;DR: In this article, a cyclical cascade of care for people with HIV infection is presented, aiming to facilitate assessment of outcomes, and the authors present a cycle-based approach to the treatment of HIV infection.
Abstract: Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.
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TL;DR: This article found that migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable leve...
Abstract: Migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable leve...
10 citations
TL;DR: In this paper, the authors used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to reengagement.
Abstract: Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that individuals are likely to miss ART appointments over time. Thus, it is important to understand why individuals miss appointments and how they re-engage in HIV care. We used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to re-engagement. We found that most individuals missed ART appointments due to unexpected life events such as funerals, work, and illness for both clients and their treatment guardians who were also unable to attend facilities. Several reasons differed by gender—work-related travel was common for men, while caring for sick family members was common for women. Barriers to re-engagement included continued travel, illness, and restricted clinic schedules and/or staff shortages that led to repeat facility visits before being able to re-engage in care. Strong internal motivation combined with social support and reminders from community health workers facilitated re-engagement in HIV care.
9 citations
TL;DR: In this article , the authors report that despite falling HIV incidence, the cost effectiveness of voluntary male medical circumcision in Eastern and Southern Africa (ESA) has not yet been evaluated, and that the model usually neglect non-HIV effects of VMMC.
Abstract: Abstract Purpose of Review Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. Recent Findings Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Summary Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
3 citations
TL;DR: In this article , the authors describe existing evidence and identify future directions for intervention research related to improving HIV care outcomes for persons with HIV involved in the carceral system in the USA, a population with high unmet HIV care needs.
Abstract: To describe existing evidence and identify future directions for intervention research related to improving HIV care outcomes for persons with HIV involved in the carceral system in the USA, a population with high unmet HIV care needs. Few recent intervention studies focus on improving HIV care outcomes for this population. Successful strategies to improve care outcomes include patient navigation, substance use treatment, and incentivizing HIV care outcomes. Technology-supported interventions are underutilized in this population. Notable gaps in the existing literature include intervention research addressing HIV care needs for cisgender and transgender women and those under carceral supervision in the community. Future research should address existing gaps in the literature and respond to emergent needs including understanding how the changing HIV care delivery environment resulting from the COVID-19 pandemic and the approval of new injectable ART formulation shape HIV care outcomes in this population.
3 citations
TL;DR: In this article , the authors highlight the progress that has been made toward evolving the HIV care cascade to better represent actual experiences of people living with HIV, especially those that are most vulnerable and marginalized.
Abstract: Calls for stakeholders across the global HIV landscape to widely and systematically adopt person-centered care and patient-oriented research approaches have been made by HIV scholars, clinicians, patients, and groups such as the Joint United Nations Programme on HIV/AIDS (UNAIDS). Such calls implicitly acknowledge that the end goal of HIV care, research, and advocacy goes beyond HIV viral suppression or undetectability toward ensuring optimal health-related quality of life (HrQoL) for people living with HIV (PLWH). Indeed, global efforts have focused on keeping people alive yet have failed to ensure that they feel alive.In this brief report, we highlight the progress that has been made toward evolving the HIV care cascade to better represent actual experiences of PLWH, especially those that are most vulnerable and marginalized. We then describe what person-centered care, patient-oriented research, and HrQoL are and why they are important for our current context in HIV. We conclude by sharing 2 propositions for the global HIV community to consider moving forward.HIV care must not only focus on viral suppression but also better recognize the intersecting and multifaceted challenges faced by PLWH when taking HIV treatment and engaging in care. Evaluating HrQoL at each step of the cascade using validated patient-reported outcome and experience measures would assist in systematically tracking and addressing challenges faced by PLWH. Measures chosen through global consensus may facilitate rigorous comparisons across jurisdictions. Adopting a patient-oriented research paradigm will also be crucial for empowering and meaningfully engaging patients throughout the research process.
3 citations
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TL;DR: In this paper, a multistep, static, deterministic model was used to estimate the rate and number of HIV transmissions attributable to persons at each of the following 5 HIV care continuum steps: HIV infected but undiagnosed, HIV diagnosed but not retained in medical care, retained in care but not prescribed antiretroviral therapy, prescribed antirrhoehrgical therapy but not virally suppressed, and virally suppressing.
Abstract: Importance Human immunodeficiency virus (HIV) transmission risk is primarily dependent on behavior (sexual and injection drug use) and HIV viral load. National goals emphasize maximizing coverage along the HIV care continuum, but the effect on HIV prevention is unknown. Objectives To estimate the rate and number of HIV transmissions attributable to persons at each of the following 5 HIV care continuum steps: HIV infected but undiagnosed, HIV diagnosed but not retained in medical care, retained in care but not prescribed antiretroviral therapy, prescribed antiretroviral therapy but not virally suppressed, and virally suppressed. Design, Setting, and Participants A multistep, static, deterministic model that combined population denominator data from the National HIV Surveillance System with detailed clinical and behavioral data from the National HIV Behavioral Surveillance System and the Medical Monitoring Project to estimate the rate and number of transmissions along the care continuum. This analysis was conducted January 2013 to June 2014. The findings reflect the HIV-infected population in the United States in 2009. Main Outcomes and Measures Estimated rate and number of HIV transmissions. Results Of the estimated 1 148 200 persons living with HIV in 2009, there were 207 600 (18.1%) who were undiagnosed, 519 414 (45.2%) were aware of their infection but not retained in care, 47 453 (4.1%) were retained in care but not prescribed ART, 82 809 (7.2%) were prescribed ART but not virally suppressed, and 290 924 (25.3%) were virally suppressed. Persons who are HIV infected but undiagnosed (18.1% of the total HIV-infected population) and persons who are HIV diagnosed but not retained in medical care (45.2% of the population) were responsible for 91.5% (30.2% and 61.3%, respectively) of the estimated 45 000 HIV transmissions in 2009. Compared with persons who are HIV infected but undiagnosed (6.6 transmissions per 100 person-years), persons who were HIV diagnosed and not retained in medical care were 19.0% (5.3 transmissions per 100 person-years) less likely to transmit HIV, and persons who were virally suppressed were 94.0% (0.4 transmissions per 100 person-years) less likely to transmit HIV. Men, those who acquired HIV via male-to-male sexual contact, and persons 35 to 44 years old were responsible for the most HIV transmissions by sex, HIV acquisition risk category, and age group, respectively. Conclusions and Relevance Sequential steps along the HIV care continuum were associated with reduced HIV transmission rates. Improvements in HIV diagnosis and retention in care, as well as reductions in sexual and drug use risk behavior, primarily for persons undiagnosed and not receiving antiretroviral therapy, would have a substantial effect on HIV transmission in the United States.
474 citations
TL;DR: A large qualitative study among patients in HIV treatment programs in sub-Saharan Africa to investigate reasons for missed visits and provide an explanation for disengagement from care finds no cause for concern.
Abstract: Background: The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIVinfected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa. Methods and Findings: Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients’ subjective sense of connectedness to care. Conclusions: Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement. Please see later in the article for the Editors’ Summary.
187 citations
TL;DR: It is indicated that it is possible to achieve these goals with a significant push to achieve rapid scale-up of key interventions between now and 2020 with the estimated resources needed to achieve them in low- and middle-income countries.
Abstract: In 2011 a new Investment Framework was proposed that described how the scale-up of key HIV interventions could dramatically reduce new HIV infections and AIDS-related deaths in low and middle income countries by 2015. This framework included ambitious coverage goals for prevention and treatment services for 2015, resulting in a reduction of new HIV infections by more than half, in line with the goals of the declaration of the UN High Level Meeting in June 2011. However, the approach suggested a leveling in the number of new infections at about 1 million annually-far from the UNAIDS goal of ending AIDS by 2030. In response, UNAIDS has developed the Fast-Track approach that is intended to provide a roadmap to the actions required to achieve this goal. The Fast-Track approach is predicated on a rapid scale-up of focused, effective prevention and treatment services over the next 5 years and then maintaining a high level of programme implementation until 2030. Fast-Track aims to reduce new infections and AIDS-related deaths by 90% from 2010 to 2030 and proposes a set of biomedical, behavioral and enabling intervention targets for 2020 and 2030 to achieve that goal, including the rapid scale-up initiative for antiretroviral treatment known as 90-90-90. Compared to a counterfactual scenario of constant coverage for all services at early-2015 levels, the Fast-Track approach would avert 18 million HIV infections and 11 million deaths from 2016 to 2030 globally. This paper describes the analysis that produced these targets and the estimated resources needed to achieve them in low- and middle-income countries. It indicates that it is possible to achieve these goals with a significant push to achieve rapid scale-up of key interventions between now and 2020. The annual resources required from all sources would rise to US$7.4Bn in low-income countries, US$8.2Bn in lower middle-income countries and US$10.5Bn in upper-middle-income-countries by 2020 before declining approximately 9% by 2030.
156 citations
TL;DR: Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention, and structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.
Abstract: BACKGROUND: Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART) but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care. METHODS: We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda Tanzania and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed. RESULTS: Among 18 081 patients 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status 340 (69%) were alive and in 278 (82%) cases updated care status was obtained. Among all patients initiating ART weighted estimates incorporating tracing outcomes found that 2 years after ART 69% were in care at their original clinic 14% transferred (4% official and 10% unofficial) 6% were alive but out of care 6% died in care ( /= 60 days after last visit). Among lost patients found in care elsewhere structural barriers (eg transportation) were most prevalent (65%) followed by clinic-based (eg waiting times) (33%) and psychosocial (eg stigma) (27%). Among patients not in care elsewhere psychosocial barriers were most prevalent (76%) followed by structural (51%) and clinic based (15%). CONCLUSIONS: Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers whereas psychological and social barriers tend to result in longer-term care discontinuation. (c) The Author 2015. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions e-mail journals.permissions@oup.com.
133 citations
TL;DR: It is hypothesize that supplementing the traditional linear cascade model with patient health-seeking behaviors that allow patients who are not in pre-ART care to be initiated on ART, is essential to fully characterizing the current functioning of ART programs.
Abstract: HIV Prevention Trials Network studies are testing a number of new technologies for preventing HIV infections and reducing AIDS morbidity and mortality, but strengthening existing antiretroviral therapy (ART) programs may be among the most promising ways to generate greater health benefits using available resources. A cascade to care for HIV-positive patients has been described-HIV testing, retention in pre-ART care, treatment initiation, and sustained suppression on ART-and it has been noted that many patients are lost at each stage. We constructed a detailed representation by combining data from different sources about each stage. We found that, although currently available data were not sufficient to specify several key aspects, the traditional model of the cascade could not fully reconcile trends in HIV testing, linkage to care, retention in pre-ART care, and retention on ART with the large numbers of persons on ART and the large percentage of patients initiating treatment at late stages of infection. We hypothesize that supplementing the traditional linear cascade model with patient health-seeking behaviors that allow patients who are not in pre-ART care to be initiated on ART, is essential to fully characterizing the current functioning of ART programs. We have termed this additional channel to ART as the "side door." Understanding the relative roles of the different channels to care will be important to intervening effectively to improve the cascade to care, and we propose several new types of data that should be collected. With these insights, it may be possible to considerably strengthen the impact of ART programs.
98 citations