Challenges in the Evaluation of Interventions to Improve Engagement Along the HIV Care Continuum in the United States: A Systematic Review

Abstract

In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. ‘Linkage’ studies utilized 11 different outcome definitions, while ‘retention’ studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework.

Recent mobile health interventions to support medication adherence among HIV-positive MSM

“…Societal stigma and discrimination within health care systems impede access to quality HIV care for MSM and influence adherence and viral suppression [15–17]. Many MSM manage multiple adherence barriers (e.g.…”

“…mental health, unstable housing) [16, 18, 19], with each factor increasing the chances of having a detectable viral load [16, 20**]. Despite clear need, few ART adherence interventions have focused explicitly on MSM [21*, 22]. Among 117 US-based ART adherence interventions published between 2007 and 2015, only two focused on MSM [21*].…”

“…Despite clear need, few ART adherence interventions have focused explicitly on MSM [21*, 22]. Among 117 US-based ART adherence interventions published between 2007 and 2015, only two focused on MSM [21*]. …”

Short-term effectiveness of HIV care coordination among persons with recent HIV diagnosis or history of poor HIV outcomes

“…Case management interventions vary significantly in design and target population, making cross-study comparisons difficult. [ 19 ] Randomized trials of case management interventions have not evaluated VLS outcomes; however trial data suggest that case management (versus usual care) improves a) linkage to care among newly diagnosed PLWH and among PLWH who are leaving prison and b) retention in HIV medical care for PLWH with a history of inconsistent HIV care attendance [ 17 , 20 , 21 ]. To a degree our results align with and extend these findings; among PLWH who need linkage assistance and/or have been unable to achieve suppression at all during the past year, case management under this care coordination model is more effective than usual care at achieving VLS.…”

What Will It Take to Reduce HIV Incidence in the United States: A Mathematical Modeling Analysis

“…Our proposed quality metric for HIV programs of retaining at least 95% of individuals in care on an annual basis will require dedicated effort in the United States. Current estimates of annual rates of retention in HIV care in the United States are heterogeneous and sparse, and defining retention in care has been difficult, with no consensus definition [ 12 , 14–16 ]. Current literature reviews estimate that current rates of retention in care range from 45% to 70% per year, although retention has mostly been evaluated in cross-sectional analyses and has not yet been fully studied longitudinally [ 3 , 12 , 14 , 17–20 ].…”