The cascade of care following community-based detection of HIV in sub-Saharan Africa – A systematic review with 90-90-90 targets in sight

Abstract

IntroductionWe aimed to establish how effective community-based HIV testing services (HTS), including home and community location based (non-health facility) HIV testing services (HB-/CLB-HTS), are in improving care in sub-Saharan Africa (SSA), with a view to achieving the 90-90-90 targets.MethodsWe conducted a systematic review of published literature from 2007–17 which reported on the proportion of individuals who link-to-care and/or initiate ART after detection with HIV through community-based testing. A meta-analysis was deemed inappropriate due to heterogeneity in reporting.Results and discussionTwenty-five care cascades from 6 SSA countries were examined in the final review– 15 HB-HTS, 8 CLB-HTS, 2 combined HB-/CLB-HTS. Proportions linked-to-care over 1–12 months ranged from 14–96% for HB-HTS and 10–79% for CLB-HTS, with most studies reporting outcomes over short periods (3 months). Fewer studies reported ART-related outcomes following community-based testing and most of these studies included <50 HIV-positive individuals. Proportions initiating ART ranged from 23–93%. One study reported retention on ART (76% 6 months after initiation). Viral suppression 3–12 months following ART initiation was 77–85% in three studies which reported this.There was variability in definitions of outcomes, numerators/denominators and observation periods. Outcomes varied between studies even for similar time-points since HTS. The methodological inconsistencies hamper comparisons. Previously diagnosed individuals appear more likely to link-to-care than those who reported being newly-diagnosed. It appears that individuals diagnosed in the community need time before they are ready to link-to-care/initiate ART. Point-of-care (POC) CD4-counts at the time of HTS did not achieve higher proportions linking-to-care or initiating ART. Similarly, follow-up visits to HIV-positive individuals did not appear to enhance linkage to care overall.ConclusionThis systematic review summarises the available data on linkage to care/ART initiation following community-based detection of HIV, to help researchers and policy makers evaluate findings. The available evidence suggests that different approaches to community-based HTS including HB-HTS and CLB-HTS, are equally effective in achieving linkage to care and ART initiation among those detected. Engagement and support for newly diagnosed individuals may be key to achieving all three UNAIDS 90-90-90 targets. We also recommend that standardised measures of reporting of steps on the cascade of care are needed, to measure progress against targets and compare across settings.

Diagnostic applications for Lassa fever in limited-resource settings

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Increased prevalence of hypertension among people living with HIV: where to begin?

“…The “cascade of care” concept aids in portraying and analyzing patient behavior regarding the diagnosis, treatment, retention steps, and achievement of predefined goals in HIV care, especially achieving UNAIDS 90-90-90 targets by 2020. The UNAIDS 90-90-90 targets are as follows: to diagnose 90% of all PLHIV worldwide, provide antiretroviral therapy to 90% of those diagnosed, and achieve viral load suppression in 90% of those treated 13 . However, room for improvement in each stage exists.…”

Characterizing a Leak in the HIV Care Cascade: Assessing Linkage Between HIV Testing and Care in Tanzania

“…Linkage to care rates vary throughout sub-Saharan Africa. In Kenya, 88% of adults linked to care within three months (20); a field assessment in Mozambique showed 67% linked to care (21); a retrospective cohort study in Cape Town, South Africa identified linkage to care as 63% (22); in Lesotho, a study found linkage to care at a facility to be 43% versus 69% if ART was initiated at home (23); and a systematic review showed linkage to care of newly diagnosed with HIV in sub-Saharan Africa ranged from 10-79% (24). As the expanded referral form includes location information it will be possible for facilities to intervene to locate and engage with persons not immediately linking to care; this important intervention was not assessed during the pilot.…”