Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind

Abstract

Purpose of Review Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. Recent Findings There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. Summary There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

“…A third program may identify missed clinic visits during the first six months after initiation (Stage 3) as the critical predictor of disengagement; these latter programs could then focus on how to optimize early retention for PLHIV with the characteristics of those most likely to drop out in Stage 3. Further, this new cascade may help motivate the design of interventions beyond those currently included in WHO guidelines ( Table 2 ) [ 37 ] or described in the published literature [ 5 ] as new population needs are identified.…”

“…Facilities that serve large numbers of migrant workers, for example, are likely to see very different patterns of disengagement and reengagement than those that serve more settled populations. It will thus be incumbent on researchers and program evaluators to understand and note the local characteristics of PLHIV behavior and tailor recommendations according to best practices, many of which were defined in a recent review [ 5 ].…”

“…Being "disengaged" or "engaged" is not a final state: It is an interval within the lifetime of a recipient of care. A cascade that documents actual PLHIV behavior-the cycle of engaging and reengaging in care-would inform and prioritize efforts intended to prevent missed clinic visits, overcome barriers to reentry, and minimize onset of advanced HIV disease [5,[23][24][25].…”

“…To understand why countries continue to fall short of achieving the 95-95-95 targets, one must understand the frequency and circumstances within which people enter and leave HIV care. While PLHIV continue to disengage from care between HIV diagnosis and ART initiation [ 4 ], the recent push for rapid, including same-day, ART initiation, which essentially eliminates losses from care before ART initiation, is leading to a shift of interruptions in care to a point further down the cascade [ 5 ]. This effect becomes even more pronounced during periods of major service disruption through conflict, natural disaster, or epidemics [ 6 ].…”

Ethics of HIV cure research: an unfinished agenda

“…Given the importance placed by many PLWH on becoming and remaining undetectable for HIV so that they do not transmit HIV to partners [ 80 – 82 ], understanding the ethical challenges related to mitigating risks during ATIs is of paramount importance [ 83 ]. Determining appropriate risk mitigation strategies will further require effective stakeholder engagement in local contexts [ 84 – 86 ]. Developing self-administered point of care rapid tests to detect and measure viral rebound with clearly delineated ART restart criteria would also help to mitigate risks to participants and the risk of onward HIV transmission during ATIs.…”