Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

Herce, Michael E; Benjamin, H.; Liao, Rodrigo C.; Hoffmann, Christopher J.

doi:10.1007/s10461-019-02541-5

Cited by 25 publications

(29 citation statements)

References 61 publications

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“…Interestingly, similar to the RapIT study results, a higher proportion of men was diagnosed with HIV and initiated ART, suggesting that the offer of immediate ART may be more attractive to men than women [14]. Being in a partnership may signify access to social support in some cases, but being in an insecure partnership may amplify fears associated with HIV status disclosure, and limit ART adherence [38‐44]. Fears of HIV stigma also compel some patients to access HIV care further away to avoid being identified at a nearby clinic [45].…”

Section: Discussionmentioning

confidence: 89%

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Onoya

Hendrickson

Sineke

et al. 2021

J. Intern. AIDS Soc.

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Introduction Policies for Universal Test & Treat (UTT) and same‐day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. Methods We enrolled three cohorts of newly diagnosed HIV‐infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre‐UTT, N = 144), May‐September 2017 (UTT, N = 178) and October‐December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow‐up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow‐up (being >90 days late for the last scheduled appointment) at 12 months post‐HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. Results Overall, 410 of 580 screened HIV‐positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre‐UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre‐UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non‐marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time‐varying ART initiation status, compared to the pre‐ART period of care, the hazard of on‐ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre‐UTT (aHR 1.9, 95% CI: 1.1 to 2.9). Conclusions Overall, nearly two‐fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on‐ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long‐term attrition from care.

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Section: Discussionmentioning

confidence: 89%

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Onoya

Hendrickson

Sineke

et al. 2021

J. Intern. AIDS Soc.

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“…It is increasingly important to understand differentiated service delivery strategies and outcomes for linkage from different testing modalities as the endorsement of universal test and treat (UTT) has seen global expansion, whereby all PLWH are initiated on ART regardless of disease stage [4]. UTT gradually becoming standard of care has led to increased demand for linkage to ART, including for PLWH who are asymptomatic [5,6 ▪ ,7,8 ▪▪ ,9].…”

Section: Introductionmentioning

confidence: 99%

Reaching the second 90

Bunda¹,

Bassett

2019

Current Opinion in HIV and AIDS

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Purpose of reviewWe present recent literature describing interventions for linkage to HIV care in the era of Universal Test and Treat (UTT) policies. We also provide information for ongoing studies of linkage to care strategies registered with ClinicalTrials.gov.Recent findingsDifferentiated service delivery for linkage to care involves implementing strategies that simplify and adapt HIV services to better serve individual needs and reduce unnecessary burdens on the health system. Recent strategies have focused not only on clinic-based populations testing for HIV but also emphasize community-based services and HIV self-testing, which create different challenges for linkage to the healthcare system. Some recent developments in linkage to care strategies include: case management, care integration with other desirable health services, financial incentives, home-based, and peer-led services. The demonstrated strategies have varying levels of success and engagement in care; further work is needed to address ongoing barriers in HIV care.SummaryProgress towards meeting the 90–90–90 benchmarks has left gaps in linkage to care that require care-system development to facilitate increased access to care under UTT policies. Most notably, new strategies will need to focus on addressing the distinct needs of key populations and bolstering linkage to care from community-based and self-testing services.

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“…Although it is unclear in whom ART would have altered these outcomes, the effects of rapid and universal ART initiation may be blunted if they do not occur in tandem with sustained retention after linkage. Thus, effective strategies for rapidly cultivating meaningful engagement beyond the initial visit are needed, and metrics for early treatment success should integrate both ART initiation and early retention to be most relevant for the contemporary era [ 30 , 31 ].…”

Section: Discussionmentioning

confidence: 99%

Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis

Mody

Glidden

Eshun‐Wilson

et al. 2020

Clinical Infectious Diseases

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Background Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. Methods We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. Results In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28–41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. Conclusion Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.

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Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

Cited by 25 publications

References 61 publications

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Reaching the second 90

Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis

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