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

Ehrenkranz, Peter; Rosen, Sydney; Boulle, Andrew; Eaton, Jeffrey W.; Ford, Nathan; Fox, Matthew P.; Grimsrud, Anna; Rice, Brian; Sikazwe, Izukanji; Holmes, Charles B.

doi:10.1371/journal.pmed.1003651

Cited by 80 publications

(59 citation statements)

References 25 publications

(35 reference statements)

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“…In addition, this may point to the need to better understand bidirectional movements along the steps of the HCC (e.g., managing loss-to-follow-up of MLWH due to further migration). In this respect, future scholars may want to consider utilizing the HCC framework established by Kay et al, 29 which highlights these dynamic movements along the spectrum of HIV care engagement, or the revised HCC framework presented by Ehrenkranz et al, 115 which explicitly integrates the idea of disengagement and reengagement with HIV care.…”

Section: Discussionmentioning

confidence: 99%

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

Arora

Ortiz-Paredes

Engler

et al. 2021

AIDS Patient Care and STDs

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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 levels of engagement with HIV care and treatment when compared to native-born populations. A systematic mixed studies review was conducted to generate a multilevel understanding of the barriers and facilitators affecting HIV Care Cascade steps for migrant people living with HIV (MLWH) in OECD countries. Medline, Embase, Scopus, CINAHL, and the Cochrane Library were searched on March 25, 2020. Screening, critical appraisal, and analysis were conducted independently by two authors. We used qualitative content analysis and the five-level Socio-Ecological Model (i.e., individual, interpersonal, organizational, community, and policy) to categorize barriers and facilitators. Fifty-nine studies from 17 OECD countries were included. MLWH faced similar barriers and facilitators regardless of their host country, ethnic and geographic origins, or legal status. Most barriers and facilitators were associated with the individual and organizational levels and centered around retention in HIV care and treatment. Adapting clinical environments to better address MLWH's competing needs via multidisciplinary models would address retention issues across OECD countries.

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Section: Discussionmentioning

confidence: 99%

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

Arora

Ortiz-Paredes

Engler

et al. 2021

AIDS Patient Care and STDs

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“…These findings contribute knowledge critical to better understanding service delivery to enhance client-cantered care. Part of this is revising the expectation of continuous, contiguous days' use of PrEP as required in HIV treatment, programs which have also begun to appreciate the cyclical nature of engagement in HIV care, and instead embracing flexibility for PrEP services [36][37][38]. There are now multiple studies definitively showing that PrEP offered at population levels, even with imperfect use and regardless of epidemic type, will have a significant impact on reducing new infections [15,16,[39][40][41][42][43].…”

Section: Discussionmentioning

confidence: 99%

HIV PrEP is more than ART‐lite: Longitudinal study of real‐world PrEP services data identifies missing measures meaningful to HIV prevention programming

Reed¹,

Shrestha

Were³

et al. 2021

J Int AIDS Soc.

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Introduction Evidence indicates HIV oral pre‐exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non‐continuous and still effective, since HIV risk fluctuates. Real‐world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale‐up programs in Africa. Methods We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego‐supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen‐Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two‐step Heckman probit. Results Among 47,532 clients initiating PrEP, approximately half returned for follow‐up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first‐step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second‐step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on‐time (refill) versus delayed (restarting). Conclusions PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non‐continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.

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“…Widespread illiteracy levels, as well as a lack of information about HIV or awareness about services, represent other barriers that impede uptake even where services are available [65]. Ehrenkranz et al have proposed a cyclical cascade to discern more realistic pathways that clients navigate and articulate the attending barriers [5].…”

Section: Discussionmentioning

confidence: 99%

“…Health system characteristics such as lack of coordination between the multiple data sources likely contribute to the variability observed between these two estimates [4]. Additionally, a linear progression through the HIV care cascade assumed by the targets over-simplifies the actual pathways clients navigate as they engage the health system to access services [5].…”

Section: Introductionmentioning

confidence: 99%

The Shinyanga Patient: A Patient’s Journey through HIV Treatment Cascade in Rural Tanzania

Okere

Sambu²,

Ndungile³

et al. 2021

IJERPH

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The 2016–2017 Tanzania HIV Impact Survey (THIS) reported the accomplishments towards the 90-90-90 global HIV targets at 61-94-87, affirming the need to focus on the first 90 (i.e., getting 90% of people living with HIV (PLHIV) tested). We conducted a patient-pathway analysis to understand the gap observed, by assessing the alignment between where PLHIV seek healthcare and where HIV services are available in the Shinyanga region, Tanzania. We used existing and publicly available data from the National AIDS Control program, national surveys, registries, and relevant national reports. Region-wide, the majority (n = 458/722, 64%) of THIS respondents accessed their last HIV test at public sector facilities. There were 65.9%, 45.1%, and 74.1% who could also access antiretroviral therapy (ART), CD4 testing, and HIV viral load testing at the location of their last HIV test, respectively. In 2019, the viral suppression rate estimated among PLHIV on ART in the Shinyanga region was 91.5%. PLHIV access HIV testing mostly in public health facilities; our research shows that synergies can be achieved to improve access to services further down the cascade in this sector. Furthermore, effective engagement with the private sector (not-for-profit and for-profit) will help to achieve the last mile toward ending the HIV epidemic.

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

Cited by 80 publications

References 25 publications

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

HIV PrEP is more than ART‐lite: Longitudinal study of real‐world PrEP services data identifies missing measures meaningful to HIV prevention programming

The Shinyanga Patient: A Patient’s Journey through HIV Treatment Cascade in Rural Tanzania

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