The Spectrum of Engagement in HIV Care and Its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection

Denver Public Health, Denver, Colorado, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 03/2011; 52(6):793-800. DOI: 10.1093/cid/ciq243
Source: PubMed


(See the editorial commentary by Lange, on pages 801–802.)

For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral
therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective
antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of
HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care
for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum
of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the
magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention.

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Available from: Carlos Del Rio, Jan 03, 2014
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    • "Unlike attempts to depict the HIV treatment cascade with a population-based sampling method (Gardner et al., 2011), we aimed to describe patterns of engagement in HIV clinical care among Internet sex-seeking MSM in Latin America. Results demonstrated that approximately one-fourth of the sample had never been tested for HIV. "
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    ABSTRACT: HIV/AIDS in Latin America is concentrated among men who have sex with men (MSM). However, accurate estimates of engagement in HIV care in this population can be difficult to ascertain because many do not self-identify as MSM. Given evidence of decreased HIV transmissibility in the context of antiretroviral therapy (ART) adherence, identifying individuals not in care who are engaging in HIV transmission risk behavior is crucial for secondary prevention. Primary aims of this study were to examine engagement in care from testing to ART adherence among MSM using online social/sexual networking across Latin America, and whether individuals not in care at each step reported greater sexual transmission risk behavior than those in care. In the overall sample (n=28,779), approximately 75% reported ever being tested for HIV, and 9% reported having received an HIV diagnosis. Among known HIV-infected individuals, 20% reported not being in care, 30% reported not taking ART, and 55% reported less than 100% ART adherence. Over one-third of HIV-infected individuals reported sexual HIV transmission risk behavior, defined as unprotected anal intercourse (UAI) with a male partner of different/unknown HIV serostatus in the past three months. HIV-infected individuals not engaged in care more often reported UAI compared to those in care (OR=1.29; 95% CI=1.01-1.66). Although not statistically significant, HIV-infected individuals not on ART more often reported UAI compared to those on ART (OR=1.18; 95% CI=0.94-1.47). Individuals who reported less than 100% ART adherence more often reported UAI compared to individuals with 100% adherence (OR=1.55; 95% CI=1.26-1.90). Findings demonstrate that a substantial portion of HIV-infected MSM in Latin America who are likely not virologically suppressed from lack of ART use or adherence report sexual HIV transmission risk. Tailoring secondary HIV prevention for MSM in Latin America who are not in HIV care or adherent to ART may be warranted.
    AIDS Care 03/2015; 27(8):1-8. DOI:10.1080/09540121.2015.1017796 · 1.60 Impact Factor
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    • "Patient engagement in care and treatment adherence is critical to achieving the full benefits of antiretroviral therapy (ART) among people living with HIV or AIDS (PLWHA). Engaging PLWHA at all points along the cascade of care is central to transforming the management of the disease from a fatal condition to a chronic one (Gardner et al. 2011). Early engagement has pronounced implications for effective disease management, including the treatment and prevention of co-morbidities, CD4 monitoring and the timely initiation of ART (Smith et al. 2013). "
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    ABSTRACT: Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.
    African Journal of AIDS Research 12/2014; 13(4):331-338. DOI:10.2989/16085906.2014.961939 · 0.79 Impact Factor
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    • "The cascade of care for HIV positive patients comprises various stages. The first is from HIV testing to staging for HIV immune status through CD4 testing and clinical examination (often referred to as ‘linkage to care’), next is the period between the staging and becoming ART-eligible, followed by initiation on ART, and finally the stage from ART initiation to retention in care [2, 18]. In this study, the focus is on the first two stages of care, that is, the stage of linkage to CD4 testing (and determining ART eligibility) and the stage of linkage to viral load testing (the latter as a proxy for initiation on ART). "
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    ABSTRACT: BackgroundWe examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care.MethodsIn a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms.ResultsThere was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p = 0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p = 0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p = 0.007).ConclusionThe PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies.Trial registrationCurrent Controlled Trials ISRCTN93692532Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-350) contains supplementary material, which is available to authorized users.
    BMC Health Services Research 08/2014; 14(1):350. DOI:10.1186/1472-6963-14-350 · 1.71 Impact Factor
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