Integrating HIV services and other health services: A systematic review and meta-analysis

Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

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Effect of Female Sex Work Targeted Community-based Interventions Along the HIV Treatment Cascade in Sub-Saharan Africa: A Systematic Review and Meta-analysis

10.21203/rs.3.rs-112779/v1 ◽

2020 ◽

Author(s):

Lydia Atuhaire ◽

Olatunji Adetokunboh ◽

Constance Shumba ◽

Peter S Nyasulu

Keyword(s):

Hiv Testing ◽

Meta Analysis ◽

Hiv Care ◽

Hiv Diagnosis ◽

Community Based Interventions ◽

Community Based ◽

Hiv Services ◽

Hiv Care Cascade ◽

Care Cascade ◽

Sub Saharan

Abstract Background: Female Sex Workers are extremely vulnerable and highly susceptibility to being infected with human immunodeficiency virus. As a result, community based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. However little is known about the specific community intervention packages that have optimal effect on FSWs access and retention in HIV care. This paper synthesized evidence on the effectiveness of community-based interventions that provided HIV services to FSWs across all stages of HIV care cascade.Methods: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely HIV testing, HIV diagnosis, linkage to care, ART use and viral suppression. We conducted a systematic search of randomized controlled trials, cohort and cross sectional studies done in sub-Saharan African countries and published from 2004 to 2020. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible and for the rest of the studies, data were synthesized using summary statistics. Results: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.Conclusions: The effect of community-based interventions varies across the different stages of HIV care cascade with impact observed in specific strategies with features unique to each cascade stage. Moreover, positive effects of these strategies were short term and with small-scale implementation. As such, the information on long-term treatment outcomes, and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.Systematic review registration: PROSPERO CRD42020157623.

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

Frontiers in Public Health ◽

10.3389/fpubh.2019.00406 ◽

2020 ◽

Vol 7 ◽

Author(s):

Richelle Harklerode ◽

Jim Todd ◽

Mariken de Wit ◽

James Beard ◽

Mark Urassa ◽

...

Keyword(s):

Hiv Testing ◽

Hiv Care ◽

Hiv Care Cascade ◽

Care Cascade

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Impact of Traditional Healers on the HIV Care Cascade in Senegal, West Africa: A Longitudinal Study

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.21-0280 ◽

2021 ◽

Author(s):

Noelle A. Benzekri ◽

Jacques F. Sambou ◽

Sanou Ndong ◽

Mouhamadou Baïla Diallo ◽

Ibrahima Tito Tamba ◽

...

Keyword(s):

Longitudinal Study ◽

Traditional Healers ◽

Cd4 Count ◽

Sub Saharan Africa ◽

Hiv Care ◽

People Living With Hiv ◽

Hiv Care Cascade ◽

Art Initiation ◽

Care Cascade ◽

Prospective Longitudinal

Consultation with traditional healers (THs) is common among people living with HIV in sub-Saharan Africa. We conducted a prospective longitudinal study to determine the association between consultation with THs and HIV outcomes following 12 months of antiretroviral therapy (ART). HIV-infected individuals presenting for care and initiation of ART in Dakar and Ziguinchor, Senegal were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart reviews at enrollment, 6 months after ART initiation, and 12 months after ART initiation. Among the 186 participants, 35.5% consulted a TH. The most common reason for consulting a TH was “mystical” concerns (18%). Those who consulted a TH before ART initiation were more likely to present with a CD4 count < 200 cells/mm3 (44% versus 28%; P = 0.04) and WHO stage 3 or 4 disease (64% versus 46%; P = 0.03), and they were less likely to disclose their HIV status (44% versus 65%; P = 0.04). Those who consulted a TH more than 6 months after ART initiation were more likely to report poor adherence to ART (57% versus 4%; P < 0.01). The strongest predictor of virologic failure was consulting a TH more than 6 months after ART initiation (odd ratio [OR], 7.43; 95% CI, 1.22–45.24). The strongest predictors of mortality were consulting a TH before ART initiation (OR, 3.53; 95% CI, 1.25–9.94) and baseline CD4 count < 200 cells/mm3 (OR, 3.15; 95% CI, 1.12–8.89). Our findings reveal multiple opportunities to strengthen the HIV care cascade through partnerships between THs and biomedical providers. Future studies to evaluate the impact of these strategies on HIV outcomes are warranted.

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Associations between alcohol use and HIV care cascade outcomes among adults undergoing population-based HIV testing in East Africa

AIDS ◽

10.1097/qad.0000000000002427 ◽

2020 ◽

Vol 34 (3) ◽

pp. 405-413 ◽

Cited By ~ 1

Author(s):

Sarah B. Puryear ◽

Laura B. Balzer ◽

James Ayieko ◽

Dalsone Kwarisiima ◽

Judith A. Hahn ◽

...

Keyword(s):

Alcohol Use ◽

Hiv Testing ◽

East Africa ◽

Population Based ◽

Hiv Care ◽

Hiv Care Cascade ◽

Care Cascade

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The Benefits of Immediate ART

Journal of the International Association of Providers of AIDS Care (JIAPAC) ◽

10.1177/2325958219831714 ◽

2019 ◽

Vol 18 ◽

pp. 232595821983171 ◽

Cited By ~ 2

Author(s):

Yan Zhao ◽

Jennifer M. McGoogan ◽

Zunyou Wu

Keyword(s):

World Health ◽

Hiv Care ◽

Hiv Diagnosis ◽

Hiv Care Cascade ◽

Art Initiation ◽

Care Cascade ◽

Nations Programme ◽

United Nations Programme ◽

Health Organization ◽

Treat All

The benefits of “early” antiretroviral therapy (ART; ie, initiation when CD4 ≥500 cells/mm3) are now well accepted as reflected in the removal of the CD4-based eligibility from new ART guidelines by the World Health Organization (WHO). However, neither the “treat-all” strategy recommendations presented in the guidelines nor the HIV care cascade goals in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets adequately address the issue of ART timing. Our recent study on “immediate” ART (ie, ≤30 days after HIV diagnosis) adds important evidence demonstrating the real and meaningful benefits of rapid ART initiation even among those who have CD4 ≥500 cells/mm3. We call on WHO and UNAIDS to consider this research and encourage a shift from the treat-all strategy to an “immediately-treat-all” strategy, and from a slow, fragmented, complicated, multistep HIV care cascade to a fast, easy, and simple cascade with effectiveness measures that incorporate the important aspect of time.

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Differences between migrants and Spanish-born population through the HIV care cascade, Catalonia: an analysis using multiple data sources

Epidemiology and Infection ◽

10.1017/s0950268817000437 ◽

2017 ◽

Vol 145 (8) ◽

pp. 1670-1681 ◽

Cited By ~ 11

Author(s):

J. REYES-URUEÑA ◽

C. CAMPBELL ◽

C. HERNANDO ◽

N. VIVES ◽

C. FOLCH ◽

...

Keyword(s):

At Risk ◽

Hiv Testing ◽

Sub Saharan Africa ◽

Retention Rates ◽

Hiv Care ◽

Hiv Care Cascade ◽

Care Cascade ◽

Barriers To Access ◽

Hiv Testing Services ◽

Shared Risk

SUMMARYMigrants are considered a key group at risk for HIV infection. This study describes differences between migrants and the Spanish-born population as they progress through the HIV care cascade in Catalonia, Spain. This study found that among people reached by prevention activities, migrants had a higher number of barriers to access HIV testing services than Spanish-born people, driven primarily by shared risk factors. Between 2001 and 2013, 9829 new HIV diagnoses were reported in Catalonia, the proportion of migrants increasing from 24% in 2001 to 41% in 2013. Compared with Spanish-born people, migrants had a higher proportion of women at diagnosis (24·6% vs. 16·7%), and were younger (median age of 33 vs. 37). The most frequent at-risk population was MSM (men who have sex with men) in both migrants and Spanish-born people, (40% and 43%, respectively), although there were significant differences by region of origin. People from sub-Saharan Africa had the highest proportion of late diagnosis (63·7%). Compared with the Spanish-born population, migrants on follow-up had a lower proportion of people on antiretroviral therapy (ART) (93·7% vs. 90·8%, P < 0·001) and with viral suppression (87·2% vs. 82·9%, P < 0·001). Migrants have higher number of barriers to access HIV testing services, lower retention rates and proportions on ART as compared with Spanish-born people, these differences not being uniform between migrants from different regions.

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HIV care cascade among cisgender men who have sex with men in a key population-led community center in the Philippines

International Journal of STD & AIDS ◽

10.1177/0956462420987435 ◽

2021 ◽

pp. 095646242098743

Author(s):

Patrick C Eustaquio ◽

Steffen S Docken ◽

Katerina T Leyritana ◽

Luh Putu Lila Wulandari

Keyword(s):

The Philippines ◽

Hiv Care ◽

Sexually Transmitted ◽

Effective Strategies ◽

Hiv Care Cascade ◽

Art Initiation ◽

Care Cascade ◽

Key Population ◽

Hiv Test ◽

Sex With Men

The HIV epidemic in the Philippines is the fastest growing globally, and disproportionately affects cisgender men who have sex with men (cis-MSM) demanding effective strategies for this key population (KP) group. KP-specific and community-based (CB) interventions have improved the HIV response elsewhere, but these have yet to be evaluated locally. We analyzed the HIV care cascade outcomes in a KP-led, CB HIV test-and-treat center and determined factors that affect these by performing a retrospective study of medical records of 3137 patients diagnosed from January 2016 to March 2019 in LoveYourself in Manila, Philippines. Multivariate logistic regression was performed to determine predictors affecting the likelihood of antiretroviral therapy (ART) initiation and viral load (VL) suppression. As to UNAIDS 90–90–90 targets, LoveYourself had higher rates than national outcomes with 78% initiated ART and 84% achieved VL suppression. Such satisfactory performance is consistent with other studies exploring CB, KP-led approaches among cis-MSM. Patients who presented with WHO Stages 2–4 and those with sexually transmitted infections were less likely to initiate ART. Patients who presented with WHO Stages 2–4 and those whose ART was started late were less likely to be virally suppressed. These findings suggest the need to develop responsive interventions to reach the UNAIDS targets.

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District-level strategies to control the HIV epidemic in Zimbabwe: a practical example of precision public health

10.21203/rs.2.22644/v4 ◽

2020 ◽

Author(s):

Richard Makurumidze ◽

Tom Decroo ◽

Lutgarde Lynen ◽

Zororo Kudzaishe Chinwadzimba ◽

Wim Van Damme ◽

...

Keyword(s):

Hiv Testing ◽

Cross Sectional Study ◽

District Level ◽

Hiv Care ◽

Cross Sectional ◽

Hiv Care Cascade ◽

Hiv Epidemic ◽

Care Cascade ◽

Remediation Strategies ◽

Level Performance

Abstract Objective We conducted a descriptive cross-sectional study using survey and programme data to assess district-level performance along the HIV care cascade (HIV testing target achievement, linkage to ART and ART coverage) in order to formulate district-specific recommendations, taking into consideration prevalence and yield of testing. Results Data from 60 districts were analysed. Forty-eight districts (80.0%) surpassed 90% of their 2018 HIV testing targets. Linkage to ART was less than 90% in 40 districts (83.3%). Thirty districts (50.0%) had ART coverage above 90%. Of the 30 districts with suboptimal (<90%) ART coverage, 18 districts had achieved high HIV testing target but with suboptimal linkage to ART, 6 had achieved high HIV testing targets and high linkage to ART, 4 had both suboptimal HIV testing target achievement and linkage to ART and 2 had suboptimal HIV testing target achievement and high linkage to ART. Priority should be given to districts with suboptimal ART coverage. Remediation strategies should be tailored to address the poorly performing stage of the cascade in each of the districts.

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District-level strategies to control the HIV epidemic in Zimbabwe: a practical example of precision public health.

10.21203/rs.2.22644/v2 ◽

2020 ◽

Author(s):

Richard Makurumidze ◽

Tom Decroo ◽

Lutgarde Lynen ◽

Zororo Kudzaishe Chinwadzimba ◽

Wim Van Damme ◽

...

Keyword(s):

Hiv Testing ◽

Cross Sectional Study ◽

District Level ◽

Hiv Care ◽

Cross Sectional ◽

Hiv Care Cascade ◽

Hiv Epidemic ◽

Care Cascade ◽

Remediation Strategies ◽

Level Performance

Abstract Objective We conducted a descriptive cross-sectional study using survey and programme data to asses district-level performance along the HIV care cascade (HIV testing target achievement, linkage to ART, ART coverage) in order to formulate district-specific recommendations, taking into consideration prevalence and yield of testing.Results Data from 60 districts were analysed. Most 48 (80.0%) of districts surpassed 90% of their 2018 HIV testing targets. Linkage to ART was less than 90% in 40 (83.3%) of districts. Half (30) of districts had an ART coverage above 90%. Of 30 districts with suboptimal(<90%) ART coverage, 18 had achieved high HIV testing target achievement but suboptimal linkage to ART, 6 had achieved high HIV testing targets and high linkage to ART, 4 had both suboptimal HIV testing target achievement and linkage to ART and 2 had suboptimal HIV testing target achievement and high linkage to ART. Priority should be given to districts with suboptimal ART coverage. Remediation strategies should be tailored to address the poorly performing stage of the cascade in each district.

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

Clinical Infectious Diseases ◽

10.1093/cid/ciaa268 ◽

2020 ◽

Vol 71 (10) ◽

pp. e561-e570

Author(s):

Aaloke Mody ◽

David V Glidden ◽

Ingrid Eshun-Wilson ◽

Kombatende Sikombe ◽

Sandra Simbeza ◽

...

Keyword(s):

Antiretroviral Therapy ◽

Retention In Care ◽

Hiv Care ◽

Hiv Care Cascade ◽

Art Initiation ◽

Care Cascade ◽

Hiv Cascade ◽

Care Outcomes ◽

Analytical Approaches ◽

Over Time

Abstract 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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