Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men

Background HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique. Methods This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI). Results Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women. Conclusion The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

Opportunities for use the cascade model of medical care for people living with HIV

The HIV cascade model can be used as an epidemiological surveillance tool and for assessing the quality of medical care for HIV-positive people. It is possible to use the model for the entire population of people living with HIV, in various socio-demographic groups, by region, years and other indicators. This article describes the features of a HIV cascade model depending on the goals for its use.

"It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada

Background There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade." Methods The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. Results Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. Conclusions We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges.

The LIVE project: A Protocol for Rapid Living Reviews of HIV Implementation Research

Background: HIV implemention research evolves rapidly and is often complex and poorly characterized, making synthesis of data on HIV implementation strategies inherently difficult. This is further compromised by prolonged data abstraction processes, restrictions on study design and delays in publication of review findings, at times resulting in outdated and irrelevant systematic reviews. The LIVE project aims to overcome some of these challenges by conducting rapid living systematic reviews and meta-analyses.Methods: The LIVE team will generate a series of systematic reviews exploring implementation strategies targeted at improving HIV cascade outcomes. We will search Embase and Medline databases for studies conducted after 2004, using predefined search terms to identify studies conducted in any age group or setting, and using implementation strategies - targeting policy makers, society, health organizations, health workers, and patients and their families - to prevent HIV, increase HIV testing, increase ART linkage and retention, and improve viral suppression rates and survival. Randomized controlled trials and observational studies will be identified through optimized searches conducted six-monthly and features of the implementation strategies and methodological quality will be assessed using recognized tools. Review teams will publish living systematic review protocols on PROSPERO. Review results will be presented on a publically facing dashboard, with review updates conducted on a six monthly basis, and publication in peer reviewed journals supporting living review processes.Discussion: Living reviews based on both pragmatic and explanatory HIV implementation research and supported by an ongoing data abstraction process will generate rapid reviews in the HIV field which are current, relevant and maximally useful to patients, health workers and policy makers.

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

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, &gt;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.

Health Worker Experiences of and Perspectives on Engaging Men in HIV Care: A Qualitative Study in Cape Town, South Africa

Men generally fare worse than women across the HIV cascade. While we know much about how men perceive the health services, we know little about how health workers (HWs) themselves have experienced engaging with men and what strategies they have used to improve this engagement. We interviewed 12 HWs in public health care services in Cape Town to better understand their experiences and perspectives. Health workers felt there were significant gaps in men’s engagement with HIV care and identified masculine gender norms, the persistent impact of HIV stigma, and the competing priorities of employment as key barriers. They also highlighted a number of health service-related challenges, including a poor perception of the patient–provider relationship, frustration at low service quality, and unrealistic expectations of the health services. Health workers also described several strategies for more effectively engaging men and for making the health services both more male friendly and more people friendly.