Improving linkage to pre-antiretroviral therapy care and antiretroviral therapy initiation

Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review.

Govindasamy D, Meghij J, Kebede Negussi E, Clare Baggaley R, Ford N, Kranzer K. J Int AIDS Soc. 2014 Aug 1;17(1):19032. doi: 10.7448/IAS.17.1.19032. eCollection 2014.

Introduction: Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.

Methods: An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.

Results: A total of 11 129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.

Conclusions: Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. Results from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.

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Editor’s notes: To maximise the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed as early as possible, after acquiring HIV infection. They should be enrolled and retained in pre-ART care, initiated on ART and retained in ART care. And at the same time ensuring long-term adherence to achieve and maintain viral load suppression.

This review focuses on the first few steps in the treatment cascade. The authors review the evidence for activities that enhance the linkage from HIV testing to pre-ART care, retain people in pre-ART care and enhance the linkage to ART initiation. Streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives appear to decrease attrition between HIV testing and ART initiation. However, the authors point out that most of the included studies looked at the effect of a single activity on a single point, in the continuum of care. There is a gap in evidence of the effect of combined activities and programmes across the continuum of care.

With the clear trend towards the earliest possible initiation of ART, the pre-ART care period will become much shorter. However there will be need for activities to improve immediate linkage from a positive test result, to ART initiation and ART care.

Health care delivery
Africa, Asia
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