Optimization of the HIV care cascade in rural Uganda and Kenya
Abstract
By 2017, an estimated 36.9 million (31.1million - 43.9 million) people globally were living with HIV. The HIV epidemic remains uncontrolled with 1.8 million people reported to have been newly infected in the same year, and 940,000(670,000-1.300,000) dying from AIDS-related illnesses globally. The therapeutic and preventive benefits of ART highlight the importance and urgency to identify all people living with HIV (PLWH), link them to care, initiate them on ART, attain and maintain viral suppression among them. The progress towards achieving this has been evaluated using the care cascade, which unfortunately demonstrates massive drop-offs along the cascade in almost all care settings. To achieve the goals of the WHO test and treat strategy, each step of the cascade must be optimized. The losses from the cascade in the test-and-treat era need therefore to be quantified, the steps suffering the largest dropouts identified, the reasons for these dropouts analysed, and novel interventions designed.
The thesis explores the barriers to care engagement along the HIV care cascade and evaluates the effectiveness of a streamlined patient-centered care model in addressing the barriers along the cascade within the context of an ongoing test and treat trial called SEARCH (Sustainable East African Research for Community Health) conducted in rural Uganda and Kenya. A qualitative analysis conducted among the study communities identified multiple barriers along the cascade with stigma in its different manifestations (anticipated, internalized and enacted) appearing as a major barrier across multiple steps of care engagement. Other barriers identified were behavioral (treatment fatigue, forgetting to take medications), structural (distance to clinics, poverty), health system (poor health provider attitudes, patient-unfriendly clinic set-up), social (work interference, lack of social support), and drug related (drug side effects, pill burden). A combination intervention strategy with multiple interventions targeting different barriers and different phases on the cascade simultaneously to improve outcomes among PLWH was identified as the optimal approach to improve the care cascade. We thus designed and applied a streamlined patient-centered multi-component strategy to improve patient outcomes along the care cascade. The strategy achieved 73% linkage among individuals not engaged in care, 96% retention among all patients in care at 12 months and 80% population-wide viral suppression at year two.
The streamlined patient-centered care model improved outcomes along all components of the HIV care cascade. However, the cascade still has leakages. Innovative, targeted interventions to seal the leaks need to be developed to help end the HIV epidemic.