Date Published: April 11, 2017
Publisher: Public Library of Science
Author(s): Matthew P. Fox, Sydney Rosen
Abstract: Matthew Fox and Sydney Rosen discuss a cascade of HIV care adapted to WHO-recommended antiretroviral therapy irrespective of CD4 cell count.
Partial Text: Over the past decade, the concept of the “cascade of care” has become a standard way of describing and analyzing patient behavior in the interval between an HIV diagnosis and long-term retention on antiretroviral therapy (ART) [1,2]. Care cascade research has helped quantify losses of patients from care, identify the points of greatest attrition, and target interventions to addresses losses [2,3].
We previously divided pre-ART care into three stages (S1 Fig). Others have presented variations on this pre-ART model, often including a fourth stage for retention on ART. As noted, attrition is high at every stage; Box 1 summarizes existing estimates. The new WHO guidelines have implications for each stage of care.
As this discussion suggests, a new model will be needed to capture the delivery of HIV care and treatment under a “treat all” policy. In Fig 1, we present a new cascade, with the aim of more effectively monitoring the outcomes as guidelines evolve. This cascade, as in previous cascades, begins after patients are diagnosed with HIV. HIV testing could certainly be added as the starting point, however, as some have suggested . As the cascade is meant to capture patient care-seeking behavior and not the results of treatment, it also does not explicitly include adherence, viral suppression, or mortality (either on or off treatment). These could be added as subcategories when the cascade is used for specific purposes. This new cascade diverges from S1 Fig in three ways. First, we have eliminated the previous Stage 2 so that the pre-ART period now has only two stages: HIV testing to linkage to care (Stage 1) and linkage to care to ART initiation (Stage 2). Second, to reflect the differences in retention on ART between the first and later years, we have divided the previous Stage 4 into two new stages: Stage 3 for early retention and Stage 4 for later lifelong retention. Finally, determination of treatment eligibility, previously included in Stage 1 and as the transition from Stage 2 to Stage 3, is no longer required under a “treat all” policy. In the new cascade, we define linkage to care (or enrollment in care) as the point at which an HIV-infected individual is recorded as making a first visit to a health care facility or other ART provider. In the new cascade, all patients completing Stage 1 immediately enter Stage 2. The challenge for health care providers will be to make this transition as seamless in practice as it appears in the illustration. WHO recommends differentiated care (i.e., care delivered in differing locations, frequency, intensity, etc. for those in different stages of illness, with different levels of adherence to treatment, etc.) as part of the process of ensuring better retention in care across the cascade, and the new consolidated guidelines for “treat all” make specific recommendations . The guidelines also provide a summary of the evidence base for interventions to improve the care cascade.
The new “treat all” cascade guides us towards two points of intervention that appear to be most important for improving outcomes. The first is linkage to care. We recently reviewed the literature on pre-ART interventions and found few examples of successful efforts to increase the rate at which patients diagnosed with HIV enroll in care . As the new guidelines are likely to alter the population tested for HIV, and not just treatment eligibility, research to strengthen linkage to care is urgently needed.