Improving the care cascade in African countries

Improving the care cascade in African countries - "With advances in HIV testing, treatment and care, some countries are making great progress towards the UNAIDS 90-90-90 target.

Interventions aimed at improving the proportion of people diagnosed, linked to care and remaining on treatment were a major theme at this year’s conference.

While mobile testing and counselling units can increase the diagnosis rate in men and other underserved groups, poor linkage to care is a challenge. A randomised South African study found that entry into care was modestly increased if people receive a point-of-care CD4 test and counselling sessions to overcome personal barriers to seeking HIV care. Nonetheless, only half the people who were in need of immediate treatment made it onto treatment within six months of their HIV diagnosis, highlighting the need for further improvements in linkage to HIV care. Point-of-care CD4 testing alone did not improve entry into care.

Malawi’s Option B+ programme has transformed the treatment cascade for pregnant women living with HIV so that in just four years the proportion who are diagnosed has gone from 49 to 80%, and the proportion who are virally suppressed has jumped from 2 to 48%, the conference heard. The programme was conceived with the constraints of the country’s health system in mind – the number of sites offering antiretroviral therapy (ART) was doubled, bringing treatment within walking distance for most people. So that health workers with limited training could deliver ART, guidelines were simplified and clinical supervision stepped up.

Nonetheless, retention after pregnancy remains a challenge. Women who have not disclosed their HIV status to their partner, who do not know their partner’s status or who have limited knowledge of the benefits of lifelong treatment are especially likely to drop out.

A randomised study in Kenya showed improvements in the retention of women living with HIV six months after birth. Lay counsellors provided a package of interventions including individualised health education, home visits, appointment reminders, physical tracing after a missed clinic visit, and individualised adherence and retention support. Compared to the standard of care, this improved retention from 19 to 28%." (Photo ©

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