Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands

Statistical methods applied for the assessment of the HIV cascade and continuum of care: a systematic scoping review

OBJECTIVES

This scoping review aims to identify and synthesise existing statistical methods used to assess the progress of HIV treatment programmes in terms of the HIV cascade and continuum of care among people living with HIV (PLHIV).

DESIGN

Systematic scoping review.

DATA SOURCES

Published articles were retrieved from PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and Excerpta Medica dataBASE (EMBASE) databases between April and July 2022. We also strategically search using the Google Scholar search engine and reference lists of published articles.

ELIGIBILITY CRITERIA

This scoping review included original English articles that estimated and described the HIV cascade and continuum of care progress in PLHIV. The review considered quantitative articles that evaluated either HIV care cascade progress in terms of the Joint United Nations Programme on HIV and AIDS targets or the dynamics of engagement in HIV care.

DATA EXTRACTION AND SYNTHESIS

The first author and the librarian developed database search queries and screened the retrieved titles and abstracts. Two independent reviewers and the first author extracted data using a standardised data extraction tool. The data analysis was descriptive and the findings are presented in tables and visuals.

RESULTS

This review included 300 articles. Cross-sectional study design methods were the most commonly used to assess the HIV care cascade (n=279, 93%). In cross-sectional and longitudinal studies, the majority used proportions to describe individuals at each cascade stage (276/279 (99%) and 20/21 (95%), respectively). In longitudinal studies, the time spent in cascade stages, transition probabilities and cumulative incidence functions was estimated. The logistic regression model was common in both cross-sectional (101/279, 36%) and longitudinal studies (7/21, 33%). Of the 21 articles that used a longitudinal design, six articles used multistate models, which included non-parametric, parametric, continuous-time, time-homogeneous and discrete-time multistate Markov models.

CONCLUSIONS

Most literature on the HIV cascade and continuum of care arises from cross-sectional studies. The use of longitudinal study design methods in the HIV cascade is growing because such methods can provide additional information about transition dynamics along the cascade. Therefore, a methodological guide for applying different types of longitudinal design methods to the HIV continuum of care assessments is warranted.

Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort

Objectives

We aimed to study the incidence rate, predictors and outcomes of HIV care interruption (HCI) in Belgium.

Methods

We analysed data for adult patients with at least two HIV care records in the Belgian HIV cohort between 1 January 2007 and 31 December 2016. An HCI episode was defined as 1 year without an HIV care record. The HCI incidence rate was analysed using Poisson regression, return to HIV care using a cumulative incidence function with death as a competing risk, and viral load (VL) status upon return to HIV care using logistic regression.

Results

We included 16 066 patients accounting for 78 625 person‐years of follow‐up. The incidence rate of HCI was 5.3/100 person‐years [95% confidence interval (CI) 5.1–5.4/100 person‐years]. The incidence of return to HIV care after HCI was estimated at 77.5% (95% CI 75.7–79.2%). Of those who returned to care, 43.7% had a VL ≤ 200 HIV‐1 RNA copies/mL, suggesting care abroad or suboptimal care (without an HIV‐related care record) in Belgium during the HCI, and 56.3% returned without controlled VL and were therefore considered as having experienced a real gap in HIV care; they represented 2.3/100 person‐years of follow‐up. Factors individually associated with HCI were no antiretroviral therapy (ART) uptake, lower age, injecting drug use, non‐Belgian nationality, male gender, not being a man who has sex with men, a shorter time since HIV diagnosis, no high blood pressure and CD4 count < 350 cells/µL.

Conclusions

This study highlights the need to investigate return to care and viral status at return, to better understand HCI. Identified predictors can help health care workers to target patients at higher risk of HCI for awareness and support.

Evaluation of Selected Outcomes of Combination Antiretroviral Therapy: Yemen Cohort Retrospective Descriptive Studies

In 2007, HIV treatment services were established in five main governorates out of twenty-two which resulted in low access to services and poor treatment outcomes. The main goal of this study was to evaluate and analyse the selected treatment outcomes of eight cohorts of PLHIV who were treated with cART during 2007–2014. The method used was a retrospective descriptive study of 1,703 PLHIV who initiated cART at five public health facilities. The results: Retention rate was less than 80%, male: female ratio 1.661, with a mean age of 35 years (±9.2 SD), 85% had been infected with HIV via heterosexual contact. 65% of patients presented with clinical stages 3 and 4, and 52% of them were initiated cART at a CD4 T-cell count ≤200 cells/mm. 61% of cART included Tenofovir and Efavirenz. TB treatment started for 5% of PLHIV, and 22% developed HIV-related clinical manifestations after cART initiation. 67% of PLHIV had experienced cART substitution. The mean AIDS-mortality rate was 15% and the mean LTFU rate was 16%. Conclusion: Although cART showed effectiveness in public health, mobilization of resources and formulation of better health policies are important steps toward improving access to cART and achieving the desired treatment outcomes.

Compliance with laboratory monitoring guidelines in outpatient HIV care: a qualitative study in the Netherlands

Evidence-based guidelines in HIV care aim to improve patients' health outcomes, quality of care, and cost-effectiveness. Laboratory monitoring plays an important role in assessing clinical status of patients and forms an integral part of HIV treatment guidelines. The Dutch HIV monitoring foundation (Stichting HIV Monitoring) previously observed variation between HIV treatment centres in the Netherlands in terms of compliance with guidelines for performing laboratory tests. Drawing on qualitative research methods, this article aims to describe factors that influence guideline compliance for laboratory monitoring in outpatient HIV care in the Netherlands. Twelve semi-structured in-depth interviews were conducted with a convenience sample of physicians from four HIV treatment centres. In general, physicians perceived laboratory guidelines as useful. However, unclear online visual representation of the guidelines, a lack of set reminders for tests, and assessment of patients' risk behaviour, which differs per patient, were identified as barriers to guideline compliance. The compartmentalisation of the Dutch healthcare system was viewed as hampering guideline compliance. A clinical-decision-support tool could possibly facilitate compliance with laboratory monitoring guidelines. Moreover, better alignment of HIV outpatient care, municipal health services and primary care, in terms of laboratory testing, could optimize efficiency, increase cost-effectiveness, and improve quality of HIV care.

Losses to follow-up of HIV-infected people in the Spanish VACH cohort over the period between 2013 and 2014: The importance of sociodemographic factors

OBJECTIVE

To determine the proportion of people infected by HIV or AIDS under follow-up in the VACH Cohort in 2012 who were lost to follow-up from 2013 to 2014, and to establish the sociodemographic features relating to this loss.

METHODS

We considered subjects with less than one recorded consultation per year studied to be lost to follow-up. We built logistic regression models to calculate the odds ratios (OR) and their 95% confidence intervals (95% CI), of the variables relating to loss to follow-up.

RESULTS

The overall percentage of losses to follow-up was 15.5% (95% CI 14.9-16-1). The variables associated with loss to follow up were: not receiving antiretroviral treatment (ART) (OR: 1.948, 95% CI: 1.651 -2.298), being an immigrant (OR: 1.746; 95%CI: 1.494-2.040), intravenous drug consumption being the mechanism for HIV transmission (OR: 1.498, 95% CI: 1.312-1.711), being unemployed (OR: 1.331; 95% CI: 1.179-1.503), being without a partner (OR: 1.948, 95% CI: 1.651-1.298), belonging to a low socioeconomic class (OR: 1.279; 95% CI: 1.143-1.431), and being attended in a hospital with fewer than 1000 patients under follow-up (OR: 1.257, 95% CI: 1.121-1.457), as well as being under age and having spent less time under follow-up in the Cohort.

CONCLUSIONS

15.5% of the patients were lost to follow-up over a period of 2years in the VACH Cohort. This was associated with a series of sociodemographic and epidemiological variables that it might be useful to identify to design initiatives targeting the populations most likely to abandon the circuits of care, and guide strategies towards achieving Objective 90-90-90.

Patient perspectives on the HIV continuum of care in London: a qualitative study of people diagnosed between 1986 and 2014

OBJECTIVES

To describe the experiences of the HIV treatment cascade of diagnosis, engagement with care and initiation of treatment from the perspective of patients; we explored whether this differed according to the year of their diagnosis, for example, whether they had experienced HIV care in the pretreatment era.

DESIGN

Qualitative interview study with framework analysis.

SETTING

Two large HIV adult outpatient clinics in central London.

PARTICIPANTS

52 HIV-positive individuals, 41 men, 11 women, purposively sampled to include people who had been diagnosed at different stages in the history of the epidemic classified as four 'generations': pre-1996 (preantiretroviral therapy (ART)), 1997-2005 (complex ARTs), 2006-2012 (simpler ARTs) and 2013 onwards (recent diagnoses).

RESULTS

Some important differences were identified; for earlier generations, the visible illness and deaths from AIDS made it harder to engage with care following diagnosis. Subsequent decisions about starting treatment were deeply influenced by the fear of severe side effects from early ART. However, despite improvements in ART and life expectancy over the epidemic, we found a striking similarity across participants' accounts of the key stages of the care continuum, regardless of when they were diagnosed. Diagnosis was a major traumatic life event for almost everyone. Fear of testing positive or having low self-perceived risk affected the timing of testing and diagnosis. Engaging with care was facilitated by a flexible approach from services/clinicians. Initiating treatment was a major life decision.

CONCLUSION

We found patients' experiences are influenced by when they were diagnosed, with earliest cohorts facing substantial challenges. However, being diagnosed with HIV and starting treatment continue to be significant life-altering events even in the era of effective, simple treatments. Despite the advances of biomedical treatment, services should continue to recognise the needs of patients for whom the diagnosis and treatment remain significant challenges.

Health-related quality of life of people with HIV: an assessment of patient related factors and comparison with other chronic diseases

OBJECTIVES

The health-related quality of life (HRQOL) of people with HIV is lower than in the general population, but it is unknown how it compares with that of persons with other chronic medical conditions. We compared HRQOL in HIV with HRQOL in diabetes mellitus type 1, diabetes mellitus type 2 and rheumatoid arthritis (RA). In addition, we investigated factors associated with HRQOL in HIV.

DESIGN

Cross-sectional study.

METHODS

HRQOL was measured with the Medical Outcomes Study Short Form 36-item Health Survey in a nationwide sample of people with HIV in care in the Netherlands and on combination antiretroviral therapy for at least 6 months. We added data from studies in diabetes mellitus types 1 and 2, and RA. Logistic regression analysis was used to examine: the association between disease group and a poor HRQOL, and patient factors associated with poor HRQOL in HIV.

RESULTS

The odds of a poor physical HRQOL in the HIV group were comparable with the odds in diabetes mellitus types 1 and 2, but lower than in RA patients. The odds of a poor mental HRQOL in HIV were higher than in the other groups. In HIV, a history of AIDS, longer duration of combination antiretroviral therapy and severe comorbidity were associated with a poor physical HRQOL. Sub-Saharan African descent and CD4 cell count of less than 350 cells/μl were associated with poor mental HRQOL.

CONCLUSION

People with HIV were more likely to have a poor mental HRQOL than patients with other chronic conditions. Addressing mental health should be an integral part of outpatient HIV care.

HIV-Positive Individuals on Antiretroviral Therapy and with Viral Load Suppressed in 12 Infectious Diseases Clinics in Italy: Successes and Disparities in the HIV Continuum of Care

The HIV care continuum is a tool that describes the quality of HIV care for people living with HIV and assesses the extent to which the goal of viral suppression has been achieved. In 2014, we conducted a retrospective cross-sectional study to assess the characteristics associated with three steps of the HIV continuum of care in Italy [i.e., most recent diagnoses, people diagnosed and in care who are on therapy, and people with viral load (VL) suppressed among those on therapy]. Among the 10,262 individuals diagnosed and linked to care, 9,810 (95.6%) were on therapy and among these 8,383 (85.7%) had VL suppressed. The comparison between people diagnosed in 2013 to those diagnosed before 2013 shows that they were more likely to be male [adjusted odds ratios (AOR) = 1.46; 95% confidence interval (95% CI): 1.18-1.79], <25 years of age (AOR = 7.59; 95% CI: 4.17-13.79), and born in Italy (AOR = 1.33; 95% CI: 1.09-1.62). Factors significantly associated with not being in therapy were as follows: age <35 years (AOR = 4.03; 95% CI: 2.50-6.51), age 35-55 years (AOR = 1.85; 95% CI: 1.19-2.87), being migrants (AOR = 1.25; 95% CI: 1.13-1.39), being men who have sex with men (MSM) (AOR = 1.54; 95% CI: 1.22-1.95), have been diagnosed in 2010-2012 (AOR = 4.51; 95% CI: 3.03-6.73), or before 2010 (AOR = 3.18; 95% CI: 2.41-4.21), and not had previous clinical AIDS (AOR = 8.24; 95% CI: 3.33-20.23), whereas factors significantly associated with not having VL suppressed were as follows: age <35 years (AOR = 1.56; 95% CI: 1.13-2.13) and age 35-55 years (AOR = 1.23; 95% CI: 1.10-1.38), being migrants (AOR = 1.38; 95% CI: 1.11-1.70), have been diagnosed in 2010-2012 (AOR = 1.34; 95% CI: 1.14-1.57), in 2013 (AOR = 4.35; 95% CI: 2.47-7.68), and not having had previous clinical AIDS (AOR = 0.74; 95% CI: 0.63-0.86). Despite this we observed significant disparities for young people, MSM, and migrants, overall in Italy the vast majority of people diagnosed with HIV and in care in 2013 received therapy and the percentage of people who are VL suppressed is near the Joint United Nations Programme on HIV/AIDS goal.