How Can we Combat Abandonment of Antiretroviral Therapy Among HIV-Positive People in Africa?

[This post has been written by Denise Naniche, Laura de la Fuente, Elisa López, Lucía Pastor and Elisabetta Salvo]

International collaboration and integrated efforts are essential

Mozambique is a country with a particularly high HIV prevalence in adults. Estimated at 10.6%, it is said to be the eighth highest in the world. In 2014, according to UNAIDS, an estimated 1.5 million people were living with HIV in the country and the mother-to-child transmission of HIV was around 12%. In Manhiça District, in southern Mozambique, it is estimated that 40% of all adults and close to 29% of pregnant women are infected with HIV. Many of these individuals receive lifesaving antiretroviral therapy (ART), which has been available in Mozambique since 2004, due in large part to international support.

Health Systems Struggling with Impact of HIV & AIDS

In Mozambique, ART coverage for those who need it is currently estimated at approximately 50% in adults

The magnitude of the HIV epidemic and the fact that ever more effective guidelines recommend earlier initiation of ART mean that immediate sustainability is unlikely without a huge effort to strengthen health systems countrywide. Indeed, very few health systems in the world could cope with the logistics and costs of the clinical management of 40% of the population needing lifelong care and treatment. Consequently, international collaboration and integrated efforts are essential if we are to reach the target set by the Global Health Sector Strategies for HIV, which stipulate that, by 2020, 90% of all people living with HIV will know their status, 90% of people diagnosed will be on antiretroviral therapy, and 90% of people receiving antiretroviral therapy will be virally suppressed, with the ultimate goal of eradicating AIDS by 2030.

Over a quarter of a million adults who are eligible for ART are not receiving treatment

In Mozambique, ART coverage for those who need it is currently estimated at approximately 50% in adults and 39% in children, according to UNAIDS country report. These figures illustrate the sheer number of people dependent on the health system for HIV prevention and care. Despite the rapid expansion in coverage seen in recent years, over a quarter of a million adults who are eligible for ART are not receiving treatment. Stigma, overburdened health systems and poverty present daily challenges to retention in care and treatment.

Tesfam Study

The aim is to optimize HIV counselling and testing strategies

The objective of the Tesfam study, which focuses on the Manhiça district, is to give more people access to HIV testing, link them to care, and retain them in care and treatment. The study compared clinic-based and home-based HIV testing and counselling approaches, comparing rates of linkage to care and cost-effectiveness. Ultimately, the hope is that the findings of Tesfam will optimize HIV counselling and testing strategies, leading to the engagement of as many people as possible in the care cascade.

The HIV care cascade shows the various stages that a person diagnosed with HIV must go through, and the proportion of individuals engaged at each step.

Source: The LINKAGES program - Across the Continuum of HIV Services for Key Populations

Despite increased rates of HIV testing, loss to follow up at each step in the HIV care cascade is very common

Over the course of the study, approximately 16,000 adults were offered HIV testing. Of those eligible for the study, almost 15% already knew their HIV-positive serostatus. The 1,122 adults identified as new HIV diagnoses were enrolled for follow up. A key step in the HIV care cascade from testing to treatment is the CD4 test to determine eligibility for ART. In the Tesfam study, at 3 months post diagnosis, only 43.7% of those enrolled had undergone CD4 testing.

Despite increased rates of HIV testing, loss to follow up at each step in the HIV care cascade is very common in both resource-constrained settings and in more resource-rich countries. The reasons why patients drop out of the HIV care cascade are very complex and are influenced by multiple factors relating to the healthcare system and the individual, including socioeconomic profile.

The home visit was very effective at re-engaging a large proportion of those who received this additional visit

Standard of care in many sub-Saharan African settings does not include routine patient tracing, and the fate of individuals lost to follow-up is largely unknown. Since the HIV-infected population is especially vulnerable to illness and early death, it is important that these patients are traced and re-engaged into care. The design of the Tesfam study included home visits and counselling for the 850 individuals who abandoned treatment at different phases of the cascade. While some had migrated or died, the home visit was very effective at re-engaging a large proportion of those who received this additional visit. Moreover, these patients were interviewed to ascertain why they had dropped out of the study.

Proportion of individuals reaching different stages of the HIV care cascade in Manhiça

Raising Awareness in the Community of HIV

One of the main contributions of the Tesfam project in Manhiça was that it raised awareness in the community of HIV and HIV treatment through organised community events and presentations at public markets to discuss the obstacles and solutions relating to accessing HIV/AIDS care and treatment. These sessions are dynamic and enriching discussions led by an experienced counsellor. Community members actively participate by presenting their concerns and offering suggestions on ways the barriers to adherence to care for HIV-positive patients could be overcome. These events bring the community together to discuss the best approaches to HIV/AIDS care and treatment and health-seeking behaviour and to emphasise the importance of HIV testing, prevention and transmission mechanisms. The discussions brought to light various reasons why people do not go to the hospital for testing or treatment, such as a lack of time and the fact that they do not feel comfortable with the hospital staff.

Community participation can reduce stigma

Finally, community participation can reduce stigma and give people an opportunity to share their views on HIV/AIDS programmes and contribute to their improvement. In this respect, the Tesfam project clearly identified a need for a better understanding of the barriers and facilitators of retention in care. Local leaders were also shown to have considerable influence on the behaviour of members of their communities.

Dona Eugenia explaining procedures related to HIV counselling and testing to the community.

In the future, more efforts aimed at retaining and re-engaging patients in care will be crucial. A few weeks could mean the difference between life and death. In addition, there is a great need to train health care workers to create a non-judgmental enabling environment. There is no one-size-fits-all approach, and in order to achieve the 90-90-90 target we must adapt our strategies to different settings and cultures so that all HIV-positive individuals are diagnosed, linked and retained in care. This challenge can only be met by intervening at various stages of the HIV care cascade.