The cascade of care following community-based detection of HIV in sub-Saharan Africa - A systematic review with 90-90-90 targets in sight

• Published in: PloS one Vol. 13; no. 7; p. e0200737
• Main Authors: Sabapathy, Kalpana, Hensen, Bernadette, Varsaneux, Olivia, Floyd, Sian, Fidler, Sarah, Hayes, Richard
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 27.07.2018; Public Library of Science (PLoS)
• Subjects: Acquired immune deficiency syndrome; Adolescent; Adult; Africa South of the Sahara; AIDS; Anti-HIV Agents - therapeutic use; Antiretroviral drugs; Bias; Biology and Life Sciences; Cascades; CD4 antigen; CD4 Lymphocyte Count; Communicable Disease Control; Communities; Community Health Services - organization & administration; Continuity of Patient Care; Delivery of Health Care; Drug therapy; Engineering and Technology; Female; Health care facilities; Health Facilities; HIV; HIV Infections - diagnosis; HIV Infections - therapy; Human immunodeficiency virus; Humans; Hygiene; Infectious Disease Medicine; Literature reviews; Location based services; Male; Mass Screening; Medical diagnosis; Medical tests; Medicine; Medicine and health sciences; People and Places; Point-of-Care Systems; Research and Analysis Methods; Reviews; Studies; Systematic review; Young Adult; Africa South of the Sahara; South Africa; United Kingdom > UK; Sub-Saharan Africa; Africa
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0200737

We aimed to establish how effective community-based HIV testing services (HTS), including home and community location based (non-health facility) HIV testing services (HB-/CLB-HTS), are in improving care in sub-Saharan Africa (SSA), with a view to achieving the 90-90-90 targets. We conducted a systematic review of published literature from 2007-17 which reported on the proportion of individuals who link-to-care and/or initiate ART after detection with HIV through community-based testing. A meta-analysis was deemed inappropriate due to heterogeneity in reporting. Twenty-five care cascades from 6 SSA countries were examined in the final review- 15 HB-HTS, 8 CLB-HTS, 2 combined HB-/CLB-HTS. Proportions linked-to-care over 1-12 months ranged from 14-96% for HB-HTS and 10-79% for CLB-HTS, with most studies reporting outcomes over short periods (3 months). Fewer studies reported ART-related outcomes following community-based testing and most of these studies included <50 HIV-positive individuals. Proportions initiating ART ranged from 23-93%. One study reported retention on ART (76% 6 months after initiation). Viral suppression 3-12 months following ART initiation was 77-85% in three studies which reported this. There was variability in definitions of outcomes, numerators/denominators and observation periods. Outcomes varied between studies even for similar time-points since HTS. The methodological inconsistencies hamper comparisons. Previously diagnosed individuals appear more likely to link-to-care than those who reported being newly-diagnosed. It appears that individuals diagnosed in the community need time before they are ready to link-to-care/initiate ART. Point-of-care (POC) CD4-counts at the time of HTS did not achieve higher proportions linking-to-care or initiating ART. Similarly, follow-up visits to HIV-positive individuals did not appear to enhance linkage to care overall. This systematic review summarises the available data on linkage to care/ART initiation following community-based detection of HIV, to help researchers and policy makers evaluate findings. The available evidence suggests that different approaches to community-based HTS including HB-HTS and CLB-HTS, are equally effective in achieving linkage to care and ART initiation among those detected. Engagement and support for newly diagnosed individuals may be key to achieving all three UNAIDS 90-90-90 targets. We also recommend that standardised measures of reporting of steps on the cascade of care are needed, to measure progress against targets and compare across settings.