Know your treatment cascade

By Matteo Cassolato

Matteo Cassolato is the Alliance's Senior Advisor: HIV Technical (Treatment)

Thanks to HIV treatment, people living with HIV can live long and healthy lives, in most cases as long as their HIV-negative peers. However, although HIV treatment is becoming increasingly available, at the end of 2015 more than 19 million people (over half of all people living with HIV) were still not accessing it.

HIV treatment, known as anti-retroviral therapy (ART), works by lowering the amount of HIV in the body to very low levels. This is also called achieving viral suppression.

Once viral suppression is achieved, the immune system can repair itself and prevent the virus from causing damage. Critically, for the anti-HIV drugs to be effective, they need to be taken every day; failing to do so may result in development of drug resistances, which could mean having to switch to less preferred and more expensive combinations of anti-retrovirals.

Because it is better to start HIV treatment sooner rather than later, it is important for people living with HIV to know that they have the virus. Ensuring access to HIV testing is therefore critical.

HIV finger prick test at Kisumu District hospital, as part of an MSM forum and outreach run by MAAYGO, Kisumu, Kenya (c) Corrie Wingate/International HIV/AIDS AllianceHIV finger prick test at Kisumu District hospital, as part of an MSM forum and outreach run by MAAYGO, Kisumu, Kenya.  ©Corrie Wingate/International HIV/AIDS Alliance

Challenges to accessing treatment

Knowing your HIV status is only the first step though. People living with HIV can face many other challenges before accessing treatment and achieving viral suppression. These can be associated with initial difficulties of coming to terms with a lifelong condition, or with facing the stigma still attached to HIV. For some people the distance to the HIV clinic can be a problem, and for others it might simply be difficult to find the time to attend medical appointments.

For those who do start treatment, side effects of the medications, drug stock-outs or other reasons can impact a person’s ability to adhere to treatment. Not taking the medications every day means not achieving viral suppression, which is what ultimately allows people living with HIV to enjoy long and healthy lives.

Understanding the barriers to accessing care

It is therefore critical for providers of HIV care to understand why, where and when people living with HIV do not manage to engage with services, or respond well to treatment, and then to implement interventions that address these issues.

The HIV continuum of care model helps them to do precisely this.

The HIV continuum of care, also called the HIV treatment cascade, is a useful way to describe and monitor the progress that people living with HIV make in achieving viral suppression.

The HIV continuum of care model

The five stages of the HIV continuum of care model are

  1. getting tested and diagnosed
  2. being linked to care
  3. being retained in care
  4. being prescribed ART
  5. achieving viral suppression

Via Libre in Peru used the HIV continuum of care model to assess and monitor the progress that people living with HIV were making at their clinic. Using this information, they implemented a series of interventions to increase the number of people retained in care, accessing ART and achieving viral suppression.

A complete organisational assessment was carried out to gather information on the clinic’s clients and their needs, and to track their flow through Vìa Libre’s services.

Lessons learned from Via Libre

The lessons learned from the assessment and the process of implementing solutions were documented in Strengthening the HIV continuum of care - the experience of Via Libre.

This is a summary of the main conclusions and responses:

1. HIV clinics need systems that generate and utilise strategic information

To develop a reliable treatment cascade capable of monitoring patients, Via Libre had to strengthen the processes through which the clinic generated and used data. In response, they introduced and standardised the use of unique identifier codes and installed a central database to store and manage patients’ records.

2. Greater effort is needed to successfully test and link patients to care

Vìa Libre saw that almost half of the people who tested positive at the clinic were not subsequently retained in treatment (they were “lost to follow up”). After investigating the underlying reasons, Via Libre simplified their testing procedures and modified their processes so that people who tested positive could get their first medical consultation quicker, thereby reducing the risk of patients dropping out before being enrolled in HIV care.

3. Innovative use of information and communication technology (ICT) can help retain people in care

After assessing its clients’ usage and preferences with regard to ICTs, Vìa Libre started using text messaging, WhatsApp and Facebook chat to provide tutoring to patients, giving them critical information about their health, appointment reminders and psychosocial support.

4. The importance of staff awareness of the continuum of care

In implementing the interventions, Vìa Libre took particular care in ensuring that the entire staff, both medical and administrative, understood why these changes were being made. Management created spaces where staff could openly discuss and validate each of the planned interventions in a culture of transparency and respect.

As a result of these interventions the number of people linked to care after a positive HIV diagnosis increased by 36%, the number of people retained in care increased by 39%, and the number of people starting on ART increased by 23%.

Read the case study here, and watch a video by Via Libre explaining the HIV contiuum of care.