Table of Contents
Studies in recent times indicate that antiretroviral therapy (ART) not only improves the health of people living with HIV (PLWH) but also radically mitigates the risk of PLWH infecting others by decreasing the virus count in their bodies. From this premise, a new approach in the fight against HIV has been envisaged (CDC, 2017). Ultimately, if all PLWH are cognizant of their status and are receiving care; new infections are choked. Further, persons with the infection get a chance to improve their health and quality of life. The above prelude is a major part of CDC’s High Impact HIV Prevention strategy in America. According to the CDC, this strategy aims to reduce HIV infection by allotting resources where said resources would leave prodigious impact. HIV Care Continuum is based on the above overture and will form the foundation of this document. The CDC tracks the HIV Care Continuum to assist in gauging progress on HIV prevention and treatment national goals. HIV Care Continuum is essentially a series of steps that begins from HIV diagnosis through to successful treatment of the infection.
HIV Continuum Care Retention
According to the CDC, the HIV Continuum Care involves testing for HIV and getting the ART. Kay, Batey, and Mugavero (2016) highlight a five-step series that includes linkage to care (LTC), diagnosis, retention in care (RiC), adherence to antiretroviral therapy (ART), and viral suppression. HIV Continuum Care was established in 2013 as a step in the National HIV/Aid strategy. The initiative was a Federal department strategy that accelerates national efforts aimed at increasing testing, care, and treatment of HIV. The goal of this initiative was to address HIV care continuum drop offs while increasing persons at each stage of the continuum (CDC, 2017).
Testing and Diagnosis of HIV
The most common method for HIV testing and diagnosis is blood tests (Pavie et al., 2010). The tests function by recognizing HIV antibodies that the body produces in an effort to wade off the virus. The body can take up to one year to produce the antibodies. Therefore follow up tests are a necessity for conclusive diagnosis. The main tests and diagnosis for HIV and Aids include home tests, enzyme-linked immunosorbent assay, western blot, saliva tests and viral load test (Aiyedun, 2014).
Attaining Antiretroviral Therapy
The expert committee of the International Association of Physicians in AIDS Care (IAPAC) commends that the appraisal of patient ART adherence be tied to individual self-report. Currently, there is no standard methodology of asserting that a patient has consistently stayed on ART (Nachega et al. 2014). As of 2016, the number of PLWH both diagnosed and undiagnosed prescribed ART usage was estimated between 24-37 % (Kay et al., 2016; CDC, 2014; Gardner, McLees, Steiner, Del Rio, & Burman, 2011). Attainment and adherence rate in other high income areas such as Australia and British Columbia are in the range of 44-66% (Kay et al., 2016; Nosyk et al., 2014; Raymond, Hill, & Pozniak, 2014)
Achieving Viral Suppression
Viral suppression is the concluding phase in the HIV care continuum. This step also forms the main object of HIV treatment. According to the CDC, PLWH (persons living with HIV) are considered virally suppressed if their latest viral load is less than 200 c/mL (CDC, 2017). In the US, the CDC estimates that 70% of PLWH are not virally suppressed. Most of these persons include individuals ignorant of their status and those yet to get into care. A more restrictive cutoff of 50c/mL puts the US at 62% (Raymond et al., 2014). Another study estimates that all PLWH diagnosed, retained in care and adhered to ART have a 90% viral suppression (Bradley et al., 2014). Viral suppression fluctuates and is never a constant proposition; patients have been known to changeover between non suppressed status and suppressed status over a period. The NHAS goal for 2020 is set at 80% suppression.
Challenges or Barriers of Receiving and Continuing HIV Continuum of Care
One of the main barriers and challenges to receiving and continuing HIV Continuum of Care is stigma. Unsupportive family, friends and colleagues make it hard for PLWH to access care and when they do will likely do so in a surreptitious fashion. In low income areas, high financial costs associated with receiving ART have been presented as a challenge hindering access HIV Continuum of Care. Other barriers and challenges include fear of side effect and job insecurity as a result of extended leave of absence (Ankomah et al., 2016).
Current HIV Continuum of Care Research in Tennessee
Tennessee Center for AIDS Research (CFAR)
Wester et al.’s (2013) work measured patient commitment in HIV continuum of care in Tennessee. The object was to access progress towards statewide 2015 goals. According to these authors, the Tennessee’s HIV continuum of care in 2013 indicated impressive results. Even so, these authors recommended that future energies to better HIV continuum of care in Tennessee be fixed toward susceptible groups including the young, Nashville and East Tennessee residents, Hispanic people, African Americans and users who inject drugs.
Successful Quality Improvement Continuum Care and Retention Strategies
Increase HIV Testing
According to the National Institute of Health, community efforts such as mobile testing and community mobilization have been known to increase the number of persons being tested. Interventions such as improved access to voluntary testing and counselling, community-wide change in attitude towards HIV and AIDS, and improvement in safe testing increase the number of HIV testing.
Improve Linkage to HIV Care and Support Services, Treatment and Prevention
The Institute of Medical Treatment and the CDC define LTC (Linkage to HIV care) as the period between documentation of HIV diagnosis and start of treatment usually less than three months (Kay et al. 2016). The current updated data on PLWH linked to care is between 59%- 80% (CDC, 2017). The NHAS target for 2020 is 85%. To achieve these high numbers, approaches such as the STTR which have been used successful to improve linkage to HIV care should be evoked (Chandler et al., 2015).
Enhance Surveillance Systems
There is little consensus on how best to survey PLWH (Kay et al., 2016). Most of surveillance systems are based on patient reports; further, the CDC and the NHAS are for the most part keen on PLWH on care who routinely make visits to HIV care providers and not necessarily whether or not said PLWH are transitioning into and out of care or changing providers. According to Kay et al. (2016), as of 2014, the CDC placed the number of RiC in the USA at 40%. These numbers are low and an improvement in surveillance systems warranted. Coordination among care providers has been cited as one of the main ways to improve surveillance.
Reinforce HIV Provider Reporting Practices
HIV provider reporting practices is iterative and thus more challenging than other steps such as testing or LTC which are dichotomous in nature. One way to reinforce reporting is through legislation. In New York for example NYS Public Health Law Article 21 requires reporting of person with HIV and AIDS on NYSDOH. Persons diagnosed fill Medical Provider Form that consist data such as needle sharing and sex partners among other information.
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HIV care continuum is a useful approach used by HIV care providers. This guide outlines a progressive estimates from diagnosis through to viral suppression. The HIV care continuum has since be adopted worldwide and is a standard for providing a snapshot of the population of PLWH. The successive phases in the HIV care continuum facilitate measurement, provision of care, and monitoring. While the HIV care continuum has proved effective to a point, a good chunk of the PLWH are dropped at every successive HIV care continuum step. To address this shortfall addressing all levels of HIV care continuum is necessary. This document endeavors to outline ways to improve HIV care continuum. Specifically, the work outlines steps in HIV care continuum; successful quality improvement continuum care and retention strategies, current HIV Continuum of Care Research in Tennessee and challenges of receiving and continuing HIV continuum of care.
- Aiyedun, A. (2014). Predictors of high levels of knowledge of the HIV window period among diverse men: An online study that includes evaluation of an avatar video intended as e- health on the HIV window period (Doctoral dissertation, Teachers College, Columbia University).
- Ankomah, A., Ganle, J. K., Lartey, M. Y., Kwara, A., Nortey, P. A., Okyerefo, M. P. K., & Laar, A. K. (2016). ART access-related barriers faced by HIV-positive persons linked to care in southern Ghana: A mixed method study. BMC infectious diseases, 16(1), 738.
- Bradley, H., Hall, H. I., Wolitski, R. J., Van Handel, M. M., Stone, A. E., LaFlam, M., … Patel, R. (2014). Vital signs: HIV diagnosis, care, and treatment among persons living with HIV—United States, 2011. MMWR Morb Mortal Wkly Rep, 63(47), 1113-7.
- Centers for Disease Control and Prevention. Understanding the HIV care continuum. 2014. Chandler, R. K., Kahana, S. Y., Fletcher, B., Jones, D., Finger, M. S., Aklin, W. M., … Webb, C. (2015). Data collection and harmonization in HIV research: The seek, test, treat, and retain initiative at the National Institute on Drug Abuse. Journal Information, 105(12).
- Gardner, E. M., McLees, M. P., Steiner, J. F., Del Rio, C., & Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases, 52(6), 793-800.
- Kay, E. S., Batey, D. S., & Mugavero, M. J. (2016). The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future. AIDS Research and Therapy, 13(1), 35.
- Nachega, J. B., Uthman, O. A., Del Rio, C., Mugavero, M. J., Rees, H., & Mills, E. J. (2014). Addressing the Achilles’ heel in the HIV care continuum for the success of a test-and-t reat strategy to achieve an AIDS-free generation. Clinical Infectious Diseases, 59(suppl_1), S21-S27.
- Nosyk, B., Montaner, J. S., Colley, G., Lima, V. D., Chan, K., Heath, K., & Gustafson, R. (2014). The cascade of HIV care in British Columbia, Canada, 1996–2011: A population- based retrospective cohort study. The Lancet Infectious Diseases, 14(1), 40-49.
- Pavie, J., Rachline, A., Loze, B., Niedbalski, L., Delaugerre, C., Laforgerie, E., … Simon, F. (2010). Sensitivity of five rapid HIV tests on oral fluid or finger-stick whole blood: A real-time comparison in a healthcare setting. PloS One, 5(7), e11581.
- Raymond, A., Hill, A., & Pozniak, A. (2014). Large disparities in HIV treatment cascades between eight European and high-income countries–analysis of break points. Journal of the International AIDS Society, 17(4).
- Wester, C., Rebeiro, P. F., Shavor, T. J., Shepherd, B. E., McGoy, S. L., Daley, B., & Pettit, A. C. (2016). The 2013 HIV continuum of care in Tennessee: progress made, but disparities persist. Public Health Reports, 131(5), 695-703.