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ART COVERAGE IN RWANDA: SUCCESSES AND REMAINING CHALLENGES

Friday, 1st of May 2015 Print

“An important finding is a high loss to follow-up and mortality in men: a clear gap exists for the design, evaluation, and implementation of innovative strategies to motivate men to be tested, linked to care, and achieve viral suppression in Africa.”

ART COVERAGE IN RWANDA: SUCCESSES AND REMAINING CHALLENGES

Ruanne V Barnabas, Connie Celum

Published Online: 26 March 2015

DOI: http://dx.doi.org/10.1016/S2352-3018(15)00038-7

 

The Lancet HIV,Volume 2, No. 5, e176–e177, May 2015

About 13·6 million people are on antiretroviral therapy (ART) worldwide,1 leading to improved survival for people with HIV and a slowly declining incidence of infection.2 The progression from knowledge of HIV infection to engagement in care and ART initiation to virological suppression is known as the HIV continuum of care.3 UNAIDS has recently established the aspirational goal of 90-90-90 by 2020 for the continuum of care (90% of HIV-positive people aware of their status, 90% of HIV-positive people who know their status taking ART, and 90% of individuals on ART being virologically suppressed).

The rewards of reaching the 90-90-90 goal would be immense; it would avert HIV-associated mortality, prevent new cases of HIV, reduce HIV to low endemic rates, and decrease costs of HIV care.4 However, to reach this goal, upwards of 15 million more people need access to ART worldwide,5 in the context of stagnant funding for HIV.6 What can be done to strengthen HIV treatment programmes as they expand to more than double their capacity?

In The Lancet HIV, Sabin Nsanzimana and colleagues7 analysed national and facility level data to estimate engagement in HIV care at each stage of the continuum of care in Rwanda, aiming to identify strengths and areas for improvement. They collated data for people with HIV in national HIV programmes, using national surveillance (TRACnet), clinic record review, retrospective studies, and a Ministry of Health survey of linkages to care in 8598 people with HIV. They estimated transitions between the stages of HIV care, and analysed factors associated with mortality. Overall, of the estimated 204 899 HIV-positive people in Rwanda in 2013, 52% were estimated to be virally suppressed; loss to follow-up was 3·9% in the pre-ART stage and 2·2% in the ART stage; mortality was 0·6% in the pre-ART and 1·0% in the ART stage. Risk factors for loss to follow-up included younger age and male sex, while risk factors for mortality included older age, low CD4 cell count at ART initiation, and male sex.

Previous studies of the continuum of HIV care could have underestimated the number of HIV-positive people at each stage because they assumed an underlying linear structure that did not account for individuals moving in and out of care and transferring facilities.8 One of the strengths of the Article by Nsanzimana and colleagues7 is that it captures these transitions and mobility through use of the national TRACnet database of individuals with HIV linked to care in the public and private sector. Notably, they identified 20% of HIV-positive people retained in care as transferred to another facility at least once.

This insightful study highlights several areas for improvements to be made in surveillance, HIV treatment, and prevention programming. An important gap is data for the number of people tested for HIV and the number of HIV-positive individuals identified; data were only available from the first linkage to care step. Surveillance systems should strive to link HIV-testing data with clinical surveillance databases to capture outcomes across the entire testing to care continuum.9 Tracking of suboptimum outcomes,10 such as delayed ART initiation after eligibility is established and missed ART refills, would also help to strengthen programmes. An important finding is a high loss to follow-up and mortality in men: a clear gap exists for the design, evaluation, and implementation of innovative strategies to motivate men to be tested, linked to care, and achieve viral suppression in Africa. Lastly, few viral load results were available (n=3066) representing less than 3% of the total number of HIV-positive people estimated to have viral suppression. To expand ART programmes, scalable strategies to monitor viral suppression such as use of dried blood spots for specimen collection11 or semiquantitative viral load assays need refinement and validation.

Strong surveillance systems that link health records across health-care facilities expedite clinical care, and can be anonymised to provide vital information on engagement in the continuum of care, people moving between facilities, and optimum and suboptimum outcomes. Rwanda is leading the way with practical, efficient surveillance systems that allow monitoring, evaluation, and quality improvement in the continuum of HIV care. With these methods in place, real-world facilities can track their performance, and share efficient approaches to high retention and viral suppression.12 With implementation science to strengthen the continuum of HIV care, we can maximise the gains for HIV treatment and prevention.

We declare no competing interests.

References

1UNAIDS. Fast-Track: ending the AIDS epidemic by 2030. http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf; 2014. ((accessed Dec 9, 2014).)

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2Murray, CJ, Ortblad, KF, Guinovart, C et al. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014; 384: 1005–1070

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3McNairy, ML and El-Sadr, WM. The HIV care continuum: no partial credit given. Aids. 2012; 26: 1735–1738

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4Granich, RM, Gilks, CF, Dye, C, De Cock, KM, and Williams, BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009; 373: 48–57

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5WHO. Antiretroviral therapy for HIV infection in adults and adolescents. World Health Organization, Geneva; 2010

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6Institute for Health Metrics and Evaluation. Financing Global Health 2013: Transition in an Age of Austerity. Institute for Health Metrics and Evaluation, Seattle; 2014

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7Nsanzimana, S, Kanters, S, Remera, E et al. The HIV care continuum in Rwanda: a cross-sectional analysis of the national HIV care programme. Lancet HIV. 2015; (published online March 27.)http://dx.doi.org/10.1016/S2352-3018(15)00024-7.

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8Hallett, TB and Eaton, JW. A side door into care cascade for HIV-infected patients?. J Acquir Immune Defic Syndr. 2013; 63: S228–S232

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9Suthar, AB, Ford, N, Bachanas, PJ et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med. 2013; 10: e1001496

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10McNairy M, Lamb M, Elul B, Abrams E, El-Sadr W. A new paradigm for evaluating the HIV care cascade. Conference on Retroviruses and Opportunistic Infections; Boston, MA, USA; March 3–6, 2014.

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11Campion, EW. Treating millions for HIV—the adherence clubs of Khayelitsha. N Engl J Med. 2015; 372: 301–303

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12Murray, CJ. Maximizing antiretroviral therapy in developing countries: the dual challenge of efficiency and quality. JAMA. 2015; 313: 359–360

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