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Welcome to the second differentiated service delivery (DSD) newsletter of 2022 from IAS – the International AIDS Society. In this edition, we focus on re-engagement in HIV care and upcoming DSD events and science at AIDS 2022, the 24th International AIDS Conference.

Re-engaging in HIV care in PEPFAR-supported programmes

Lana Lee (USAID), Jessica Stephens (USAID) and Catherine Godfrey (Office of the Global Health Coordinator, United States), write:

With more robust and better-tolerated dolutegravir-based antiretroviral (ARV) regimens now widely available, achieving the third 95 target on viral suppression should be within reach, provided HIV treatment programmes can ensure continuity of treatment for all people living with HIV. Treatment interruptions can lead to a loss of virological control, which has profound implications for people on HIV treatment. There is a growing body of scholarship implicating even low-level viremia with adverse treatment outcomes, including mortality.

Treatment interruptions are common for many chronic conditions, including HIV, and the US President's Emergency Plan for AIDS Relief (PEPFAR) has begun evaluating programme-level data on treatment interruptions, hoping to determine factors that may help identify individuals at risk for interruption.

PEPFAR defines a treatment interruption as no clinical contact or ARV pick-up for greater than 28 days since a client’s last expected clinical contact or ARV pick-up.

This information is disaggregated to include those who interrupt within three months and those who have dropped out of care for more than a year. Treatment re-engagement, however, is important, and it may be that the side-by-side analysis of these two distinct entities points to areas for further study.

Evaluation of treatment interruptions in PEPFAR globally provides some information about who interrupts treatment and when. Data from FY2021 shows that the percentage of individuals who drop out of care within the first three months of therapy is considerably higher than those who drop out later in care and that this percentage in 2021 is consistent across all adult age groups.

The major caveat with these data is that the data on individuals who are returned to treatment do not represent the same people who interrupted treatment, so no client-level inferences may be made from aggregate programme statistics. However, these new programme metrics may help us better understand who may interrupt treatment more commonly, as well as some of the broader motivators for re-engagement. Further, longitudinal client records in national public health data systems will be vital in assessing risk and refining approaches that will prevent interruptions in treatment and promote successful re-engagement.

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DSD in action: Welcome back! Re-engagement in HIV care in South Africa

“The treatment journey on ART is not linear – like for many other chronic diseases – where someone is diagnosed, starts treatment and stays on it continuously for the rest of their lives.”

We spoke with Diana Mokoena, a medical doctor with a diploma in HIV medicine who currently works as District Programme Manager at Anova Health Institute in Johannesburg, South Africa.

What do you want people to know about ART continuity and viral suppression in South Africa?

While 92% of people living with HIV in South Africa know their status, significant improvements in retention and viral suppression will be required to reach the global 95-95-95 targets. The treatment journey on ART is not linear – like for many other chronic diseases – where someone is diagnosed, starts treatment and stays on it continuously for the rest of their lives. Many people on ART in South Africa experience interruptions along this journey. There is usually not one factor that causes disengagement; multiple factors act together to reach a tipping point to keep people out of care.

What is the role of healthcare providers in keeping clients from disengaging?

We need to be mindful of the way that interactions and issues, even at initial points of contact like testing, can continue to affect care engagement along the entire care cascade. As healthcare workers, we need to accept that clients may continue to face life challenges that make it difficult for them to stay in care; flexible health services delivered with an empathetic attitude can minimize interruptions when “life happens”.

What are the key components of Anova’s work around re-engagement?

In 2019, Anova started the two-part “Welcome Back” campaign in collaboration with the Johannesburg District Health Services to encourage clients to return to care.

The first phase involved healthcare worker training on how to manage clients on ART, including those who need to restart ART. Phase 2 entailed mass media messaging via radio with 34 community and national radio stations about the importance of returning to care with the theme, The Time is Now, Your Health in Your Hands.

What were the main preliminary outcomes of the Welcome Back campaign?

A total of 1,142 clients were successfully restarted on ART over the four months of the first phase, higher than the 825 restarts reported prior to the campaign. Mobility, COVID-19 lockdown restrictions, mandatory transfer letters and negative healthcare worker attitudes were reported as the main reasons that clients interrupted treatment, especially when difficult life circumstances made it challenging for them to plan ahead.

Read the full interview

Don't miss

AIDS 2022 DSD roadmap

Check out the AIDS 2022 DSD roadmap and discover the latest DSD science – pre-conferences, satellites, symposia, oral abstract sessions and posters.

Get involved

Free DSD online course

Register for this free DSD online course, developed by the IAS, and learn more about DSD for HIV treatment, specific populations and how it can be leveraged for integration of other health services.

Looking ahead, looking back

Looking ahead …

14 July: Join EpiC for the webinar, "Leaving no one behind: focus on people with advanced HIV disease in the context of differentiated and decentralized ART".
29 July-2 August: AIDS 2022 will take place in person in Montreal, Canada, and virtually. Review the full conference programme here and learn more about the IAS-organized DSD pre-conference meeting on re-engagement and satellite sessions on DSD science and PrEP here.

Looking back …

Watch the recording of the webinar, “Leveraging Decentralized Drug Distribution for HIV prevention: Implementation considerations and case studies”, organized by EpiC on 21 April.
View the slides of the webinar, “Differentiated TB/HIV Services: Integrating TB Preventive Treatment into the Fast Track Model in Zimbabwe and Zambia”, organized by CQUIN on 3 May.
View the resources and presentations from the workshop, “Delivering Quality at Scale in Differentiated Service Delivery (DSD) Programs”, organized by CQUIN at ICAP Columbia in Joha.

What we're reading

How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi, Chamberlin S et al, AIDS and Behavior, March 2022

This qualitative sub-study conducted in-depth interviews with adults in Malawi who initiated antiretroviral therapy (ART), had been at least two weeks late for a routine ART appointment, and re-engaged in HIV care prior to study recruitment. Common reasons for missing clinic visits were unexpected travel or caregiving and inflexible HIV care programmes posing challenges for timely re-engagement.

HIV Self-testing Among Previously Diagnosed HIV-Positive People in Khayelitsha, South Africa: No Evidence of Harm but may Facilitate Re-engagement in ART Care, Hacking D, AIDS and Behavior, March 2022

This short report describes the rate of retesting via HIV self-testing (HIVST) kits among previously diagnosed adults living with HIV and their prior and subsequent engagement in ART care. Despite stressing that those previously diagnosed and on ART should not use the HIVST kit, 11% of study participants had a record of prior HIV diagnosis. The authors conclude that the confirmation of positive status might serve as a gateway to re-engaging in services as 18% of those previously diagnosed, but not on ART, linked to care.

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis, Le Tourneau N, PLOS Med, March 2022

This systematic review evaluated the effect of reducing the frequency of clinical appointments and ART refills for people established on ART on retention and viral suppression. The authors found that retention in care was comparable for three- vs. six-monthly clinical consultants, three- vs. 12-monthly clinical consultations and three- vs. six-monthly ART refills. This review informed the revised 2021 World Health Organization guidelines on frequency of clinical visits and duration of ART refills.

Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis, Mirzazadeh A, PLOS Med, March 2022

This systematic review assessed interventions to re-engage people living with HIV in care. Most of the studies included focused on contacting clients as the intervention to support re-engagement, and there was insufficient data to conclude which strategies are most effective. Future research is required to understand what strategies should be implemented to support re-engagement and reduce interruption in treatment.

Estimating the effect of increasing dispensing intervals on retention in care for people with HIV in Haiti, Parrish C, EClinicalMedicine, July 2021

Using data from Haiti’s clinical system, this study assessed one-year retention in care among ART-naïve people living with HIV and estimated the causal impact of multi-month dispensing (MMD). Extending ART dispensing intervals increased the probability of retention 12 months after ART initiation. The authors also observed better retention among those receiving MMD.

HIV Testing Approaches to Optimize Prevention and Treatment for Key and Priority Populations in Malawi, Rucinski K, Open Forum Infectious Diseases, April 2022

This study analysed programme data to compare HIV case finding across different testing modalities. HIV case finding varied by modality and population, with index testing and enhanced peer outreach demonstrating the highest yield. Female sex workers tested via risk network referral were more likely to initiate ART within 30 days compared with those attending clinic-based testing. For gay men and other men who have sex with men, index testing and testing through a drop-in centre were associated with 30-day ART initiation.

Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis, Salomon A, PLOS One, May 2022

This systematic review analysed five interventions to improve linkage: co-location of testing and/or treatment services; client education and counselling; dedicated personnel; peer support; and financial support. Service co-location had the most consistent positive relationship with uptake of HIV testing and treatment initiation among people with TB and with TB case detection among people living with HIV. Operational system, human resources and/or laboratory strengthening were common in successful interventions.

What we're watching

Monkeypox under the spotlight

This IAS-organized webinar on monkeypox, held on 3 June, provided the latest information on the epidemiology of monkeypox in non-endemic countries and discussed prevention options, as well as updates on clinical presentation and treatment and research networks. Presenters also discussed the intersection of monkeypox and HIV.

Get in touch

Do you have content for the next newsletter? We want to hear from you.
Email us at dsd@iasociety.org.

www.differentiatedservicedelivery.org

Photo credits in order of appearance:
(1), (2) Anova Health Institute, (3) IAS

IAS - the International AIDS Society

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