The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions

International epidemiology Databases to Evaluate AIDS in Southern Africa

Research output: Contribution to journalReview article (Academic Journal)peer-review

Abstract

INTRODUCTION: The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.

METHODS: We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.

RESULTS AND DISCUSSION: Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.

CONCLUSIONS: The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

Original languageEnglish
Article numbere25761
Number of pages14
JournalJournal of the International AIDS Society
Volume24
Issue number7
DOIs
Publication statusPublished - 22 Jul 2021

Bibliographical note

Funding Information:
Funding of the International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA‐SA) collaboration was provided by 10 institutes, centres and programmes of the US National Institutes of Health (NIH): the U.S. National Institutes of Health’s National Institute of Allergy and Infectious Diseases (NIAID) ( https://www.niaid.nih.gov ), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) ( https://www.nichd.nih.gov ), the National Cancer Institute (NCI) ( https://www.cancer.gov ), the National Institute of Mental Health (NIMH) ( https://www.nimh.nih.gov ), the National Institute on Drug Abuse (NIDA) ( https://www.drugabuse.gov ), the National Heart, Lung, and Blood Institute (NHLBI) ( https://www.nhlbi.nih.gov ), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) ( https://www.niaaa.nih.gov ), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) ( https://www.niddk.nih.gov ), the Fogarty International Center (FIC) ( https://www.fic.nih.gov ) and the National Library of Medicine (NLM) ( https://www.nlm.nih.gov/ ) under Award Number U01AI069924. The research reported is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health. ME was supported by special project funding (Grant No. 189498) from the Swiss National Science Foundation ( www.snf.ch ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health or any governments or institutions mentioned earlier.

Funding Information:
Funding of the International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration was provided by 10 institutes, centres and programmes of the US National Institutes of Health (NIH): the U.S. National Institutes of Health?s National Institute of Allergy and Infectious Diseases (NIAID) (https://www.niaid.nih.gov), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (https://www.nichd.nih.gov), the National Cancer Institute (NCI) (https://www.cancer.gov), the National Institute of Mental Health (NIMH) (https://www.nimh.nih.gov), the National Institute on Drug Abuse (NIDA) (https://www.drugabuse.gov), the National Heart, Lung, and Blood Institute (NHLBI) (https://www.nhlbi.nih.gov), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (https://www.niaaa.nih.gov), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (https://www.niddk.nih.gov), the Fogarty International Center (FIC) (https://www.fic.nih.gov) and the National Library of Medicine (NLM) (https://www.nlm.nih.gov/) under Award Number U01AI069924. The research reported is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health. ME was supported by special project funding (Grant No. 189498) from the Swiss National Science Foundation (www.snf.ch). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health or any governments or institutions mentioned earlier.

Publisher Copyright:
© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society

Keywords

  • HIV
  • care cascade
  • sub-Saharan Africa
  • ART outcomes
  • virological suppression

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