Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance: Findings From 4 Sub-Saharan African Countries

Abstract

Background: The traditional HIV treatment cascade has been noted to have limitations. A proposed comprehensive HIV care cascade that uses cohort methodology offers additional information as it accounts for all patients. Using data from 4 countries, we compare patient outcomes using both approaches.

Methods: Data from 390,603 HIV-infected adults (>15 years) enrolled at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from 2005 to 2011 were included. Outcomes of all patients at 3, 6, and 12 months after enrollment were categorized as optimal, suboptimal, or poor. Optimal outcomes included retention in care, antiretroviral therapy (ART) initiation, and documented transfer. Suboptimal outcomes included retention in care without ART initiation among eligible patients or those without eligibility data. Poor outcomes included loss to follow-up and death.

Results: The comprehensive HIV care cascade demonstrated that at 3, 6 and 12 months, 58%, 51%, and 49% of patients had optimal outcomes; 22%, 12%, and 7% had suboptimal outcomes, and 20%, 37% and 44% had poor outcomes. Of all patients enrolled in care, 56% were retained in care at 12 months after enrollment. In comparison, the traditional HIV treatment cascade found 89% of patients enrolled in HIV care were assessed for ART eligibility, of whom 48% were determined to be ART-eligible with 70% initiating ART, and 78% of those initiated on ART retained at 12 months.

Conclusions: The comprehensive HIV care cascade follows outcomes of all patients, including pre-ART patients, who enroll in HIV care over time and uses quality of care parameters for categorizing outcomes. The comprehensive HIV care cascade provides complementary information to that of the traditional HIV treatment cascade and is a valuable tool for monitoring HIV program performance.

FIGURE 1

HIV treatment cascade (N = 390,603 adults at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from January 2005 to June 2011).

FIGURE 2

A, Comprehensive HIV care cascade with outcome categories, and (B) comprehensive HIV care cascade with subgroups within outcome categories (N = 390,603 adults at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from January 2005 to June 2011).

FIGURE 3

HIV treatment cascade by country program (N = 390,603 adults at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from January 2005 to June 2011).

FIGURE 4

Comprehensive HIV care cascade by county program (Kenya N = 101,938 patients at 85 facilities, Mozambique N = 201,503 patients at 34 facilities, Rwanda N = 32,105 patients at 41 facilities, and Tanzania N = 55,057 patients at 57 facilities).