DOI: 10.1111/hiv.12174 HIV Medicine (2015), 16, 1–2
© 2014 British HIV Association
EDITORIAL
The HIV cascade of care in Georgia: implications for countries in Eastern Europe and Central Asia (EECA) MC Donoghoe* Division of Communicable Diseases, Health Security and Environment, World Health Organization Regional Office for Europe, Copenhagen, Denmark Accepted 28 March 2014
here [8]. This is helpful in identifying particular failures or bottlenecks in the treatment programme. The second way is to show percentages at each stage calculated as a proportion of all PLHIV – typically how the US continuum is described and the basis for the 28% figure for those achieving viral suppression [6]. This is helpful in monitoring and evaluating the overall success or failure of the programme. Application of each of the two approaches produces different results. In the Georgian example, while 77% of those on ART achieved viral suppression, only 20% of the estimated 4900 PLHIV are virally suppressed – a slightly worse achievement than that which caused so much concern in the USA. In the USA, the major gap is at the stage of retention, while in Georgia it is at the stage of diagnosis – with an estimated 48% of PLHIV not diagnosed. Undiagnosed HIV infection is a major obstacle to achieving the individual and public health benefits of ART. In countries of EECA, up to 65% of PLHIV are undiagnosed [9]. The HIV cascade has been variously applied to all PLHIV in several countries, including the USA [6,7] and France [10], and to key vulnerable populations, including men who have sex with men in the UK [11] and black PLHIV in the USA [12]. The Georgian cascade makes an important contribution to our understanding of treatment programmes elsewhere in the EECA region, where countries typically have similar HIV epidemiology and health systems. Because little has been published to date on the application of the cascade to EECA countries, it highlights gaps and failures in the cascade that are probably common in other countries in the region, notably in HIV testing and diagnosis, and demonstrates what can be achieved in linkage and retention. The cascade is a useful tool for demonstrating the strengths in ART delivery programmes; in Georgia at the stages of retention and linkage, particularly for people who inject drugs. The HIV cascade can also identify weaknesses; in Georgia at the stage of diagnosis. Claims here that Georgia has made substantial progress in scaling up ART are well founded; however, the claim that Georgia has achieved ‘universal access’ is premature given
Expansion of access to HIV treatment is a global health priority. Recent international evidence, guidance and recommendations for a public health approach to the use of antiretroviral drugs to treat and prevent HIV infection moves us closer to controlling the HIV epidemic [1,2]. Despite the global increase in HIV treatment, gains are unevenly distributed. In Eastern Europe and Central Asia (EECA), only 35% of people eligible for antiretroviral therapy (ART) actually start it [3]. As a result, the numbers of AIDS cases and AIDS deaths are increasing rapidly in all EECA countries [4]. The HIV cascade of care is the sequential stages, or continuum, of care from HIV diagnosis, through linkage to and retention in care, to prescription of ART and viral suppression. In some circumstances the cascade also includes an interim stage between retention and prescription, namely eligibility for ART. The HIV cascade stresses the importance of engaging and retaining people along the care continuum, increasing the numbers receiving ART and being successfully treated. Failure across the HIV cascade is a major barrier to achieving universal access to ART and viral suppression of sufficient magnitude to control the epidemic. The concept of the cascade was given impetus with the establishment of the HIV Care Continuum Initiative in the USA [5]. The initiative came as a response to data showing that only 25% of people living with HIV (PLHIV) in the USA had achieved the national HIV/AIDS treatment goal of viral suppression. The data showed that patients were ‘lost’ at each stage of the cascade, including at the first stage where many PLHIV were undiagnosed, right through to the last stage where not all of those on ART achieved viral suppression [6,7]. The HIV cascade can be considered in two ways. While both approaches present the number of patients at each stage, the first uses percentages representing achievement at each stage, calculated as a proportion of patients from the previous stage, as in the Georgian example published *Correspondence: [email protected]
1
2 Editorial
that an estimated 48% of PLHIV are undiagnosed and untreated. Late diagnosis is a problem in Georgia and throughout EECA. Data published elsewhere show that 44% of newly diagnosed individuals in Georgia in 2012 had CD4 cell counts < 200 cells/μL and 70% < 350 cells/μL [4]. Georgia has a ‘successful’ HIV treatment programme in that 77% of those on ART achieve viral suppression. However, with an estimated 48% of PLHIV in Georgia undiagnosed, viral suppression is only achieved in 20% of all PLHIV in Georgia. As in all countries in the region, where 65% of PLHIV are undiagnosed and only 35% of people eligible actually start ART, the number of patients diagnosed, linked to and retained in care and put on ART needs to be drastically scaled up. Commendably, the authors recognize the gap in testing and diagnosis, particularly low testing coverage of key populations at risk. This is common across the region, where in 2012 less than 50% of people in the key populations had been recently tested. Solutions are proposed for Georgia, including expansion of community-based HIV testing, that may be equally applicable to other countries. Georgia has a mature electronic data collection system that records and follows each patient across the cascade. Constructing, evaluating and comparing HIV treatment cascades for other countries in EECA and for key vulnerable populations in those countries would greatly assist in the task of measuring progress towards universal access but more importantly identify strengths and weaknesses in programmes. Costs are not considered here in the Georgian cascade; however, universal access cannot be achieved without lowering costs and improving efficiency by adopting a public health approach balanced with the needs of the patient. Georgia and many other EECA countries have greatly benefited from, and are highly dependent on, Global Fund allocations for HIV programmes. EECA countries will increasingly need to rely on national budgets. It is clear that Georgia needs to lower treatment costs by, for example, optimizing drug treatment regimens and using simpler diagnostic and monitoring tools. All EECA countries will face similar choices in balancing state-of-the-art treatment for the privileged few against effective/efficient treatment for all. Successful engagement across the HIV cascade of care will benefit both individual and public health.
2 World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for A Public Health Approach. Geneva, World Health Organization, 2013. Available at http://www.who.int/hiv/pub/guidelines/arv2013/download/en/ 3 World Health Organization. Global Update on HIV Treatment 2013: Results, Impact and Opportunities. Geneva, World Health Organization, 2013. Available at http://www.who.int/ hiv/pub/progressreports/update2013/en/index.html 4 European Centre for Disease Prevention and Control WHO Regional Office for Europe HIV/AIDS Surveillance in Europe 2012. Stockholm, European Centre for Disease Prevention and Control, 2013. Available at http://www.euro.who.int/en/ health-topics/communicable-diseases/hivaids/publications/ 2013/hivaids-surveillance-in-europe-2012 5 Office of the Press Secretary. Accelerating Improvements in HIV Prevention and Care in the United States through the HIV Care Continuum Initiative. Washington, DC, Office of the Press Secretary, The White House, 2013. Available at http://www.whitehouse.gov/the-press-office/2013/07/15/fact -sheet-accelerating-improvements-hiv-prevention-and-care -united-stat 6 Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to Test-and-Treat strategies for prevention of HIV infection. Clin Infect Dis 2011; 52: 793–800. 7 Cohen SM, Van Handel MM, Branson BM et al. Vital signs: HIV prevention through care and treatment – United States 2011. MMWR 2011; 60: 1618–1623. 8 Chkhartishvili N, Sharvadze L, Chokoshvili O et al. The cascade of care in the Eastern European country of Georgia. HIV Med 2014; 16: 62–66. 9 Hamers FF, Phillips AN. Diagnosed and undiagnosed HIV-infected populations in Europe. HIV Med 2008; 9: 6–12. 10 Supervie V, Costagliola D. The spectrum of engagement in HIV care in France: strengths and gaps 20th conference on Retroviruses and Opportunistic Infections (CROI), Atlanta, USA, March 2013. Abstract 1030. 11 Delpech V. Health system concerns related to TasP and most at risk populations. IAPAC Treatment as Prevention and Prep London, UK, June 2012. 12 Whiteside YO, Cohen SM, Bradley H, Skarbinski J, Hall HI, Lansky A. Progress Along the Continuum of HIV Care Among Blacks with Diagnosed HIV – United States, 2010. MMWR 2014; 63: 85–89. Available at http://www.cdc.gov/ mmwr/pdf/wk/mm6305.pdf
References 1 UNAIDS. Treatment 2015. Geneva, UNAIDS, 2013. Available at http://www.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2013/JC2484_treatment-2015 _en.pdf
© 2014 British HIV Association
HIV Medicine (2015), 16, 1–2
© 2014 British HIV Association
EDITORIAL
The HIV cascade of care in Georgia: implications for countries in Eastern Europe and Central Asia (EECA) MC Donoghoe* Division of Communicable Diseases, Health Security and Environment, World Health Organization Regional Office for Europe, Copenhagen, Denmark Accepted 28 March 2014
here [8]. This is helpful in identifying particular failures or bottlenecks in the treatment programme. The second way is to show percentages at each stage calculated as a proportion of all PLHIV – typically how the US continuum is described and the basis for the 28% figure for those achieving viral suppression [6]. This is helpful in monitoring and evaluating the overall success or failure of the programme. Application of each of the two approaches produces different results. In the Georgian example, while 77% of those on ART achieved viral suppression, only 20% of the estimated 4900 PLHIV are virally suppressed – a slightly worse achievement than that which caused so much concern in the USA. In the USA, the major gap is at the stage of retention, while in Georgia it is at the stage of diagnosis – with an estimated 48% of PLHIV not diagnosed. Undiagnosed HIV infection is a major obstacle to achieving the individual and public health benefits of ART. In countries of EECA, up to 65% of PLHIV are undiagnosed [9]. The HIV cascade has been variously applied to all PLHIV in several countries, including the USA [6,7] and France [10], and to key vulnerable populations, including men who have sex with men in the UK [11] and black PLHIV in the USA [12]. The Georgian cascade makes an important contribution to our understanding of treatment programmes elsewhere in the EECA region, where countries typically have similar HIV epidemiology and health systems. Because little has been published to date on the application of the cascade to EECA countries, it highlights gaps and failures in the cascade that are probably common in other countries in the region, notably in HIV testing and diagnosis, and demonstrates what can be achieved in linkage and retention. The cascade is a useful tool for demonstrating the strengths in ART delivery programmes; in Georgia at the stages of retention and linkage, particularly for people who inject drugs. The HIV cascade can also identify weaknesses; in Georgia at the stage of diagnosis. Claims here that Georgia has made substantial progress in scaling up ART are well founded; however, the claim that Georgia has achieved ‘universal access’ is premature given
Expansion of access to HIV treatment is a global health priority. Recent international evidence, guidance and recommendations for a public health approach to the use of antiretroviral drugs to treat and prevent HIV infection moves us closer to controlling the HIV epidemic [1,2]. Despite the global increase in HIV treatment, gains are unevenly distributed. In Eastern Europe and Central Asia (EECA), only 35% of people eligible for antiretroviral therapy (ART) actually start it [3]. As a result, the numbers of AIDS cases and AIDS deaths are increasing rapidly in all EECA countries [4]. The HIV cascade of care is the sequential stages, or continuum, of care from HIV diagnosis, through linkage to and retention in care, to prescription of ART and viral suppression. In some circumstances the cascade also includes an interim stage between retention and prescription, namely eligibility for ART. The HIV cascade stresses the importance of engaging and retaining people along the care continuum, increasing the numbers receiving ART and being successfully treated. Failure across the HIV cascade is a major barrier to achieving universal access to ART and viral suppression of sufficient magnitude to control the epidemic. The concept of the cascade was given impetus with the establishment of the HIV Care Continuum Initiative in the USA [5]. The initiative came as a response to data showing that only 25% of people living with HIV (PLHIV) in the USA had achieved the national HIV/AIDS treatment goal of viral suppression. The data showed that patients were ‘lost’ at each stage of the cascade, including at the first stage where many PLHIV were undiagnosed, right through to the last stage where not all of those on ART achieved viral suppression [6,7]. The HIV cascade can be considered in two ways. While both approaches present the number of patients at each stage, the first uses percentages representing achievement at each stage, calculated as a proportion of patients from the previous stage, as in the Georgian example published *Correspondence: [email protected]
1
2 Editorial
that an estimated 48% of PLHIV are undiagnosed and untreated. Late diagnosis is a problem in Georgia and throughout EECA. Data published elsewhere show that 44% of newly diagnosed individuals in Georgia in 2012 had CD4 cell counts < 200 cells/μL and 70% < 350 cells/μL [4]. Georgia has a ‘successful’ HIV treatment programme in that 77% of those on ART achieve viral suppression. However, with an estimated 48% of PLHIV in Georgia undiagnosed, viral suppression is only achieved in 20% of all PLHIV in Georgia. As in all countries in the region, where 65% of PLHIV are undiagnosed and only 35% of people eligible actually start ART, the number of patients diagnosed, linked to and retained in care and put on ART needs to be drastically scaled up. Commendably, the authors recognize the gap in testing and diagnosis, particularly low testing coverage of key populations at risk. This is common across the region, where in 2012 less than 50% of people in the key populations had been recently tested. Solutions are proposed for Georgia, including expansion of community-based HIV testing, that may be equally applicable to other countries. Georgia has a mature electronic data collection system that records and follows each patient across the cascade. Constructing, evaluating and comparing HIV treatment cascades for other countries in EECA and for key vulnerable populations in those countries would greatly assist in the task of measuring progress towards universal access but more importantly identify strengths and weaknesses in programmes. Costs are not considered here in the Georgian cascade; however, universal access cannot be achieved without lowering costs and improving efficiency by adopting a public health approach balanced with the needs of the patient. Georgia and many other EECA countries have greatly benefited from, and are highly dependent on, Global Fund allocations for HIV programmes. EECA countries will increasingly need to rely on national budgets. It is clear that Georgia needs to lower treatment costs by, for example, optimizing drug treatment regimens and using simpler diagnostic and monitoring tools. All EECA countries will face similar choices in balancing state-of-the-art treatment for the privileged few against effective/efficient treatment for all. Successful engagement across the HIV cascade of care will benefit both individual and public health.
2 World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for A Public Health Approach. Geneva, World Health Organization, 2013. Available at http://www.who.int/hiv/pub/guidelines/arv2013/download/en/ 3 World Health Organization. Global Update on HIV Treatment 2013: Results, Impact and Opportunities. Geneva, World Health Organization, 2013. Available at http://www.who.int/ hiv/pub/progressreports/update2013/en/index.html 4 European Centre for Disease Prevention and Control WHO Regional Office for Europe HIV/AIDS Surveillance in Europe 2012. Stockholm, European Centre for Disease Prevention and Control, 2013. Available at http://www.euro.who.int/en/ health-topics/communicable-diseases/hivaids/publications/ 2013/hivaids-surveillance-in-europe-2012 5 Office of the Press Secretary. Accelerating Improvements in HIV Prevention and Care in the United States through the HIV Care Continuum Initiative. Washington, DC, Office of the Press Secretary, The White House, 2013. Available at http://www.whitehouse.gov/the-press-office/2013/07/15/fact -sheet-accelerating-improvements-hiv-prevention-and-care -united-stat 6 Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to Test-and-Treat strategies for prevention of HIV infection. Clin Infect Dis 2011; 52: 793–800. 7 Cohen SM, Van Handel MM, Branson BM et al. Vital signs: HIV prevention through care and treatment – United States 2011. MMWR 2011; 60: 1618–1623. 8 Chkhartishvili N, Sharvadze L, Chokoshvili O et al. The cascade of care in the Eastern European country of Georgia. HIV Med 2014; 16: 62–66. 9 Hamers FF, Phillips AN. Diagnosed and undiagnosed HIV-infected populations in Europe. HIV Med 2008; 9: 6–12. 10 Supervie V, Costagliola D. The spectrum of engagement in HIV care in France: strengths and gaps 20th conference on Retroviruses and Opportunistic Infections (CROI), Atlanta, USA, March 2013. Abstract 1030. 11 Delpech V. Health system concerns related to TasP and most at risk populations. IAPAC Treatment as Prevention and Prep London, UK, June 2012. 12 Whiteside YO, Cohen SM, Bradley H, Skarbinski J, Hall HI, Lansky A. Progress Along the Continuum of HIV Care Among Blacks with Diagnosed HIV – United States, 2010. MMWR 2014; 63: 85–89. Available at http://www.cdc.gov/ mmwr/pdf/wk/mm6305.pdf
References 1 UNAIDS. Treatment 2015. Geneva, UNAIDS, 2013. Available at http://www.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2013/JC2484_treatment-2015 _en.pdf
© 2014 British HIV Association
HIV Medicine (2015), 16, 1–2
