Closing the gaps in the HIV care continuum
Authors: Ruanne V. Barnabas, Connie Celum
Journal: PLoS Medicine (2017)

the Joint United Nations Programme on HIV and AIDS (UNAIDS) reported the effect of remarkable ongoing successes in the HIV care continuum: of the estimated 33 million HIV-positive persons worldwide, 70% know their status; among those people, 77% (19.5 million) are on antiretroviral therapy (ART) for HIV and 82% of persons on ART are virally suppressed, indicating successful treatment [1].The goal set by UNAIDS for the HIV care continuum is to bring about testing of 90% of HIV-positive persons, to initiate ART among 90% of HIV-positive persons tested, and to achieve viral suppression among 90% of those on ART [2].This 90-90-90 strategy is expected to achieve control of the HIV epidemic by 2030, with significant health and economic benefits among those treated and from the number of new HIV cases prevented.Although the UNAIDS goal appears to be within reach, innovative approaches are necessary to close the gaps and reach people not already in care in the many different affected countries, and to streamline services to achieve efficiency and preserve or improve quality of services.In this issue of PLOS Medicine, two independent studies present notably consistent findings on the substantial impact of combination intervention strategies (CIS) on increasing linkage to and retention in the HIV continuum of care in two different settings in sub-Saharan Africa [3,4].The evidence-based strategies to strengthen linkage and retention in HIV care in the CIS components included point-of-care CD4 testing, accelerated ART initiation, text message reminders, and noncash financial incentives to increase linkage and retention in HIV care.Margaret McNairy and colleagues report on the Link4Health Study, a cluster-randomized controlled trial conducted in Swaziland that compared CIS (including noncash financial incentives) with the clinic standard of care (SOC) [3].Batya Elul and colleagues report on the Engage4Health study, also a cluster-randomized controlled trial, which was conducted in Mozambique and compared SOC to CIS without financial incentives and CIS with financial incentives (CIS+) [4].Both studies enrolled newly identified HIV-positive persons who were willing to initiate ART.The first step in the CIS was point-of-care CD4 testing to decrease the time to determination of ART eligibility, followed by a clinical screen to exclude criteria for delayed ART, counseling, and accelerated ART initiation.Once ART was initiated, both studies strengthened retention in care by providing reminders (phone calls or text reminders) and small noncash financial incentives (mobile phone vouchers, health educational packages, or travel reimbursements).The combined primary outcome was linkage to care at one month and retention at month 12, with secondary outcomes measuring the impact of CIS at each step in the HIV continuum.The Link4Health study randomized 2,197 HIV-positive persons to two arms and the Engage4Health study randomized 2,005 individuals to three arms.Both studies followed participants for 12 months with good ascertainment of outcomes through review of records and tracing participants who were lost to follow-up.At the time the studies were