How do we maximise global HIV treatment access? IAPAC Care Continuum Guidelines make recommendations

IAPAC, the International Association of Practitioners in AIDS Care, has issued a set of guidelines that aims to establish a common set of best practices to ensure that as many people living with HIV as possible are diagnosed, cared for, receive treatment and achieve undetectable viral loads.

The IAPAC Care Continuum Optimisation Guidelines are intended to back up the 2013 and 2015 World Health Organization (WHO) treatment guidelines, which now recommend antiretroviral therapy (ART) for everyone diagnosed with HIV, and the 90-90-90 UNAIDS strategy, which aims to have 72.9% of all people with HIV on treatment and non-infectious by 2020.

The IAPAC guidelines are based on 1047 different articles that provide evidence to back up their 36 recommendations. The comprehensive literature search and editing process behind the guidelines took nearly two years and has had to be revised continually as new evidence has come in. Fifty-seven people were involved in the writing and editing process.

The guidelines address different steps of the so-called HIV ‘care cascade’, which analyses the percentage of people with HIV who are taking HIV treatment and have a suppressed viral load as the product of the proportion diagnosed, the proportion of those in medical care, the proportion of those on ART, and the proportion of those with a suppressed viral load. It also looks at general improvements that need to be made in the HIV care environment and in the monitoring and surveillance of HIV. It has a couple of additional appendices of unmet research needs and on special considerations for certain populations, but makes an exception for adolescents, whom it includes as a special section in the main recommendations.

Optimising the HIV care environment

Recommendations for optimising the care environment start by recommending the repeal of laws that criminalise men who have sex with men, people who use drugs, transgender people and sex workers, and also the repeal of laws that criminalise “the conduct of people living with HIV based on perceived exposure to HIV without any evidence of intent to do harm”. They note that “No differences in behaviour have been noted between settings that enact such laws and ones that do not.”

They also propose the repeal of any purely HIV-related restrictions by countries on people seeking entry, stay or residence. In addition, however, they note that “although refugees are typically eligible for services including ART through human rights laws and agreements, the rights to care of internally displaced populations are often more precarious.” They make strong mention of the importance of establishing whether migrants are in secure housing and have their basic subsistence needs met, and recommend specific evidence-based treatment strategies for homeless people.

They recommend strategies to eliminate stigma and discrimination, but, just as importantly, the adoption of standardised ways of measuring them, with a recommendation for the use of the Stigma Index for People Living with HIV as an adaptable tool.

The guidelines recommend the identification and management of mental health problems for people with HIV. “Connecting people living with HIV to mental health services at critical points along the HIV care continuum” is an intrinsic part of HIV care, they comment, noting that a recent meta-analysis found that treatment for depression increased the odds of adherence to ART by 83%.

They also recommend enabling people with HIV to take responsibility through their care by means such as self-management training, noting that in one San Francisco trial, the risk of non-adherence to ART decreased by 6% for each month people stayed in a self-management programme. Finally, they add that community involvement in every step of the HIV care continuum improves access to care, especially if people with HIV are trained as tutors or peer navigators for the more recently diagnosed.

HIV testing and prevention

With regard to testing, the guidelines recommend, without exception, routine ‘opt-out’ testing to every new patient who presents for healthcare. ‘Opt out’ means that “The patient is notified orally or in writing that an HIV test will be performed unless [they] decline.” It notes that in one cohort study, 78% of a group of women with HIV had had missed opportunities for testing. The guidelines are not as keen on testing based on risk reporting or assessment, or on using ‘indicator conditions’ as the main selection basis for testing, noting that risk reporting would miss eight out of ten cases of HIV.

They are keener on taking testing out into the community, noting that community-based programmes like Project ACCEPT, while they have not in themselves had strong effects on HIV incidence (perhaps because not all parts of the care cascade were addressed), did produce a large increase in HIV testing, especially in men.

Another strategy they recommend is contact-tracing, noting that a review of studies of partner notification found an HIV rate of between 1% and 8% in partners traced, and in regular partners 20%. They also recommend self-testing “with the provision of guidance on…administering the test and direction on what to do once results have been obtained”.

There is no ‘one size fits all’ answer to diagnosing more people, the guidelines stress: “Using varied modalities has the potential to reach people who have never tested before”.

The guidelines incorporate the recommendation of pre-exposure prophylaxis (PrEP) for ‘high risk’ people who test HIV-negative, quoting the PROUD study figure of 86% effectiveness against HIV in men offered PrEP versus men not offered it. They also recommend condoms, which “when used consistently and correctly” are 80% effective in preventing HIV infections, as shown by the largest meta-analysis conducted of the effectiveness of consistent condom use as an HIV prevention strategy. They do not quote an effectiveness figure for consistent condom use in anal sex. They recommend “evidence-based treatment for substance use” in people who inject drugs, making special mention of opiate substitution therapies.

Care, treatment, monitoring and adherence

The guidelines state that it is extremely important to refer people who test positive to care immediately. People who test positive not seeking or being referred to care is a particular problem in the US, where high diagnosis rates are not matched by medical referral rates.

They recommend patient managers and the proactive follow-up of people who have not returned for care or who have dropped out of care, suggesting three months after the last scheduled appointment as the best time to start contacting non-returning patients. They cite transport problems as a major factor in some areas and support the provision of free or subsidised transport, and easily accessible pharmacies located within the community.

Not surprisingly, they recommend treatment for all on diagnosis, in line with the WHO guidelines. They are convinced by the evidence that fixed-dose combination single-pill regimens generally achieve higher adherence and viral suppression rates. They recommend viral load testing to be done at least every six months for patients with less than two years of continuous viral suppression, and at least once a year for people with more than two years of viral suppression, as the preferred tool for monitoring the efficacy of ART. The authors add that “CD4 counts can be used to help determine eligibility for opportunistic infection prophylaxis but are not effective for assessing ART effectiveness, since CD4 count and viral load levels can be discordant”.

They do not find much evidence for specific measures that improve adherence to ART, but find several studies showing that weekly SMS text reminders can support adherence and one that shows that pill box organisers are superior to leaving pills in bottles. They specifically warn against the use of directly-observed therapy (DOT) for HIV except possibly time-limited DOT for people who are actively using or detoxing from drugs and for people recently released from prison. Universal HIV testing is recommended for people in prison.

Special population needs

In the appendix on specific populations, the guidelines make special mention that doctors should ask transgender people about hormone therapy use and should ask women about other medications including hormonal contraceptives, in order to ensure there are no interactions with ART. They also recommend screening women for physical and emotional abuse and violence. For both transgender people and men who have sex with men, they stress, community-based, safe healthcare settings may be particularly important, as is the use of “peer navigators” to help people through the early period of HIV care.

As noted above, the guidelines make special mention of adolescents as a group with specific needs. They recommend the removal of legal requirements for parental consent to HIV testing in “minor adolescents with capacity to consent” and furthermore the adoption in law of an age of consent for medical testing of 12 to 14 years. Specific adolescent services are recommended, and managed transition to adult care.

Finally, the guidelines finish off with a specific series of recommendations on the most useful data that needs to be gathered to measure the steps of the HIV care cascade to ensure that the adoption of all these recommendations is working.

IAPAC President José Zuniga told Aidsmap: “Our new guidelines zero in on the Achilles heel of the global push to end AIDS as a public health threat by 2030 – the HIV care continuum.

“Our evidence-based, practical recommendations for addressing gaps across the continuum and our standardized mechanism to measure and monitor progress will support getting more people tested, linked to and engaged in care, on antiretroviral therapy, and virologically suppressed.”