Purpose: Immediate initiation of antiretroviral treatment following HIV infection is a cornerstone of the current HIV ‘universal test and treat’ approach. Delayed progress along the HIV care... Show morePurpose: Immediate initiation of antiretroviral treatment following HIV infection is a cornerstone of the current HIV ‘universal test and treat’ approach. Delayed progress along the HIV care continuum is thus framed as a major stumbling block in effective HIV epidemic control. Through examining the HIV care trajectories of people diagnosed with HIV in Shinyanga Region, Tanzania, we offer a critical interrogation of the HIV care continuum. Methods: Data are drawn from a social science study on the uptake of a ‘treat all’ model of HIV prevention and care conducted from 2018 to 2019. Methods included interviews with participants who tested positive (n = 30) and interviews (n = 25) with health staff involved in the testing campaigns.Findings: Exploring individuals’ care trajectories, we found that most participants followed pathways to care that do not easily align with the current emphasis on rapid, linear progress from testing to treatment initiation. Instead, participants’ trajectories from diagnosis to treatment happened on a different, non-linear time scale mediated through social relations and diverse communities of care. We thus conceptualize five pathways of linkage to care - virtuous/immediate, delayed testing, repeat testing, negotiated, and ‘failed’.Conclusion: Based on our findings we propose a community-centered HIV care continuum that exposes moments of potential connection with or rupture from the health system and centers the importance of social support structures and forms of relational labor involving broader communities of care. Show less
Walsh, F.; Khan, S.; Barnighausen, T.; Hettema, A.; Lejeune, C.; Mazibuko, S.; ... ; Spiegelman, D. 2020
Purpose of Review The MaxART Consortium-led by the Eswatini Ministry of Health-implemented multiple interventions between 2012 and 2017 to achieve UNAIDS 90-90-90 targets. We summarize key findings... Show morePurpose of Review The MaxART Consortium-led by the Eswatini Ministry of Health-implemented multiple interventions between 2012 and 2017 to achieve UNAIDS 90-90-90 targets. We summarize key findings from community outreach strategies in support of the first 90 goal, and from the Early Access to ART for All (EAAA) trial on the implementation of a "Treat All" strategy to achieve the second and third 90 goals within a government-managed public health system. Recent Findings The MaxART Consortium demonstrated that "Fast Track," a problem-solving approach, was effective at increasing testing coverage in the community. Compared with baseline data at 3 months prior to the start of the Fast Track, there was a 273% proportional increase in HIV tests conducted among adolescent males, adolescent females, and adult men, and 722% over baseline for adolescent males. The MaxART EAAA trial further showed that implementation of the Treat All policy was associated with significant two-fold shorter time from enrollment into care to ART initiation than under the standard CD4+ cell threshold-based treatment guidelines. Finally, through the MaxART trial, Eswatini was able to identify areas for further investment, including addressing the system-side barriers to routine viral load monitoring, and designing and implementing innovative community-based approaches to reach individuals who were not more routinely accessing HIV testing and counseling services. As low- and middle-income countries adopt the Treat All approach in their national HIV care and treatment guidelines, further implementation science research is needed to understand and address the system-level barriers to achieving the benefits of Treat All for HIV-infected individuals and those at risk. Show less
