Diagnosis and monitoring of HIV programmes to support treatment initiation and follow up and improve programme quality
The much-discussed HIV ‘cascade of care’ has demonstrated marked loss between HIV diagnosis, linkage and initiation of antiretroviral treatment (ART), compromising mortality and morbidity benefits to the individual, as well as public health prevention impact. As large-scale programmes provide more long-term data, opportunities have arisen to reduces losses across the cascade. In an era of tenofovir disoproxil fumarate (TDF; Gilead Sciences, CA, USA) and nonnucleoside reverse transcriptase inhibitor (NNRTI)-based therapy, programmes rely on monitoring and excellent adherence to prevent movement to less well tolerated and nonco-formulated drugs. The UNAIDS Fast Track approach calls for 90% of people with HIV to know their HIV status, 90% of those diagnosed to receive sustained ART and 90% of these to have viral suppression, by 2020. New antiretrovirals that have better safety profiles while providing a far higher resistance barrier than current drugs will help to reduce some of these programmatic complexities, but do not address the first and second ‘90’ of the UNAIDS 90/90/90 targets, namely diagnosis and linkage to care.
In this article we consider the challenges in the cascade, and consider the role of national laboratories in improving outcomes across the continuum of care, with a call for focus on unique single patient national identifiers, as a means to better assess and improve HIV programme and pharmacovigilance in an era where electronic data systems are making contact and tracking of patients more of an option.