Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance: Findings From 4 Sub-Saharan African Countries.

BACKGROUND: The traditional HIV treatment cascade has been noted to have limitations. A proposed comprehensive HIV care cascade that uses cohort methodology offers additional information as it accounts for all patients. Using data from 4 countries we compare patient outcomes using both approaches. METHODS: Data from 390603 HIV-infected adults (>15 years) enrolled at 217 facilities in Kenya Mozambique Rwanda and Tanzania from 2005 to 2011 were included. Outcomes of all patients at 3 6 and 12 months after enrollment were categorized as optimal suboptimal or poor. Optimal outcomes included retention in care antiretroviral therapy (ART) initiation and documented transfer. Suboptimal outcomes included retention in care without ART initiation among eligible patients or those without eligibility data. Poor outcomes included loss to follow-up and death. RESULTS: The comprehensive HIV care cascade demonstrated that at 3 6 and 12 months 58% 51% and 49% of patients had optimal outcomes; 22% 12% and 7% had suboptimal outcomes and 20% 37% and 44% had poor outcomes. Of all patients enrolled in care 56% were retained in care at 12 months after enrollment. In comparison the traditional HIV treatment cascade found 89% of patients enrolled in HIV care were assessed for ART eligibility of whom 48% were determined to be ART-eligible with 70% initiating ART and 78% of those initiated on ART retained at 12 months. CONCLUSIONS: The comprehensive HIV care cascade follows outcomes of all patients including pre-ART patients who enroll in HIV care over time and uses quality of care parameters for categorizing outcomes. The comprehensive HIV care cascade provides complementary information to that of the traditional HIV treatment cascade and is a valuable tool for monitoring HIV program performance.