Review
The HIV care continuum in Latin America: challenges and opportunities

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Summary

Combination antiretroviral therapy (ART), also known as highly active antiretroviral therapy, provides clinical and immunological benefits for people living with HIV and is an effective strategy to prevent HIV transmission at the individual level. Early initiation of ART as part of a test and treat approach might decrease HIV transmission at the population level, but to do so the HIV continuum of care, from diagnosis to viral suppression, should be optimised. Access to ART has improved greatly in Latin America, and about 600 000 people are on treatment. However, health-care systems are deficient in different stages of the HIV continuum of care, and in some cases only a small proportion of individuals achieve the desired outcome of virological suppression. At present, data for most Latin American countries are not sufficient to build reliable metrics. Available data and estimates show that many people living with HIV in Latin America are unaware of their status, are diagnosed late, and enter into care late. Stigma, administrative barriers, and economic limitations seem to be important determinants of late diagnosis and failure to be linked to and retained in care. Policy makers need reliable data to optimise the HIV care continuum and improve individual-based and population-based outcomes of ART in Latin America.

Introduction

Combination antiretroviral therapy (ART) has greatly improved the prognosis for HIV infection.1 ART benefits the individual, but could also have an important role in the prevention of HIV transmission at a population level.2 However, for ART to have the desired effect, high proportions of HIV-infected people must be diagnosed early in the disease course, be engaged in care, receive and adhere to effective treatment, and be virologically suppressed. The initial description of the HIV care continuum by Gardner and colleagues in 20113 showed that only a small proportion of HIV-infected individuals in the USA were virologically suppressed, despite widespread use of ART in the USA since 1997. This finding might explain why no appreciable reduction in HIV transmission has occurred. Deficiencies in the HIV continuum of care, from late diagnosis to poor ART adherence, limit the effectiveness of treatment for both therapeutic and preventive interventions.

Most countries in Latin America have concentrated HIV epidemics, with many undiagnosed individuals, and late diagnosis and late ART initiation are common. Brazil has a strong publication record for the continuum of care, as do, to a lesser extent, Argentina, Mexico, and Peru; many other Latin American countries have very little or no meaningful information available. In this Review, we aim to address what is known about continuums of care in Latin America, what the gaps in knowledge are, and how to address these gaps to improve comprehensive care for individuals living with HIV in the region.

We defined three HIV continuum stages in accordance with the standardised cascade-related measures, published by the US Institute of Medicine in 2012:4 linkage to HIV care (proportion of people with HIV who are linked to care within 3 months of diagnosis); retention in care (proportion diagnosed who are in continuous care with two or more routine HIV care visits at least 3 months apart in the preceding 12 months); and viral suppression (proportion who have been on ART for 12 months or more and have viral load below the level of detection).

Section snippets

HIV infection in Latin America

According to the Joint UN Programme on HIV/AIDS (UNAIDS), by the end of 2012, an estimated 1·5 million people were living with HIV/AIDS in the Latin American region, with 52 000 AIDS-related deaths and 84 000 new HIV infections (figure).5 In most of Latin America, the epidemic is concentrated in men who have sex with men (MSM) in whom HIV prevalence is between 15% and 20%.6, 7, 8, 9 Intravenous drug use, which was a main route of HIV transmission in Argentina in the 1990s, has become a less

Proportion of undiagnosed individuals and late HIV diagnosis

The step in the continuum of care with perhaps the poorest coverage and greatest uncertainty in ascertainment is the first—HIV testing. According to data from the Pan American Health Organization (PAHO), only 2·4% of the total spend on HIV in Latin America is allocated to provider-initiated HIV counselling and testing.13 Undiagnosed HIV-infected people are more likely to engage in HIV risk behaviours and could therefore contribute to a higher rate of transmission than those who are aware of

Linkage to and retention in HIV medical care

Prompt linkage to medical care for people who test positive for HIV is as important as testing. Failure to link to medical care is a common source of loss in the care continuum and yet the reasons for this failure are poorly understood or characterised. The consequences of failure to link to medical care are similar to those of being undiagnosed: ongoing high-risk behaviour and missed benefits from ART (which would limit both disease progression and transmission).34

In Latin American countries,

Virological suppression

To estimate the proportion of people with HIV in Latin America who are virologically suppressed is difficult. According to unpublished data from Venezuela and Mexico, between 12% (in Venezuela) and 25% (in Mexico) of the total HIV population achieves and sustains HIV-1 RNA suppression.15 Similar proportions have been reported from Peru by Caceres and colleagues,37 who showed that 18·3% of people reached viral suppression after 6 months of ART. Data derived from the national HIV monitoring

Test and treat strategy

Early initiation of ART decreases the frequency of clinical events, leading to health benefits in the HIV-infected individual.2 This observation coupled with the realisation that ART can prevent HIV transmission has led to major efforts to expand treatment uptake as a crucial component in biomedical interventions for HIV prevention.2, 41 Brazil, France, and the USA have already adopted the so-called test and treat strategy. Some African countries are also moving towards this approach to

Conclusions

Latin American countries face many challenges regarding HIV diagnosis and engagement in HIV care. The absence of reliable data from most Latin American countries on the HIV care continuum makes it difficult to develop and implement tailored interventions that could improve HIV care outcomes and lead to a decrease in the number of new HIV infections. Establishment of appropriate national databases would provide information about epidemic dynamics in local and national settings.

The fight against

Search strategy and selection criteria

We reviewed international and Latin American databases (PubMed, Scielo, LiLacs) with the search terms “HIV cascade”, “HIV continuum”, “HIV diagnosis” or “HIV testing”, “HIV linkage to care” or “HIV retention in care”, “HIV viral suppression”, and “HIV treatment access” for Latin American countries of South and Central America (excluding the Caribbean islands), for articles published in English and Spanish between January, 2000, and Nov 28, 2014. Grey literature such as presentations at

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