title: Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance: Findings From 4 Sub-Saharan African Countries.
abstract: 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 390,603 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.
authors.affiliation: *ICAP at Columbia University, New York, NY; †Department of Medicine, Weill-Cornell Medical College, New York, NY; ‡Department of Epidemiology, Mailman School of Public Health, New York, NY; and §Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, NY.
authors.forename: Margaret L
authors.initials: ML
authors.lastname: McNairy
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Lamb
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
authors.forename: Batya
authors.initials: B
authors.lastname: Elul
authors.forename: Ruben
authors.initials: R
authors.lastname: Sahabo
authors.forename: Mark P
authors.initials: MP
authors.lastname: Hawken
authors.forename: Antonio
authors.initials: A
authors.lastname: Mussa
authors.forename: Ayele
authors.initials: A
authors.lastname: Zwede
authors.forename: Jessica
authors.initials: J
authors.lastname: Justman
authors.forename: Wafaa M
authors.initials: WM
authors.lastname: El-Sadr
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003153:Community Health Services; D005260:Female; D006078:Government Programs; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents