title: Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa?
abstract: Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.
authors.affiliation: Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA, 02120, USA. IKatz2@Partners.org.|Harvard Medical School, Boston, MA, USA. IKatz2@Partners.org.|Massachusetts General Hospital Center for Global Health, Boston, MA, USA. IKatz2@Partners.org.
authors.forename: Ingrid T
authors.initials: IT
authors.lastname: Katz
authors.affiliation: Harvard Medical School, Boston, MA, USA.|Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
mesh_terms: D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003657:Decision Making; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control; D006801:Humans; D057545:Social Stigma; D016312:Treatment Refusal
chemical_list: D019380:Anti-HIV Agents
keywords: ART refusal; Antiretroviral medications; Global epidemic; HIV prevention; HIV/AIDS; Point of testing; Review; Science of prevention; Treatment refusal