Review

The HIV care continuum in Latin America: challenges and opportunities Alicia Piñeirúa, Juan Sierra-Madero, Pedro Cahn, Rafael Napoleón Guevara Palmero, Ernesto Martínez Buitrago, Benjamin Young, Carlos Del Rio

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, healthcare 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 individualbased 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 www.thelancet.com/infection Vol 15 July 2015

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).

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%.6–9 Intravenous drug use, which was a main route of HIV transmission in Argentina in the 1990s, has become a less important risk factor for HIV acquisition, because drug use in the country has shifted towards non-injectable drugs such as cocaine taken by snorting or smoking.9,10 Some countries such as Guatemala and Honduras have generalised epidemics with predominantly heterosexual transmission and a high proportion of women affected; prevalence in the general population in these countries is greater than 1%.9,11,12 In Mexico and Central America, migration to the USA adds complexity to the HIV epidemic dynamics. The relation between migration and HIV vulnerability has been extensively addressed in the Garífuna region of Honduras, Guatemala, and the southern Mexican border.9 Many international organisations and initiatives have been developed and implemented to increase availability of ART and other HIV-care-associated expenditures in response to an HIV epidemic. In Latin America and the Caribbean, international funding represents only 6% of the total HIV expenditure.13 However, funding varies substantially between these countries. Middle-income countries such as Mexico, Brazil, Venezuela, Colombia, Chile, Argentina, and Costa Rica have less than 10% of international funding, Panama has 13%, and Bolivia 87%13,14 (table 1).

Lancet Infect Dis 2015; 15: 833–39 Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA, USA (A Pineirua MD, Prof C Del Rio MD); Instituto Nacional de Ciencias Medicas y Nutricion ‘Salvador Zubiran’, Tlalpan, Mexico (A Piñeirúa, J Sierra-Madero MD); Juan A Fernandez Hospital, Fundación Huésped, Buenos Aires, Argentina (P Cahn MD); Department of Infectious Diseases, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela (R N Guevara Palmero MD); Infectious Diseases, Department of Internal Medicine, Universidad del Valle, Santiago de Cali, Colombia (E Martínez Buitrago MD); International Association of Providers of AIDS Care, Washington, DC, USA (B Young MD); Josef Korbel School of International Studies, University of Denver, Denver, CO, USA (B Young); and Emory University Center for AIDS Research, Atlanta, GA, USA (Prof C Del Rio) Correspondence to: Dr Benjamin Young, International Association of Providers of AIDS Care, 1990 M Street, NW Suite 380, Washington, DC 20036, USA [email protected]

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Review

Mexico (0·3%) Belize (1·8%) Guatemala (0·8%) Honduras (1·2%) El Salvador (0·8%)

Nicaragua (

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

Combination antiretroviral therapy (ART), also known as highly active antiretroviral therapy, provides clinical and immunological benefits for people ...
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