The importance of supporting re-engagement in HIV treatment services: A new WHO policy brief

Clarice Pinto, Technical Officer, DSD for HIV Treatment, at the World Health Organization (WHO) writes:

Significant progress has been made toward achieving the UNAIDS 95-95-95 targets. In 2022, 86% [73- >98] of people living with HIV knew their status, 89% [75- >98] who knew their status were receiving ART and 93% [79- >98] receiving antiretroviral therapy were virally suppressed[1]. Nevertheless, treatment interruptions, which are common, challenge these gains: studies show that in central, eastern, southern and western Africa, 20-50% of ART clients have previously interrupted treatment[2].

Supporting tracing and re-engagement in HIV treatment services is crucial. Disengagement from HIV care can lead to advanced HIV disease, increased mortality, higher rates of transmission and drug resistance. The World Health Organization’s (WHO’s) 2021 Consolidated guidelines on HIV include a strong recommendation for tracing people who have disengaged from care and providing support for re-engagement to reduce the chance of future disengagement[3].

A recent systematic review examining reasons for disengagement during the “treat all” era showed that the reasons for disengagement are multifaceted, encompassing individual, interpersonal, health system and structural factors. Lack of transportation, unplanned mobility, stigma, mental health problems and a lack of perceived benefits from ART, among other issues, often hinder sustained engagement in treatment and care[4].

WHO’s Supporting Re-engagement in HIV Treatment Services: Policy Brief is, therefore, timely and essential. This brief consolidates existing WHO recommendations and summarizes evidence-based strategies to address barriers to sustained engagement in HIV treatment and care. By focusing on person-centred solutions, it emphasizes understanding the diverse needs and challenges faced by individuals who disengage from treatment.

Life is dynamic with needs continually evolving, and health programmes must be prepared and flexible to adapt to these changing needs. The brief highlights key WHO recommendations to support and sustain engagement of people living with HIV in treatment and care, such as tracing approaches (e.g. phone, text messages, or home visits), adherence support (e.g. cognitive behavioural therapy, peer support and counselling), community-based interventions (e.g. patient advocates, treatment and peer support interventions providing adherence and psychosocial support in the community), the use of person-centred client data to monitor treatment interruptions and differentiated re-engagement support interventions. Practical approaches include implementing clinical assessments, offering rapid ART initiation, offering an advanced HIV disease package of care and providing adherence support upon re-engagement, tailored to client’s needs and reasons for disengagement. These approaches can significantly improve health outcomes for people living with HIV.

This policy brief calls for a shift from merely increasing ART access to supporting sustained engagement in treatment and care, through the implementation of some guiding principles for improving the quality of HIV services (e.g. ensuring a welcoming, non-stigmatizing environment; ensuring equitable access to care; and engaging communities), that are relevant across contexts to support durable re-engagement. It urges HIV programmes to ensure that HIV services are adapted to the needs and preferences of people living with HIV by implementing differentiated re-engagement support pathways.

[1] UNAIDS, https://aidsinfo.unaids.org/, accessed 17 May 2024.

[2] Mariet Benade, Mhairi Maskew, Allison Juntunen, David B Flynn, Sydney Rosen. Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or reinitiation in sub-Saharan Africa: a systematic review BMJ Open. 2023 Nov 19;13(11):e071283. doi: 10.1136/bmjopen-2022-071283.

[3] World Health Organization, 2021. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. https://www.who.int/publications/i/item/9789240031593

[4] Burke RM, Rickman HM, Pinto C, Ehrenkranz P, Choko A, Ford N. Reasons for disengagement from antiretroviral care in the era of “treat all”: A systematic review. J Int AIDS Soc. 2024 Mar;27(3):e26230. doi:10.1002/jia2.26230.