9.3 Retention across the continuum of care
Consolidated ARV guidelines, June 2013
9.3.2 Good practices for retention across the continuum of care
Optimizing retention in HIV care requires interventions at multiple levels of the health care system as well as implementation research. Given the broad array of challenges and heterogeneity of barriers across settings, no single approach is likely to work for everyone in all settings. Improving the understanding of barriers and innovative strategies to address them are important priorities in implementation research and public health.
Studies show that the direct and indirect costs of care affect the ability of people living with HIV to remain in care. They consistently report that the distance from health care facilities is a barrier to retention in diverse settings and along the continuum of HIV care. Related transport costs and loss of income while seeking care serve as disincentives when health facilities are located far from the person’s home. Bringing services closer to communities, where feasible, reduces the indirect costs of care for the people living with HIV and their families and improves retention.
Waiting times at the facility during consultation are frequently high, especially in settings with a high burden of HIV infection (58,59). Reorganizing services, such as systems for appointment, triage, separating clinical consultation visits from visits to pick up medicine, integrating and linking services and family-focused care may reduce waiting times at the health facility (59,60).
Many people living with HIV who are not yet eligible for ART may not attend clinic appointments and may not return to care until they are symptomatic. Regularly following up these individuals is important to ensure continual monitoring and timely initiation of ART. Countries have used approaches and achieved positive outcomes, including providing co-trimoxazole prophylaxis free of user charges, on-site or immediate CD4 testing with same-day results and peer support to improve retention in care (22,61,62).
Key populations generally experience more barriers to accessing health services. Interventions harnessing social support have emerged as a promising approach to counteract the structural, economic, service delivery and psychosocial constraints that affect retention in care.
Table 9.1 summarizes the factors related to the health system and people receiving ART influencing retention and adherence and potential interventions.