This article first appeared on the website of Pacific AIDS Network here. Republished with permisision of the author. Folllow PAN on twitter at @PAN_CBR
I didn’t attend AIDS 2012 in Washington last July, but I do remember that when others came back they were all abuzz about the concept of the treatment cascade as possibly the next “big thing” in the way that we conceptualize HIV prevention and treatment. Now, many months later, and numerous references to the treatment cascade in meetings, policy documents, articles, and other HIV-discourse hubs later, I have to give my AIDS 2012-attending friends and colleagues pats on the back because I think they were right.
This example of an HIV cascade of prevention and care appears in the 2012 document “From Hope To Health,” which lays out the BC government’s framework for the provincial expansion of the STOP HIV/AIDS program.
While the meme of “AIDS free generation” also took hold at AIDS2012, it’s purpose was mainly to offer hope and buoy a movement, while the treatment cascade seems to be a model that is transforming how we approach HIV treatment and work to identify gaps in the continuum of care (from prevention, to testing, to care and treatment) so that fewer individuals are lost along the way.
Roughly defined, the HIV treatment cascade (or the cascade in care) is a way of calculating what proportion of HIV in a country or community is on anti-retroviral treatment and is virally suppressed – meaning no detectable virus in the blood – and how many people “fall off” the cascade at each step. Below are some interesting and key documents to look at in order to build an understanding of this concept.
From Hope to Health: Towards an AIDS-free Generation – On December 1, 2012, the British Columbia Ministry of Health released a guidance document for the province’s expansion of the Seek and Treat for Optimal Prevention (STOP) project across the province. What was notable in the document was the inclusion of a figure illustrating a “treatment and care cascade for BC” (see image above), which was expanded from the traditional cascade model to also include “number of people at risk for HIV but not infected” as the starting point. It will be very interesting to see how the model is implemented.
The HIV treatment cascade – patching the leaks to improve HIV prevention – This comprehensive article written by James Wilton and Logan Broeckaert at CATIE is excellent in that translates the treatment cascade by explaining each “step” of the cascade and provides real-world examples of interventions and services that are used to help stop the leaks in the cascade. Wilton and Broechaert also address a concern regarding human rights that arises when using models such as this, which may reduce people to numbers and risk the goal (ie of low viral load in a population) seeming more important than individual agency. They say, “It’s critical that human rights are respected and that people living with or at risk of HIV are empowered to make decisions about testing and treatment that are right for them.”
Grappling with the HIV Treatment Cascade – In this PositiveLite.com article (originally published aidsmap.com), Gus Cairns looks at reports from the USA and Europe in terms of the proportion of individuals that are virally suppressed. This piece is interesting because it indicates that – although that the treatment cascade is a model that allows us to conceptualize the proportion of a population that has been tested and is retained in care – it is not a simple task to obtain actual numbers for each step. As PositiveLite.com editors suggest, without reliable data on the actual numbers, more research is certainly needed to confirm the extent of treatment penetration and to monitor future treatment as prevention initiatives.
North American Housing and HIV/AIDS Research Summit VII: Closing the Housing Gap in the HIV Treatment Cascade – This upcoming conference, to be held in Montreal in late September 2013, is a great example of the where the concept of treatment cascade is going next. As the title of the conference suggests, there is certainly a need to query how the social determinants of health, such as housing, inequitable distribution of resources, gender, food security, etc., can impact how many people are “lost” at each step of the cascade. The Summit will explore the potential of housing strategies to improve HIV treatment effectiveness in various jurisdictions. I believe that this is the tip of the iceberg in how we will be seeing various segments of the HIV service and research community engage with this concept.
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Andrea Langlois (above) is the Community-Based Research Manager, Pacific AIDS Network. She is on twitter at @PAN_CBR.