Title

The double-sided cascade of prevention and care and beyond

Code

THBS02

Session Type

Bridging Session

Venue

Hall 12

Date Time

Thursday 26 July, 14:30 - 16:00

Co-Chairs:

Geoff Garnett, Bill and Melinda Gates Foundation, United States
Susan Buchbinder, Bridge HIV, United States

This session will give an overview on how HIV treatment and prevention cascades are constructed and how the cascade data could be used most efficiently to guide HIV programmes. Efforts will be made to familiarize the audience to the prevention side of HIV cascade, which has not yet been widely discussed and used by countries. The panellists will provide guidance on how a standardized prevention cascade should be created and how it could be used to drive HIV prevention programme implementation. HIV treatment and prevention cascade data from various key populations in various countries will be shared, along with best practices on how these countries have been using the data to improve programme implementation for key populations. Lastly, innovative delivery models aimed at serious simplification of HIV testing services, as well as initiation and maintenance of ART and PrEP, will be discussed in order to improve both treatment and prevention cascades.

14:30 THBS0201	Introduction

14:35 THBS0202	Constructing and using cascades for HIV treatment and prevention James Hargreaves, London School of Hygiene and Tropical Medicine, United Kingdom	Slides

14:50 THBS0203	What do effective cascade-driven HIV programs look like Celestine Mugambi, National AIDS Control Council (NACC) Kenya, Kenya	Slides

15:05 THBS0204	Double-sided HIV cascades for key populations Chris Akolo, FHI 360, United States	Slides

15:20 THBS0205	Serious simplifications of HIV testing, ART, and PrEP to enhance the cascade Praphan Phanuphak, Thai Red Cross AIDS Research Centre, Thailand	Slides

15:35 THBS0206	Panel discussion

15:55 THBS0207	Closing remarks

AUTHOR

Raminta Stuikyte

SUMMARY

This session presented the current developments and thinking in treatment, PrEP and to some degree prevention cascades: how to construct them? how the cascade data could be used most efficiently to guide HIV programs? Examples including for several vulnerable and key populations came from PEPFAR countries, Kenya and Thailand.

HIGHLIGHTS

There has been a great progress in constructing and measuring treatment cascades including for eMTCT and 90-90-90 for populations. They greatly helped draw high-level political attention, build country ownership, and accountability. Similarly, cascades for PrEP helped to see the diversity of programs implemented with diverse results and particularly highlighted the limited integration of the retention aspect in cascades so far. More needs to be done to develop prevention cascades, maybe under UNAIDS leadership: there are no unified concepts, a doubt is present regarding feasibility of overcoming variety of challenges in developing either population or intervention-based cascades – including looking more integratively at structural, biomedical and behavioural issues, high stigma and discrimination, changing needs, disconnect between service M&E. The promise of cascades as a tool of communicating clearly the results has its limitations – how these snapshots of situation could be used in time, what causes leakages, etc.

CRITICAL ASSESSMENT

Several people raised questions about sustainability of the services that were presented through cascades – for MSM, trans people, sex workers particularly in middle income countries. We are failing in prevention not because there is lack of data on gaps. This is the second AIDS2018 where prevention cascades are discussed but some participants expressed a continued concern whether prevention cascades among key populations have a potential to overcome the political challenges to develop and generate uptake of community-based prevention tools, particularly for adolescent girls and key populations who together account for >70% of new HIV cases globally.

AUTHOR

Brian Rice

SUMMARY

With real-world examples from numerous countries, including Kenya and Thailand we were presented with an overview on how HIV treatment and prevention cascades are constructed and how they can guide HIV programmes. There was particular methodological focus on the prevention cascade.

HIGHLIGHTS

James Hargreaves (LSHTM / MeSH-Consortium, UK) highlighted treatment-cascades may be constructed cross-sectionally or longitudinally and arise from population-based surveys or programme data – re. latter point, likely “countries are often doing something in-between”. James argued that we “need to think about the frailties in surveys, models and clinic data” when interpreting prevention and treatment-cascades (P&TCs). Celestine Mugambi (NACC, Kenya) presented on both P&TCs in Kenya. Celestine considered why prevention programmes are often not scaled-up. Celestine stated “investments in cascades should cause minimal interruption to already existing health and other sector data systems”. Chris Akolo (LINKAGES, USA) presented country examples of P&TCs for key-populations, and identified gaps across these. Praphan Phanuphak (Red-Cross, Thailand) argued that “HIV testing is the centerpiece for the P&TC”.Praphan made a number of recommendation for filling gaps in the P&TC for key-populations. In discussion, it was agreed that tackling measurement and programming challenges must be a priority.

CRITICAL ASSESSMENT

When interpreting cross-sectional / “snapshot” cascades need to be aware some people in-care will not be included; for longitudinal-cascades we need to consider changing-states / temporal-dimensions. In treatment-cascades we need to develop methods to capture patterns of service-use and measure sustained viral-suppression. In prevention-cascades we need to consider how people travel in-and-out of being at risk and define risk clearly. The P&TCs highlight importance of being diagnosed – negative or positive. Important to link P&TC outputs to programmatic action (not just cascades for cascades sake) and to invest in routine HIV data systems to drive local, regional and national action.

AUTHOR

Saskia Janssen

SUMMARY

This session illustrated how HIV treatment and prevention cascades are constructed. Data from key populations in various countries were shared. Also, delivery models were presented that simplify HIV testing services, along with initiation and maintenance of ART and PrEP, aimed at improving both HIV prevention and treatment cascades.

HIGHLIGHTS

Dr Hargreaves started with giving an introduction to HIV treatment and prevention cascades, highlighting the differences but importantly also the similarities. Treatment and prevention cascades help us to find gaps in current health programmes, allowing us to identify interventions to address these. Dr Mugambi discussed the example of Kenya, where the PMTCT cascade was used for political engagement. The importance of linking several prevention cascades is essential; for example engaging males in prevention cascades of condom use to prevent HIV infection of young women. Dr Akolo presented the Linkage programme on prevention and treatment cascades in key populations in several countries, and highlighted that these programmes need to be key-population centered in order for them to be effective. Finally, Dr Phanuphak presented recent data on key-population led health service programmes in Thailand. By introducing same-day ART and PrEP initiation, the uptake of prevention and treatment strategies was enhanced.

CRITICAL ASSESSMENT

Prevention and treatment cascades are useful tools to evaluate health care programmes and to identify how to strengthen them. Integration of HIV prevention and treatment cascades is essential in enhancing uptake of preventive and therapeutic strategies. Key population centered approaches like key population led health care services are promising. Major challenges remaining are population dynamics and how to integrate retention into cascades; treatment cascades end at ‘viral suppression’ whereas the persistence of viral suppression is most important.