Strengths and weaknesses of HIV care in Uganda exposed

An assessment of test-and-treat, which was rolled out nationally in Uganda in 2017, finds that more than 90% of people diagnosed with HIV in Tororo, Eastern Uganda started treatment. But more than one in five were no longer in care after 12 months, linked to a lack of pre-treatment counselling and adherence support, and only half received viral load monitoring. Among those able to access a viral load test, viral suppression was high at 89%.

In this retrospective study, the records of 580 people newly diagnosed with HIV between June 2017 and May 2018 in a clinic run by NGO The Aids Support Organization were analysed. Test and treat, a policy to provide lifelong antiretroviral treatment (ART) to all people living with HIV irrespective of clinical stage, was being implemented during this period.

Most of the patients studied (93%) were aged 20 or above and 56% were women. Around 90% tested positive through community-based testing.

Within a month of diagnosis, 92% had begun treatment. But after 12 months only 79% were still receiving ART at the clinic. This retention-in-care rate is lower than expected, as previous studies conducted during the test-and-treat era in Uganda put the one-year care retention rate at around 90%.

People who received counselling before starting ART, those with a treatment supporter, and people with an opportunistic infection were more likely to stay on treatment than others. This highlights the importance of ensuring that every person diagnosed with HIV gets counselling and support before and during treatment as it has a clear impact on adherence.

Just under 90% of those who received viral load monitoring were virally suppressed, which is in sight of the UNAIDS’ target. Children and adolescents were less likely to be virally suppressed than those aged 20 and over, which is consistent with findings from previous studies. Offering tailored psychosocial support to younger people living with HIV remains an important strategy for ensuring their treatment is effective.

Although the viral suppression rate reported by the study is good, as only half (52.4%) of patients received viral load monitoring, the overall viral suppression rate remains unclear.

People in urban areas were more likely than people in rural areas to miss out on viral load monitoring.

The lack of viral load monitoring reveals a key weakness in the current implementation of test and treat, which must be addressed to ensure all people living with HIV who are on treatment receive this essential aspect of HIV care.