Appraisal of the Risk Stratification and Case Management Approach for Enhancing Retention in HIV Care and Treatment Among Recipients of Care in Malawi

Overview

In pursuit of eradicating the AIDS epidemic, the global community established the 95-95-95 targets. These objectives outline the ambition that by 2030, 95% of individuals living with HIV will be aware of their HIV status, 95% of those aware will receive antiretroviral therapy (ART), and 95% of those on treatment will attain viral load suppression (VLS) (1). However, the successful attainment of the third 95%, particularly regarding VLS, significantly hinges on ensuring continuous engagement in care. Sustained engagement in care, known as retention in care, is pivotal for optimizing both individual health and broader public health outcomes within the HIV care continuum (2). Retaining individuals in care facilitates treatment adherence, monitors treatment progress, prevents and manages complications, and addresses various challenges encountered in the HIV care process by providing tailored support services (2,3).

The progress achieved in combating HIV faces a growing obstacle posed by suboptimal retention in care, notably through cases of loss to follow-up (LTFU) (2,4). Inadequate retention in care and non-adherence to treatment correlate with substandard VLS, drug resistance, heightened morbidity, increased risks of complications, elevated transmission probabilities, and mortality (2). Various factors contribute to poor retention in care and LTFU, falling into several categories: HIV-related issues such as physical comorbidities and decreased functionality; demographic factors like gender, age, pregnancy, and marital status; socioeconomic and educational levels; social factors such as stigma, discrimination, and disclosure of HIV status; and health system challenges such as distrust, confidentiality, distance, transportation costs, negative experiences, strained relationships with health workers, and limited drug accessibility (2,3,5–7). Over time, numerous interventions have aimed to enhance retention in care, bolster treatment adherence, and decrease LTFU, particularly within the critical first year of treatment initiation when LTFU rates tend to be higher. These interventions include establishing youth-friendly clinics, sending text message reminders, employing community and household strategies, providing transportation assistance, and implementing conditional cash transfers (3,8,9). Nevertheless, following evaluations, the outcomes of these interventions have exhibited a mixed impact.

Despite the substantial strides Malawi has made towards meeting the 95-95-95 targets, there are further opportunities for progress, including tackling emerging concerns. For instance, the 2020 Malawi Population-Based HIV Impact Assessment (MPHIA) survey disclosed an 8.9% adult HIV prevalence and an 87.3% VLS prevalence among HIV-positive adults (10). Similarly, with an estimated annual incidence of 20,000 new HIV cases, concerted efforts are needed to ensure their enrollment and retention in care, given that LTFU predominantly occurs among newly initiated clients. In 2021, supported by PEPFAR and CDC, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) Malawi extended assistance to 304,300 individuals receiving HIV care across 179 health facilities. To optimize the outcomes of EGPAF Malawi’s program, an intervention involving risk stratification and case management was devised and implemented to enhance retention rates and diminish LTFU.