Care Cascade Research Articles

Disparities in Linkage to Care Among Children With Hepatitis C Virus in the United States.

Pediatric HCV cases have increased in the United States. Guidelines recommend beginning treatment of HCV for children as young as 3years old. However, no studies have evaluated pediatric linkage to HCV care and direct-acting antiviral (DAA) uptake on a national level. This study aims to characterize the HCV care cascade among a national cohort of children with HCV. This retrospective cohort analysis included children born between 2000 and 2018 who were diagnosed with HCV between the ages of 0 and 18years. We analyzed TriNetX Research Network data, a US national electronic health records network. Primary HCV care cascade outcomes included the number of children diagnosed with HCV infection, linked to care, and prescribed DAAs. We assessed the association between race and ethnicity with linkage to care using logistic regression. Among 928 children with HCV, 297 (32.0%) linked to HCV care and 111 (12.0%) were prescribed a DAA. Hispanic/Latinx children had double and white children had triple the odds of linkage compared with Black children (odds ratio [OR], 2.20; 95% CI, 1.05-4.59; OR, 3.44; 95% CI, 1.89-6.28) after adjusting for sex, birth cohort, and region. Pediatric access to HCV care remains low. Fewer than 1 in 3 children linked to HCV care and fewer than 1 in 8 were treated. This study uncovers racial and ethnic disparities in HCV care access. Targeting interventions toward increasing linkage to care could represent an opportunity to advance HCV elimination goals and reduce disparities.

Tuberculosis service delivery challenges and their mitigations during the COVID-19 pandemic in Tanzania: a qualitative study

ObjectiveTo describe challenges posed by COVID-19 on tuberculosis (TB) commodity supply, care cascade, active case finding and responses taken by healthcare workers (HCWs) and community health workers (CHWs) during the...

Low preventive treatment initiation and completion among young children contacts of active TB in Tbilisi, Georgia.

Within the Georgian National Tuberculosis Program (NTP), TB preventive treatment (TPT) is recommended for all child TB contacts ≤5 years. To assess adherence to this guidance, we evaluated the care cascade for the treatment of latent TB infection among children ≤5 years at the National Center for Tuberculosis and Lung Disease (NCTLD). We performed a cohort study among children ≤5 years evaluated at NCTLD during 2012-2014 as a contact of active pulmonary TB people. We recorded how many patients were recommended to start isoniazid preventive therapy (IPT) and how many initiated and completed treatment. Among 172 contacts of active TB people who visited the NCTLD between 2012 and 2014, 134 (74%) were contacts to drug-susceptible TB index cases. Among children recommended to start IPT (n= 94), 50 (51%) initiated treatment, and 16 (33%) completed IPT. Overall, 4 (4%) contacts developed active TB during 1,483 person-years of follow-up (mean 8.6 years), including 1 in the IPT group who did not complete therapy and 3 (6%) in the non-IPT group. Our findings highlight low rates of LTBI treatment recommendation, TPT initiation and completion among young children who were TB contacts in Georgia, highlighting the need for improved monitoring and enhanced treatment programs and regimens.

Engagement in hepatitis C virus cascade of care and factors associated with testing among people who inject drugs in Iran

BackgroundUnderstanding the hepatitis C virus (HCV) cascade of care (CoC) and factors associated with engagement is crucial for designing interventions for achieving HCV elimination. However, data on engagement in the HCV CoC among people who inject drugs (PWID) in the Middle East and North Africa remains limited. We examined the HCV CoC and factors associated with testing among Iranian PWID.MethodsWe recruited PWID in 14 cities using respondent-driven sampling. PWID completed structured interviews capturing measures on socio-demographics, behaviors, and HCV CoC. We examined the self-reported numbers and proportions of individuals who ever tested for HCV, tested positive for HCV antibody, were diagnosed with HCV, initiated HCV treatment, and achieved sustained virologic response (SVR). Multivariable logistic regression models were built to assess factors associated with HCV antibody testing.ResultsOf 2308 PWID, 23.1% had ever received an HCV antibody test, 13.9% received the HCV antibody test in the last year, 3.4% had tested positive for HCV antibodies, and 2.5% had received an HCV diagnosis. Of those diagnosed, 54.4% reported initiating treatment, and 31.6% had achieved SVR. HCV antibody testing was significantly associated with having knowledge about HCV transmission through sharing needle/syringe (adjusted odds ratio [aOR] 8.09; 95% confidence intervals [CI] 5.25, 12.48), living with HIV (aOR 4.15; 1.58, 10.92), no previous history of homelessness (aOR 1.89; 1.31, 2.72), history of arrest/incarceration (aOR 1.83; 1.26, 2.64), history of being diagnosed with any mental health problems (aOR 2.88; 1.79, 4.61), history of non-fatal overdose (aOR 1.51; 1.08, 2.10), receiving needle exchange programs in the last 12 months (aOR 6.20; 3.86, 9.93), opioid agonist treatment in the last six months (aOR 2.10; 1.39, 3.18), and having ever received HBV vaccine (aOR 2.31; 1.59, 3.35).ConclusionsWe found a considerably low engagement in HCV CoC among PWID in Iran. Enhancing access to testing services for PWID, especially those with limited awareness of HCV transmission and those encountering structural challenges, is essential as the initial step in the HCV CoC. This improvement is vital for strengthening HCV elimination efforts in Iran.

Postpandemic Trends and Missed Opportunities in Prevention and Diagnosis of Pediatric HIV.

Progress against HIV in the US slowed during the COVID-19 pandemic. Associated impacts for pediatric HIV may be substantial amid pandemic-related exacerbations of health inequities. We assessed pre-/post-pandemic trends in pediatric HIV diagnoses and characterized gaps in prevention or diagnosis. We performed a retrospective cohort study of children and adolescents with HIV (CAHIV) <18 years of age, treated at Indiana University Health facilities from January 2009 to December 2023. Demographic data, acquisition route, risk factor(s) and diagnosis year were abstracted, and compared pre-/post-2020. To assess trends, an interrupted time series analysis was conducted using an autoregressive integrated moving average model. Postpandemic missed opportunities for prevention or diagnosis were categorized. Among 126 CAHIV, with perinatal (73%) or nonperinatal (27%) HIV, 104 were diagnosed pre-2020 and 22 were diagnosed 2020 onwards. HIV diagnosis post-2020 was associated with nonperinatal acquisition ( P < 0.001), older age ( P = 0.004), US birth ( P = 0.002) and US diagnosis ( P < 0.001). Nonperinatal diagnoses in 2022 (n = 6) and 2023 (n = 5) were significantly higher than 1.6/year prepandemic (95% prediction interval 0-3.6). Among 8 CAHIV with perinatal HIV diagnosed post-2020-4 US-born-missed opportunities occurred across the mother-infant/pediatric care cascades. Among 14 CAHIV with nonperinatal HIV diagnosed post-2020, there were missed opportunities for preexposure prophylaxis (79%) and for HIV testing (65%) despite documented risk factors and indications. Nonperinatal HIV diagnoses increased post-2020, with gaps in adolescent prevention and diagnosis. Perinatal diagnoses in US-born infants signal critical gaps in perinatal prevention. Dedicated efforts are needed to prevent new pediatric HIV in the US.

Gaps in HIV Treatment and Care Cascade Among Men and Transfeminine Persons Who Have Sex with Men in Kenya, Malawi, and South Africa: Findings from the HIV Prevention Trials Network 075 Study (2015-2017).

Improving HIV outcomes for men who have sex with men (MSM) in sub-Saharan Africa requires addressing gaps in the HIV treatment cascade. This study examined these gaps among 71 treatment-naive MSM with HIV in the HIV Prevention Trials Network 075, a 1-year prospective biobehavioral cohort study (2015-2017) across four sub-Saharan African sites. Following a positive diagnosis, 86% of participants sought HIV care. Reasons for not having sought care or delays included a lack of perceived health issues and practical challenges. Most participants (80%) who engaged in care were prescribed antiretroviral therapy (ART). Although self-reported adherence was high, over one-third of those prescribed ART had no detectable antiretroviral drugs (ARVs) at the study's conclusion. ARV detection was significantly associated with study site, higher income, and experienced homophobia. The highest adherence rates were observed at the site offering direct, integrated treatment, underscoring the potential of "one-stop shop" services to mitigate intra-, interpersonal, and structural barriers. Despite a supportive study environment, gaps remain in linking MSM and transfeminine individuals to sustained HIV care and ART adherence. Given the urgency of addressing HIV among these populations, targeted interventions that promote engagement in care and adherence to treatment are critical.

Accessibility and quality of care for adults with hypertension in rural Burkina Faso: results from a cross-sectional household survey.

Providing quality healthcare is essential to reduce the future burden of cardiovascular disease. We assessed the quality of care for people with hypertension in Burkina Faso using the Institute of Medicine (IoM) Quality Domains of effectiveness, timeliness of access, patient-centredness and equitability of care. We performed an analysis of cross-sectional household survey data collected from a population-representative sample of 4000 adults ≥40 years in Nouna, Burkina Faso in 2018. For people with hypertension, effectiveness was assessed through care cascades describing the proportion who were screened, diagnosed, treated, and achieved hypertension control; timeliness was defined as access to care within the last three months. Patient-centredness was described using experiential quality process and outcome measures (dichotomised as higher or lower quality [score above or below and including the median, respectively]; a shared understanding and decision-making (SUDM) variable was described. Equity was assessed for effectiveness, timeliness, and patient-centredness in multivariable analyses including socio-demographic factors. In total, 1006 participants with hypertension were included. Hypertension prevalence was 34.8%; 62.3% had been screened, 42.9% diagnosed, 15.0% treated, and 6.8% were controlled; 26.8% had accessed care within the last three months. Overall, 61.8% of participants had a positive view of the health service. Clarity of communication and opinion of medical provider knowledge were the best-rated experiential quality process variables, with 40.1% and 39.7% of participants´ responses indicating higher quality care respectively. The mean SUDM score was 68.5 (±10.8), range 25.0-100.0. Regarding equity, screening was higher in females, adults with any education, those who were married or cohabiting, and those in the higher wealth quintiles. There were no associations seen between SUDM and sociodemographic variables. Although the prevalence of hypertension was high in this population, the quality of care was not commensurate, with room for improvement in all four IoM Domains assessed.

Availability and Uptake of Cervical Cancer Screening and Treatment Services at 19 Kenyan Health Facilities: A Brief Report.

In 2012, Kenya announced its commitment to prioritizing cervical cancer (CC) services with the National Cervical Cancer Prevention Program. However, gaps in implementation remain, causing suboptimal uptake. The goal of this study is to provide a situational analysis of 19 government health facilities in Kenya to assess facilities' capacity to provide CC screening and treatment. We conducted a retrospective data review at 19 health facilities in Siaya and Busia counties of Kenya from September 2021 to September 2022 to assess availability and uptake of CC services. Key variables included hospital volume, positivity, and numbers of women screened, treated, and referred. Notes were taken to document challenges with service provision and data collection. The retrospective review informed site matching for a proposed cluster-randomized trial. There were a total of 16,757 CC screenings or rescreenings documented across the 19 study sites during the study period. Across the 19 facilities, 10.8% of the women enrolled in care at the hospital were screened during the data collection period. The overall positivity was 3.8% but ranged from 0.7% to 16.7%. Of the 19 facilities offering CC screening, five lacked the required equipment to provide same-day treatment, and complex referral pathways were noted for women needing to seek care elsewhere. Challenges with documentation were noted at all stages of CC services. Gaps noted were low screening rates, opportunities to improve the efficiency of CC services, structural limitations in implementing the screen-and-treat approach, and poor documentation of CC services and outcomes. Urgent action is needed to ensure that all facilities offering CC screening are equipped with the personnel, supplies, and equipment necessary to conduct guideline-adherent same-day cryotherapy or thermal ablation treatment and improve documentation at the facility level to track CC services across the cascade of care.

Area-level socioeconomic inequalities in hypertension care cascade in China: a nationwide population-based study based on the ChinaHEART project.

Area-level socioeconomic inequalities in hypertension care cascade in China: a nationwide population-based study based on the ChinaHEART project.

Feasibility of a prison-based test-and-treat model for enhancing hepatitis C care in Kedah, Malaysia

BackgroundHepatitis C virus (HCV) infection remains a public health concern, significantly affecting vulnerable populations including people who use drugs and in prisons. This study assessed the feasibility of a new prison-based test-and-treat model for HCV in two prisons in Kedah, Malaysia.MethodsThe model was tested on participants newly admitted between June 2022 and December 2023 to one of the two selected prisons, one for pretrial detention and the other for serving sentences. It features a streamlined test-and-treat procedure within prisons, encompassing anti-HCV (exposure) testing, HCV ribonucleic acid (RNA) (current infection) testing, pretreatment assessments, and treatment initiation. The outcome assessment focused on (I) screening coverage, (II) implementation success across the HCV care cascade, ranging from anti-HCV detection, HCV RNA confirmation, treatment initiation, and completion to a sustained virological response rate and (III) practicality within resource-limited prison environments.ResultsAll 18,811 (100%) newly admitted participants were screened for HCV during the study period, with 4,054 (21.6%) of them testing positive for anti-HCV (HCV exposure). A total of 793 (19.6%) participants underwent HCV RNA testing, with 655 (82.6%) confirmed to have HCV infection. Those with HCV RNA test results were mainly male (98.1%), with nearly half (48.2%) aged 40–49 years. A vast majority (95.7%) reported at least one HCV risk factor, primarily injection drug use (95.2%). Of the 655 participants with a positive HCV RNA test, 648 (98.9%) completed pretreatment assessments. Antiviral treatment was initiated in 319 (49.2%) of them, with 165 (51.7%) completing the full course. Among those who completed treatment, 80 (48.5%) underwent HCV RNA testing 12 weeks after treatment, with 77 (96.3%) achieving a sustained virologic response.ConclusionThis new prison-based test-and-treat model for HCV infection demonstrates promising feasibility, as indicated by high screening coverage and successful implementation across the HCV care cascade using existing resources. These findings suggest the potential for broader adoption of this model in correctional facilities. Further research is needed to improve treatment completion and address factors contributing to dropout.

Evaluation of the hypercholesterolemia care cascade and compliance with NCEP-ATP III guidelines in Iran based on the WHO STEPS survey

IntroductionNoncommunicable diseases (NCDs), particularly cardiovascular disease (CVD), are the leading cause of death worldwide, with hypercholesterolemia being a major risk factor for CVD. This study evaluated the hypercholesterolemia care cascade in Iran—including prevalence, diagnosis, treatment coverage, and effectiveness—using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines.MethodsThis cross-sectional study drew on data from the 2021 Iran STEPS survey, which employed a systematic cluster sampling of adults aged ≥ 18 years across all provinces in Iran. Hypercholesterolemia was defined per NCEP-ATP III thresholds (LDL ≥ 160 mg/dL, total cholesterol ≥ 240 mg/dL, HDL ≤ 40 mg/dL, or ongoing lipid-lowering therapy). Weighted descriptive statistics were calculated, and Poisson regression with robust variance estimated crude and adjusted prevalence ratios for optimal lipid control among those treated. The 10-year CVD risk was determined using the Framingham Risk Score, stratifying participants into low (< 10%), intermediate (10–20%), and high (> 20%) risk categories.ResultsOut of 18,074 participants, 10,582 (55.32%, 95% CI: 54.29–56.35) met NCEP-ATP III criteria for hypercholesterolemia. Among these, only 20.61% (19.55–21.72) were receiving pharmacological treatment. Treatment coverage was notably lower in males (13.15%, 11.98–14.40) than females (29.12%, 27.35–30.96). Statins were the most commonly used medication (11.43% of males, 25.87% of females). Of those receiving treatment, 52.85% (females) and 53.93% (males) achieved optimal LDL, while 76.98% (females) and 81.06% (males) attained total cholesterol < 200 mg/dL. However, only 19.89% (females) and 3.97% (males) met the HDL > 60 mg/dL goal. The 10-year CVD risk was < 10% in 57.79% of participants, 10–20% in 33.27%, and > 20% in 8.94%.ConclusionDespite a high prevalence of hypercholesterolemia in Iran, treatment coverage remains suboptimal, particularly among males and working-age adults. Although most treated individuals achieve favorable LDL and total cholesterol levels, gaps persist in achieving optimal HDL targets. These findings underscore the need for strengthened screening, treatment, and adherence strategies—alongside broader preventive measures—to reduce the burden of hypercholesterolemia and CVD in Iran.

Impact of stigma on the HIV care cascade among older persons living with HIV in sub-Saharan Africa: protocol for a systematic review

IntroductionData are limited on the impact of stigma (stigma associated with HIV and/or stigma related to old age (ageism) or both) on linkage to the HIV care cascade among older...

Identifying mechanisms by which social determinants of health impact TB diagnostic evaluation uptake in Uganda: a qualitative study

BackgroundSocial and structural determinants of health (SDoH) are associated with tuberculosis (TB) outcomes but often unaddressed in TB care programs. We sought to describe the mechanism by which SDoH impact completion of TB diagnostic evaluation in Uganda using an implementation science framework rooted in behavioral theory.MethodsTrained research staff interviewed 24 purposively sampled adults undergoing TB diagnostic evaluation at six community health centers in Uganda between February-August 2019. Framework analysis was used to construct themes linked to SDoH across the TB diagnostic evaluation cascade of care. Themes were then mapped to domains of the capability, opportunity, and motivation behavior change model (COM-B).ResultsBarriers related to SDoH were identified across the diagnostic evaluation cascade of care and associated with domains central to uptake of testing and treatment. These included: limited knowledge about TB diagnosis and treatment (psychological capability); low socioeconomic status and competing financial priorities (physical opportunity); internalized and anticipated stigma of TB diagnosis, lack of social support programs and limited social support/social capital (social opportunity, reflective motivation); trust (or distrust) in the government health facility to provide quality care (reflective motivation); and fear and shame about worsening poverty (automatic motivation). Facilitators to engagement with the TB cascade of care included encouragement from friends and family to seek testing (automatic motivation, social opportunity), and trust that healthcare providers were acting in their best interests (social opportunity).ConclusionsBiomedical interventions alone are unlikely to address the spectrum of SDoH-related barriers to equitable completion of TB diagnostic evaluation. Linking barriers to a behavior change model such as COM-B may help guide the design and evaluation of appropriate people-centered strategies that integrate social and economic supports with clinical and public health programs or services.

Mental health care cascade performance and associated factors: longitudinal analyses of routine Ministry of Health services in Mozambique

IntroductionMental, neurological and substance use (MNS) disorders are leading causes of disability worldwide. Nevertheless, limited research exists regarding MNS health system performance across the care cascade and associated patient characteristics...

Breaks in the Cascade of Care: Evidence to Shift From Facility-Based Screening of Household Contacts of People With Tuberculosis in Rural Tanzania.

Breaks in the Cascade of Care: Evidence to Shift From Facility-Based Screening of Household Contacts of People With Tuberculosis in Rural Tanzania.

Care cascades of diabetes and hypertension among late adolescents in India.

Diabetes and hypertension are the most prevalent morbidities in India and are quickly becoming common among the younger age groups. Adolescents aged 10-19 years, accounting for one-fifth of the country's population, are at an increasing risk of developing these conditions. We aim to examine the prevalence, awareness, treatment, and control (ATC) of diabetes and hypertension among late adolescents (15-19 years) in India. We used microdata of 204 346 late adolescents from India's fifth round of the National Family and Health Survey, 2019-21. We defined hypertensive adolescents as those diagnosed with hypertension or those with a systolic blood pressure (BP) measurement of ≥130 mm Hg, diastolic BP measurements of levels ≥80 mm Hg, or those who used medication to lower BP at the time of the survey. Diabetic adolescents were those diagnosed as such by health professionals, those with glucose levels above 140 mg/dL, or those taking any medication to control high blood glucose levels at the time of the survey. We estimated the age-sex-adjusted prevalence of both conditions and their ATC rates, referred to as cascade care. We used the Erreygers' Concentration Index to examine the socioeconomic inequality in cascade care. We used multivariable logistic regression to estimate the average marginal effects while controlling for sociodemographic characteristics. Of 204 346 late adolescents, 27.8% (95% confidence interval (CI) = 27.6, 28.2) had either of the two conditions, with 3.5% (95% CI = 3.4, 3.6) being diabetic and 24.3% (95% CI = 24.0, 24.6) having hypertension. The ATC rate of diabetes was 13.5% (95% CI = 12.4, 14.7), 13.1% (95% CI = 11.9, 14.2), and 12.1% (95% CI = 11.0, 13.3), respectively. For hypertension, the ATC rate was extremely low at 6.2% (95% CI = 5.8, 6.5), 3.5% (95% CI = 3.3, 3.7), and 3.3% (95% CI = 3.1, 3.5), respectively. There was a pro-rich socioeconomic inequality in the prevalence of hypertension and a pro-poor inequality in the prevalence of diabetes among late adolescents. We observed significant variations in both conditions across the regions of India. The high prevalence and low care cascade levels of diabetes and hypertension among late adolescents in India are concerning. A multipronged strategy that includes screening, diagnosis, and timely interventions at school and home can reduce the burden of hypertension and diabetes among the prospective workforce in India. Sensitising adolescents through school curricula under the New Education Policy (2020) is recommended to reduce the burden of these conditions. We also recommend that longitudinal and intervention studies focussed on this age group be undertaken in the future to help reduce the disease burden.

Impact of mental health service use on the HIV care cascade among women.

While the negative effects of mental health issues on HIV clinical outcomes have been well-documented, the impact of mental health treatment on the HIV care cascade is largely uncharacterized. The objective of this study was to describe the engagement of women with mental health conditions and symptoms, who reported using mental health services, across the HIV care cascade and to assess the relationship between mental health service use and HIV care steps. Longitudinal data were analysed from participants enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) (2013-2018) who had clinically significant depressive symptoms or reported a mental health diagnosis at baseline. Among this subset, four states of HIV care were defined at baseline, 18 months and 36 months: (1) unengaged in care (did not visit an HIV provider in the past year), (2) not on antiretroviral therapy (ART) (visited an HIV provider in the past year but did not report current ART use), (3) detectable (reported current ART use but a detectable viral load) and (4) optimal (reported current ART use and an undetectable viral load). Sankey diagrams were used to illustrate the engagement of women across the HIV care cascade over 3 years based on their self-reported use of mental health services at baseline. The association between mental health service use and care state at baseline was analysed using multinomial logistic regression models. Of the 898 women in the cohort with significant depressive symptoms or mental health conditions at baseline, 3.8% (n = 34) were unengaged in care, 10.9% (n = 98) were not on ART, 12.4% (n = 111) were detectable and 72.9% (n = 655) were optimal. Over the 36 months, 51.0% of women transitioned between states at least once. When stratified by service use, women who reported use of mental health services at baseline had better engagement across the care cascade and had fewer transitions between states over the 3 years, 37.2% of which were to better states of care. The use of mental health services at baseline was also significantly associated with greater odds of engagement in the optimal state compared with not on ART (adjusted odds ratio [aOR]: 1.72, 95% confidence interval [CI]: 1.07-2.77). A similar but statistically insignificant association was found with the detectable care state (aOR: 1.67, 95% CI: 0.92-3.03). Our findings demonstrate that linkage to mental health care has a positive impact on HIV care outcomes among women. Accessible mental health services may serve to improve both mental well-being and progression of these patients along the HIV care cascade, thereby achieving individual and public health goals.

Investigating the enablers and barriers for hypertension control in Dakar: a qualitative system effectiveness study

ObjectiveCardiovascular disease is the main cause of death worldwide. The leading risk factor, hypertension, is a major public health issue in Senegal, putting the health system under pressure. This qualitative...

A step forward in tuberculosis elimination: implementing migrant latent tuberculosis screening and treatment in Oman.

A step forward in tuberculosis elimination: implementing migrant latent tuberculosis screening and treatment in Oman.

Prevalence of advanced HIV disease in sub-Saharan Africa: a multi-country analysis of nationally representative household surveys.

Prevalence of advanced HIV disease in sub-Saharan Africa: a multi-country analysis of nationally representative household surveys.