Streamlined services

The review showed that multifaceted interventions to reduce time between diagnoses and engagement in care and ART initiation were associated with increased rates of ART initiation, including (1) enhanced linkage with case management, (2) support for HIV disclosure, (3) patient tracing for those who failed to engage in care, (4) training staff to provide multiple services and (5) streamlined services to accelerate the time to initiation. Multifaceted, streamlined services may use incentives to improve linkage to care and ART initiation.

Peer support and navigation

The specific interventions evaluated included home visits, peer support, including for navigating the health-care system, and enhanced counselling. The evidence for peer support and navigation interventions was overall of moderate certainty, due either to observational study design or the small number of trials identified. In the reviewed studies, peer navigators assisted people to link from community-based testing services to health-care settings where HIV care is provided.

Quality improvement

Quality improvement interventions have shown benefits for linkage to care, especially for programmes to prevent the mother-to-child transmission of HIV (14). Integrated service delivery – providing ART in TB and maternal, newborn and child health care settings – has been found to reduce time between diagnosis and ART initiation. A qualitative evidence synthesis found that people’s experience of positive interaction with their health-care providers supports linkage to HIV care (15). Disclosure support also positively affected linkage.

Pregnant and breastfeeding women

Testing during pregnancy is usually conducted in antenatal care and – unless treatment is also provided at the same location – there is often a high rate of disengagement from care since mothers and health-care workers may be more focused on pregnancy care. Solutions include:

• integrating HIV and maternal, newborn and child health services, so that testing and treatment are provided in one place; and
• if integration is not appropriate, such as in low-prevalence settings, using peer support systems to ensure linkage between antenatal care and ART care service may be valuable.

Optimal maternal retesting time points must be considered during pregnancy and postpartum. In settings with a high burden of HIV infection, retesting is advised for all pregnant women with an unknown or HIV-negative status during late pregnancy (third trimester). Catch-up testing is needed if the first test or retest is missed or delayed. Countries with a high burden of HIV infection could consider an additional retest in the postpartum period for specific districts or regions with a high HIV burden or incidence, for women from key populations and women who have a partner living with HIV who does not have suppressed viral loads (9).

Children

There is historically poor retention among children, especially for infants tested using early infant diagnosis within programmes to prevent the mother-to-child transmission of HIV. Solutions include:

• using point-of-care early infant diagnosis to improve linkage;
• using SMS, GSM or GPRS printers to speed up the return of results from central laboratories; and
• using family-centred care service delivery models, in which the mother, her baby and her partner receive care at the same point of care.

Adolescents

Developmental changes during adolescence may mean that not all adolescents have the ability to cope with an HIV diagnosis. Adolescents may also have limited awareness of their own health needs and of the availability of services as well as limited experience and confidence in navigating health services. Consent requirements may restrict access to treatment and care. Solutions include providing adolescent friendly linkage services; mechanisms involving outreach to adolescents such as peer-based interventions; community-based services; other outreach services; support groups; mobile technology, social media or call centres. These linkage mechanisms should be introduced at the point of testing.

Key populations

Key populations have been defined as people who are at increased risk because of specific behaviour compounded by structural challenges such as criminalization, violence and stigma and discrimination which affect their access to health services. For HIV, key populations include men who have sex with men, sex workers, transgender people, people in prison and other closed settings and people who use or inject drugs.

Although the health interventions for key populations do not differ from those of other people at risk of or living with HIV, their access is often compromised and delivery of services may therefore need to be adapted. Involving key populations in designing, implementing and providing services is critical to ensure that the services are offered in a way that they can actually access them.

Community-based service delivery, including through peers, has shown to be more effective in many settings, especially where laws criminalize same-gender sex, sex work or drug use.

Particular issues are relevant for people in prisons and other closed settings. Not only access to high-quality health services when imprisoned as a matter of equity but also because of the major risk of treatment interruptions when transitioning between (and within) prisons and the community. Implementing safety measures to ensure the continuity of care is critical, such as providing several months of treatment to people who move back into the community to address issues of housing, health insurance, health-care provider, etc.

Background and rationale

Community-based HIV testing approaches are a key component of any HIV testing strategy (9). In most settings, if a positive HIV diagnosis is made in the community – for example through mobile health services, community centres, services focusing on key populations and patients’ homes – the individual is then referred to a health centre to start treatment (9).

WHO recommends rapidly initiating ART, including starting on the same day of a positive diagnosis, partly because of the large losses previously observed between diagnosis and initiation (18).

Losses to care between community HIV testing and ART initiation are substantial: a systematic review of studies in sub-Saharan Africa found that the proportions linked to care could be as low as 14% for home-based testing and 10% for community-based testing; in some settings, less than one quarter were known to have started treatment (73). The reported reasons for not initiating treatment can include feeling healthy, insufficient social support, HIV stigma, high care-seeking costs and incomplete knowledge of treatment benefits (74). This is of particular concern for vulnerable populations such as women, young girls and key populations, who have a heightened risk of stigma, discrimination and violence. WHO has provided recommendations on how national programmes should work to protect these populations (70,75). A study from South Africa and Zambia found that people testing positive in the community often delayed starting ART because of issues related to the quality of care (including long waiting times, lengthy initiation procedures and lost clinic folders) and the stigma associated with accessing care (76). Other studies have cited lack of time (77) and concern about long clinic waiting times as the main reported reasons for not linking to care and starting treatment (78).

A systematic review identified three randomized trials and four observational studies providing evidence that offering ART initiation outside the health facility was associated with an increase in the proportion of people starting ART (RR 1.86, 95% CI 1.29–2.68), increased retention in care at 6–12 months following ART initiation (RR 1.44, 95% CI 1.33–1.56) and increased suppression of viral loads (RR 1.31, 95% CI 1.13–1.61) (79); two studies included in this review included key populations (80,81), and one study included adolescents and young adults (82).

Benefits and harm

Early initiation of ART is associated with several health benefits, including reduced mortality and morbidity and reduced onward transmission (83). The offer to start ART before referral to a health facility has the potential to reduce delays in starting treatment for individuals who are unwilling or unable to be referred to the health facility to start treatment. Although the studies that assessed community ART initiation reported no intervention-specific harm, ensuring that baseline assessments and support are provided either as part of the intervention or on referral to the health facility is important.

Feasibility, cost and cost–effectiveness

When ART initiation is included as a component of existing community activities, additional expertise and resources are needed, as reflected by the studies (78). A randomized trial of community-based ART in South Africa and Uganda included an activity-based microcosting study to estimate the annual per-client cost of community-based ART initiation. The study concluded that community-based ART could cost US$ 275–452 per person with suppressed viral loads, slightly more than the US$ 214–422 per person with suppressed viral loads estimated for the facility-based initiation group (84). Another study, from Malawi, assessed optional home initiation of ART following HIV self-testing and found that the average annual cost per participant who initiated ART was US$ 172 versus an annual cost of providing ART in facilities of US$ 858–1165 (85).

Equity and acceptability

Implementing this recommendation could potentially increase access to treatment for individuals who may experience structural barriers such as criminalization, stigma and discrimination when attempting to access health-care services to initiate treatment. A study among female sex workers in the United Republic of Tanzania found that those receiving community ART initiation were more likely to have started treatment and be retained in care and less likely to have interrupted treatment or feel high levels of internalized stigma (81,86). Evidence for adolescents was limited, and the acceptability is uncertain.

Implementation considerations

Confirmatory HIV testing needs to be ensured before ART initiation, consistent with HIV testing guidance that a single reactive test always needs confirmation (9) (see Chapter 2). WHO guidelines recommend a readiness assessment when starting ART, including ART literacy, and clinical assessment that includes CD4 cell count enumeration to determine whether a person has advanced HIV disease and requires further diagnostic investigation and provision of prophylaxis (18). WHO further recommends that nurses be able to initiate ART (3), and this should be facilitated by supportive professional regulations and relevant policies at the national level.

Clients starting ART outside a health facility should be linked to a facility and enrolled in a long-term model of care. ART initiation should also be accompanied by appropriate counselling to ensure that individuals understand the importance of lifelong adherence and receive appropriate support. For those who are not ready to start, referral for care should be provided. Initiating ART outside a health facility needs to be accompanied by appropriate measures to ensure that risk assessment and counselling support are provided, including at the time of initiation and in the period thereafter. Additional practical advice may need to be provided on the administration and storage conditions of ARV drug formulations for infants and younger children; community health-care providers should be trained to provide effective counselling to caregivers to support such requirements (87). In addition, ensuring that adolescents are linked to psychosocial care and that children and parents are supported with disclosure and age-appropriate treatment literacy is important.

Implementation of community ART initiation should consider health system requirements for supporting ART delivery at the community levels, including adequate drug supply, laboratory services, training and supervising health personnel, providing preventive therapy and referral mechanisms for those who need higher-level care. Such adaptations may require a phased approach (for example, by starting implementation in settings in which community prevention and testing activities have been established). The provision of community HIV care should be included in national initiatives to ensure the quality of care.

Research gaps

Research is needed to improve understanding of client preferences about where to start ART and how to link to care by age, population and setting (88,89). Tools to support initiation outside the health facility need to be identified and evaluated. Evidence shows substantial variability in the size of the community treatment team, and implementation research would be valuable in defining the optimum staffing complement and minimum set of skills required. Evidence on how ART initiation outside the facility affects household spending and catastrophic costs would also be of value.

Background and rationale

In 2017, WHO strongly recommended that rapid ART initiation be offered to all people living with HIV following a confirmed HIV diagnosis and clinical assessment, with the offer of same-day start for people who are ready (12). This recommendation was supported by evidence showing that rapidly initiating ART leads to an increased likelihood of starting treatment and improved suppression of viral loads and retention in care and may lead to reduced mortality (90). WHO also strongly recommends that nurses be able to initiate and maintain ART (3).

The uptake of this recommendation in national policy is variable. Several countries have not adopted this recommendation in national guidance, and some (91) but not all (92,93) studies have reported poorer retention in care when ART is started on the same day compared with less rapid ART initiation. Patient perspectives have highlighted the importance of good counselling and non-judgemental, respectful personnel (94).

A systematic review was conducted to identify approaches that support accelerating the offer or uptake of ART after diagnosis among people living with HIV. The review identified 26 studies; 11 were conducted in general populations and three among pregnant women, 10 included key populations (seven included men who have sex with men, two people who inject drugs and one female sex worker) and two included adolescents.

Many strategies were examined, and these could be classified into (1) strategies targeting clients, (2) strategies targeting health-care providers and (3) strategies targeting the health system. Evidence indicated that all these approaches were associated with increased uptake of ART, suppression of viral loads at 12 months and retention in care at 12 months (95).

The systematic review identified a diversity of interventions to improve uptake and outcomes following same-day ART initiation; some of these interventions provided indirect evidence of benefit for other aspects of HIV care. This diversity of direct and indirect evidence provided high certainty in the overall benefit of providing approaches to improve uptake, treatment adherence and retention, and this led the Guideline Development Group to make a good practice statement. It was considered important to highlight strategies targeting clients, health care providers, and the health system. The most commonly assessed interventions are detailed in Table 7.1.

Table 7.1

Evidence-informed approaches to supporting same-day ART initiation at the level of the client, provider and health system.

Background and rationale

In 2016, WHO recommended clinical visits every 3–6 months and dispensing ART lasting 3–6 months for people established on ART (3). Two distinct recommendations were made to underscore the point that clinical visits and medication pick-up should be considered separately. These recommendations have been broadly adopted by national guidelines, with clinical visits and medication pick-up every three months most commonly adopted according to country surveys (51,96).

A systematic review assessed the evidence on outcomes associated with different frequencies of clinical visits and refills of ART (97). The review identified three randomized trials and three observational studies comparing clinic visit frequency at three and six months and found no difference in retention in care (RR = 0.99, 95% CI 0.94–1.03, low-certainty evidence) or suppression of viral loads (RR = 1.02, 95% CI 0.86–1.21, low-certainty evidence). The review also identified three studies, including one randomized trial, comparing ART dispensing frequency and found no difference in retention in care (RR = 1.00, 95% CI 0.98–1.02, moderate-certainty evidence); suppression of viral loads at six months was marginally reduced in one study (35) but similar in the other two studies (55,98). One study across six African countries reported that children and adolescents who transitioned to multi-month prescribing maintained favourable outcomes in terms of death, retention, adherence, immunosuppression and suppression of viral loads (51).

Benefits and harm

For people living with HIV who are established on ART, a frequency of clinical visits and dispensing of ART of 3–6 months is associated with improved outcomes compared with monthly schedules. The certainty of the evidence was low to moderate. Some of the evidence supporting these recommendations came from observational studies with methodological limitations, and there was important variability in outcomes across studies. No harm was identified.

Feasibility, cost and cost–effectiveness

Many countries have adopted the previous WHO recommendation of clinic visits and ART dispensing every 3–6 months, demonstrating feasibility across a diversity of settings (51,96). WHO has also recommended reducing client contact with health services as a way to maintain essential health services during periods of service disruption (99). Differentiated service delivery for HIV treatment, including reduced visit frequency and increased ART refills, saves substantial patient travel costs and greatly reduces the time required to receive ART, including time spent on transport, waiting in the queue or having a clinic visit (100). Reducing the visit frequency also reduces health system costs, making this a cost-saving intervention.

Equity and acceptability

A review of relative patient preferences among adults living with HIV found that, compared with monthly drug refills, people living with HIV preferred longer intervals but showed no strong preference for three-month compared with six-month refill frequency (67). The Guideline Development Group judged that providing the option of less frequent health service interaction has the potential to increase equity by improving opportunities to access care for vulnerable and mobile populations.

Implementation considerations

Reducing the frequency of drug dispensing requires adequate drug supply and the possibility for appropriate storage for clients, including for community ART delivery. Consideration should be given to harmonize and optimize scheduling while ensuring patient choice and linkage to other key services, including viral load and other laboratory investigations and dispensing of medications for TB preventive treatment and chronic conditions. Extended refills should be considered for children older than two years when the dose is adjusted less frequently (21), since younger children need to attend health services for routine services such as immunization. Additional models of community support may need to consider clinic visits for certain groups at greater risk of facing adherence challenges and those at increased risk of other conditions as a result of complications from pregnancy, such as members of key populations, adolescents and pregnant and postpartum women as well as individuals or groups requiring special care to prevent or treat pregnancy-related risks, illness and death.

Research gaps

Evidence is needed on outcomes associated with less frequent clinical visits and/or drug refills (beyond six months) for various populations. In particular, there are contexts in which annual clinical visits are the standard of care and may both benefit clients and reduce costs for health systems.

Background

Adherence to ART is the primary determinant of whether viral loads are suppressed and of the risk of transmission, disease progression and death (101–103).

Suboptimal adherence is a major challenge worldwide and is associated with a diversity of individual, interpersonal, community and structural factors. The most frequently reported individual barriers across all age groups include forgetting, being away from home and a change to daily routine. More than 15% of the people receiving ART report that depression is a barrier to adherence across all age categories, and adults and adolescents commonly report alcohol and substance misuse as a barrier. With respect to contextual barriers, secrecy or stigma is a commonly cited barrier to adherence, reported by more than 10% across all regions. Health service–related barriers are frequently reported, including distance to the clinic and stock-outs (104). Specific population groups that face additional challenges to adherence include pregnant and postpartum women, adolescents, infants and children, key populations and people with mental health and substance use disorders.

Rationale and supporting evidence

A systematic review and network meta-analysis identified 85 randomized trials of interventions to improve adherence (105). The review found moderate-certainty evidence that peer counselling results in improved adherence and suppression of viral loads. Peer-based interventions are generally well accepted, especially among adolescents who find that hearing experiences and learning from others facing the same challenges are critical for supporting adherence and engagement in care. Other interventions found to significantly improve adherence include SMS messages and cognitive behavioural therapy.

Supportive interventions

Several interventions may be of value in addressing specific challenges that affect adherence and/or suppression of viral loads (see the recommendations above).

Nutritional support

Nutritional assessment, care and support are essential components of HIV care. Studies have shown that severe food insecurity predicts disengagement from care, and persistent severe food insecurity is associated with suboptimal adherence to ART and failure to suppress viral loads (106,107). Providing nutritional support to people receiving ART can reduce the risk of non-adherence among food-insecure individuals (15,108). HIV programmes should ensure that existing national policies on nutritional support are observed to maximize adherence to ART and achieve optimal health outcomes, especially in food-insecure settings. Nutritional support could include nutritional counselling, cash transfers, subsidizing food costs and/or food vouchers.

Financial support

Financial support can reduce the risk of non-adherence and improve viral suppression (109–111). Programmes and care providers should consider a broader programmatic approach for reducing the costs of care for people living with HIV that includes avoiding out-of-pocket payments at the point of care (including drugs, diagnostics and clinical services), supporting transport costs, decentralizing care and reducing the frequency of health facility visits. Programmes need to consider the ethical and equity implications of providing financial support and non-monetary incentives for people living with HIV. Standardized criteria for supporting people receiving ART may need to be developed based on national income levels.

Implementation and population considerations

Background and rationale

WHO strongly recommends that adherence support interventions be provided to people receiving ART (3). Viral load monitoring is the gold standard for monitoring adherence and confirming treatment response. Other approaches to monitoring adherence should be considered as a way to provide additional information about the risk of failure to suppress viral loads or to support daily tablet-taking behaviour in settings in which viral load testing is not available. Knowledge of adherence can support decisions about whether a recipient of care is eligible for simplified models of service delivery and whether to switch treatment regimens when viral load is unsuppressed.

WHO further recommends that, following an initial high viral load (exceeding 1000 copies/mL), an enhanced adherence intervention should be carried out before conducting a second viral load test. This has been shown to lead to resuppression for about half the people receiving ART, avoiding unnecessary switching of treatment (135).

Simple, affordable measures suggested by WHO to measure adherence include pill counts, pharmacy refill records and self-reporting (Box 7.3) (136). A systematic review identified 50 studies to assess the comparative diagnostic accuracy of these adherence measures (137). Overall, the review found that all adherence measures had low sensitivity for identifying people who are non-adherent and have unsuppressed viral loads. For self-report, asking five or more questions as part of the assessment tended towards providing higher sensitivity in diagnosing viral non-suppression. Composite adherence measures, such as combining self-report with pharmacy refill or tablet count, appeared to provide higher sensitivity.

The Guideline Development Group determined that adherence measures have clear value as an opportunity to discuss issues relating to treatment with people receiving ART and to identify potential barriers to maintaining adequate adherence and areas in which support may be needed.

Specific population groups face additional challenges to adherence, and these should be considered when implementing the recommended interventions. People receiving ART face a range of individual, interpersonal, community and structural barriers to adherence, including issues related to social identity, gender norms, stigma and medical pluralism; unwelcoming health services; and the need for emotional, practical or financial support for long-term engagement and adherence (104,111).

Effective monitoring of adherence requires a combination of approaches based on human and financial resource capacity, acceptability to people living with HIV and health-care workers and understanding of the local context.

Research gaps

Further research is needed to determine:

• optimal ways to proactively monitor adherence and identify through simple triage the people in greatest need of adherence support;
• the most accurate measures of adherence to ART that are feasible in settings with limited resources to complement viral load testing;
• interventions to support adherence in populations at heightened risk of suboptimal adherence (children and adolescents, pregnant women, men who have sex with men and people who inject drugs);
• potential synergistic effects of combining two or more interventions that could affect individual, social support and health system factors; and
• the effectiveness of long-acting ART in improving adherence and suppression of viral loads.

Background

Disengagement from care undermines programme and patient outcomes. Data from programmes across sub-Saharan Africa shows that, five years after starting ART, almost a fifth (19%) had stopped ART and 15–20% had died (4,143). Retention in ART programmes is a major challenge in all settings and across populations, specifically children and adolescents, postpartum women and men (144). Multiple factors may play a role in disengagement from care, including male sex, unemployment, lower educational status, advanced HIV disease, poor adherence, nondisclosure, distance from a clinic and lack of understanding of the need for lifelong care (145).

Rationale and supporting evidence

A systematic review identified seven studies (one individual randomized controlled trial, one cluster-randomized controlled trial and five cohort studies) that evaluated community-level interventions to strengthen retention in HIV care: a package of community-based interventions, adherence support clubs and providing extra care for high-risk patients (146). A strong recommendation was made despite low-certainty evidence because the balance of benefit greatly outweighed the potential harm, the degree of acceptability to people living with HIV and the programmatic benefits of implementing interventions that result in positive patient and programmatic outcomes.

Package of community-based interventions

Community-based interventions identified as benefitting retention in HIV care included: support centred on the needs of the individual, counselling and psychosocial support by lay adherence counsellors or patient advocates and family and peer support. Lay counsellors or patient advocates assisted with linking health facilities with communities, providing counselling and patient-centred support and visiting people in their home environment. One cohort study included children and adolescents (younger than 16 years) and demonstrated significantly increased retention at 36 months (147).

Adherence clubs

A systematic review identified one cohort study evaluating how facility-based adherence clubs affected loss to follow-up or death at 40 months, with a significant reduction compared with standard care (148). More recent studies have reported outcomes of adherence clubs that are equivalent to or better than standard care, including for adolescents and postpartum women (25,55,149,150).

Extra care for people with advanced HIV disease

The systematic review identified one cohort study from Kenya that evaluated how nurses and non-clinical health-care workers providing weekly or biweekly contact with people with advanced HIV disease (defined in the study as CD4 count <100 cells/mm³) affected mortality (151). These patients met a non-clinical health-care worker for brief assessment and were referred to a nurse where necessary, in addition to peer support and distribution of ART every two months and a yearly follow-up review with a clinician. Long-term follow-up and death were significantly reduced at 40 months. A trial from the United Republic of Tanzania and Zambia found that people with advanced HIV disease who were given early adherence support together with diagnostics for TB and cryptococcal meningitis had better retention and survival than those receiving standard care (152).

Cost and cost–effectiveness

The cost of implementing community-level interventions varies by setting and depends on whether community-based health programmes are already established. Generally, costs related to training and remunerating lay health-care providers are much less than the cost of care provided at the facility level and care provided by health-care workers. Costs related to community support, peer support and support by patient advocates are often related to training and orienting these cadres and support groups.

Equity and acceptability

A qualitative evidence synthesis highlighted key interventions that were acceptable in improving retention (153). These included lay health-care workers providing support (moderate certainty), especially if they were also living with HIV; family and friend support (moderate certainty); mobile health interventions (moderate certainty) and developing positive and non-judgemental relationships with those implementing the intervention (moderate certainty).

Population considerations

Implementation considerations

No single model of community or peer support works in all settings, and programmes need to adapt such interventions to the local context. Some clients may choose not to receive services in the community because of concern about stigma and discrimination. Community interventions require linkage with health facilities for smooth transfer and referral, when necessary, and strategic planning and resourcing for sustainability. Community-level programmes still need to be integrated into national health sector plans in many settings.

Research gaps

Implementation research and evaluation of the different models of community-level support in different contexts are necessary to further guide programmes. Effective strategies are needed to support transitioning across care-delivery points for men, postpartum women, adolescents and children. Further data on the cost of implementing community-level interventions in different settings will guide national policy.

Background and rationale

WHO guidelines strongly recommend that programmes provide community support for people living with HIV to improve retention in HIV care (3). Poor retention undermines positive programme outcomes, including reducing mortality and achieving sustained population suppression of viral loads. Although many programmes have adopted these recommendations to support retention, loss to follow-up remains substantial in all regions, and especially in southern Africa, affecting all age groups (4,143,144). Although some individuals who are no longer engaged in care for various reasons have died, recent data suggest that many individuals who are successfully traced are alive (161), and many are willing to re-engage in care. WHO recommends patient tracing as one of many potential interventions that could improve linkage between diagnosis and ART initiation (3).

A systematic review assessed activities to trace individuals who have disengaged in care and to identify interventions to support re-engagement in care; the review identified 37 studies, eight of which included children and adolescents (163). Overall, among those who were alive, 58% (95% CI 51–65%) re-engaged in care. Tracing and re-engagement action appeared to be more successful when people were traced soon after a missed visit compared with a longer period of disengagement. Approaches to tracing included remote communication (phone, text messages, mail and email), in-person tracing and a combination of both approaches.

Benefits and harm

Tracing activities can successfully re-engage people in care and achieve resuppression of viral loads. The certainty of the evidence was judged to be low, mainly because of important heterogeneity in outcomes across studies leading to imprecise estimates of benefit. The literature did not identify any important harm. Although tracing activities carry the hypothetical risk of inadvertently disclosing HIV status that could lead to intimate partner violence, discrimination and stigma, this risk is considered small and is outweighed by the benefits of re-engaging individuals into care and onto life-saving ART, without which there would be increased illness and death. The Guideline Development Group made a strong recommendation despite low-certainty evidence given the confidence in the health benefit for people returning to care and minimal harm associated with tracing and re-engagement activities.

Feasibility, cost and cost–effectiveness

Most reports described the tracing activities undertaken by existing health facility personnel; in some cases, social workers and community health workers formed part of the tracing team, and personnel were trained. Other associated costs include establishing systems to trace and support re-engagement. In-person tracing requires resources to support the travel of tracing teams and human resources with appropriate training and remuneration, including the potential need to undertake multiple tracing attempts.

Equity and acceptability

Tracing in the absence of consent may be considered intrusive and may not be accepted by people who have disengaged from care (with various motivations). Tracing must also be sensitive to the need to respect human rights and confidentiality and avoid inadvertently disclosing HIV status. The Guideline Development Group judged that the intervention would probably increase equity and is probably acceptable to most people living with HIV if delivered in a non-judgemental approach. Clients should be provided with the opportunity to consent to tracing when ART follow-up is discussed during counselling and at ART initiation.

Implementation considerations

Support for re-engagement in care can include interventions directed towards people living with HIV, such as peer or health-care provider outreach and navigation back to care as well as towards health-care providers and health facilities (through systems to alert health-care providers that people have disengaged). Interventions could include reminders (such as phone calls or text messages), economic interventions (such as financial incentives or conditional cash transfers), case management or policy interventions, with steps taken to ensure confidentiality. Programme- or facility-level confidential contact details should be kept up to date to ensure successful tracing if and when required. When considering tracing people who are not engaged in care, adequate assessment of the risks to vulnerable and key populations is critical. For example, women are subject to increased levels of both intimate partner and gender-based violence in the context of HIV, and appropriately training health-care providers is therefore essential (164). It is critical to understand both general and local reasons for failures of retention; these are far more predictive than sociodemographic factors such as age and sex (165).

The criteria for tracing and recall should consider those who are seven or more calendar days late for a scheduled appointment. Although efforts should be made to trace everyone who has missed appointments and/or has abnormal results, the following groups should be given priority: (1) people initiating treatment in the past six months with advanced HIV disease, (2) people with abnormal results, (3) people not initiating treatment and (4) people overdue for clinical consultations or laboratory tests.

A non-judgemental approach is essential to supporting people in returning to care; this requires reducing system barriers and improving interpersonal communication by developing the capacity of health-care providers. The Welcome Back service established by Médecins Sans Frontières and the Department of Health of South Africa provides a strong example of such an approach combining medical and psychosocial support for people who have disengaged from care (162,166).

Research gaps

Several studies have described the most common reasons for disengaging from care either before or after initiating ART (74,165,167,168). Research is needed to tailor support that responds to these drivers to minimize disengagement and support re-engagement at different stages along the continuum of care. Qualitative research is important to understand the most acceptable and effective methods of tracing and re-engagement. In addition, this research should include disaggregated approaches based on the population group (such as key populations), gender and age.

Background

The number of available health-care providers remains inadequate in many settings with a high burden of HIV. Task sharing involves redistributing tasks within health workforce teams. Specific tasks are reassigned to health-care workers with shorter training and fewer qualifications to optimize the available human resources. Although increasing the number of health-care personnel is also crucial, clinical tasks need to be shared to ensure that enough health-care workers are available.

Since 2013, WHO has made a series of recommendations on task sharing relating to initiating and maintaining ART for adults, adolescents and children. These recommendations are supported by randomized trials and observational studies (169–171). Overall, the evidence shows comparable clinical outcomes and reduced rates of loss to follow-up when nurses or non-physician clinicians initiate or maintain people on ART or when community health workers maintain people on ART, relative to physicians performing these tasks. Quality of care is ensured by providing training, mentoring and supervision for nurses, non-physician clinicians and community health workers, clear referral pathways and effective monitoring and evaluation systems.

In 2016, WHO further recommended that trained community health workers be able to dispense and distribute ART. A meta-analysis of findings from two cluster-randomized trials comparing dispensing ARV drugs between pharmacists and non-pharmacists found comparable clinical outcomes and improved retention comparing people who received care from a community-based team and those who received care from health-care professionals at a health facility (59,170,172). The evidence was rated as low certainty because of indirectness, since the lay health-care providers were part of a wider community-based intervention with additional elements that supported the success of the intervention. Nevertheless, the Guideline Development Group strongly recommended that trained and supervised lay health-care providers be able to distribute ART to adults, adolescents and children living with HIV, citing existing programme experience of trained and supervised community health workers and lay health-care workers providing HIV testing, care and treatment services. In addition, the Guideline Development Group cited important examples within the broader health sector in which community health workers, with minimal training, are entrusted to provide curative and preventive care in maternal, newborn and child health services, malaria diagnosis and treatment and TB care.

Benefits and harm

The public health benefits of lay health-care providers distributing ARV drugs are increasing the overall number of providers to overcome shortages of facility personnel, reducing facility congestion and providing services closer to communities that support retention in care. If ARV drug supply and stock management are not reliable, lay personnel distributing ARV drugs outside health facilities may increase distribution sites and potentially aggravate stock-out. Neither of the two studies included people with comorbidities or children. The Guideline Development Group advised that the dose for growing children can be safely adjusted during clinic visits with maintenance treatment at the community level.

Cost and cost–effectiveness

Costs for training and other costs associated with introducing community ART distribution may be initially increased. However, studies report substantial user costs when they are required to travel to centralized health services to collect medication. A study from Uganda reported that the cost to beneficiaries receiving hospital-based care was three times higher than for people who received home-based care (172).

Equity and acceptability

A qualitative evidence synthesis found that task sharing can enhance linkage to care and treatment adherence and helped HIV programmes cope with shortages of professional health-care workers (15). Strengthened relationships between people living with HIV and local communities can empower individuals. In Malawi, people from the community were hired as pharmacy attendants to pre-package and distribute ARV drugs to enhance the capacity of pharmaceutical services, an approach that has facilitated visit spacing and reduced waiting times and health-care providers workload at health facilities (173). All providers should be sensitized to the specific needs of the various people living with HIV groups, including key populations.

Implementation considerations

Initial and ongoing training and mentoring, supportive supervision and administrative planning have been critical to the success of programmes that have implemented task sharing. Programmes adopting these recommendations need to train and establish a system for routine supportive supervision of health-care workers, including lay health-care providers. Adopting task-sharing strategies often requires revising regulatory frameworks and national policies so that new cadres of health-care workers can perform new tasks. WHO recommends that all health-care workers, including community health workers, should be appropriately trained, remunerated and supervised (174), and programme experience indicates that sustaining health services based on volunteerism alone is difficult. National regulatory bodies, professional associations and other stakeholders need to be involved in addressing the scope of practice, roles and responsibilities of health-care workers. Relevant curricula for training the various community cadres must be in place.

The local supply chain system must consider task-sharing responsibilities and community models of ARV drug delivery to ensure adequate stock. The supply management logistic information system needs to incorporate all ARV drug distribution outlets, including community and lay health-care providers’ distribution sites (see section 6.13).

Background and rationale

The 2016 WHO consolidated HIV treatment guidelines (3) stated that good practice includes trained and supervised non-laboratory personnel, including lay people, being able to collect blood samples through finger-pricks. This statement was made at a time when data comparing the performance of specimen collection and/or testing by non-laboratory personnel versus laboratory professionals were limited. Most data before the 2016 consolidated HIV treatment guidelines focused on point-of-care diagnostic accuracy studies conducted in the laboratory by laboratory professionals.

Since 2016, several additional studies have been published, including the diagnostic accuracy of decentralized and task-shared specimen collection and/or testing with non-laboratory professionals (175). In addition, clinical studies examining how point-of-care testing by non-laboratory personnel affects the people being tested have been published (176). Together, this updated evidence has supported consideration of using point-of-care infant diagnosis and viral load testing to improve health outcomes.

In several settings, trained and supervised lay health-care providers are already conducting HIV testing and collecting blood samples through finger-pricks. In 2015, WHO strongly recommended that lay health-care providers who are trained and supervised be able to independently conduct safe and effective HIV testing using rapid diagnostic tests (177).

Access to diagnostic testing and sample collection remains low in many resource-limited settings, partly because of shortages of human resources, especially in rural settings. The lack of skilled laboratory professionals at health-care facilities and the need to scale up capacity may require sharing the tasks of point-of-care diagnostic testing and sample collection with lower cadres of health-care workers. Task sharing may also increase access to testing for key populations, who may have difficulty in accessing traditional health-care services regardless of professional staffing capacity.

A systematic review identified 65 studies, mainly diagnostic accuracy studies (175). Three randomized controlled trials assessed the clinical impact of point-of-care testing. Most studies (86%) were carried out in Africa. The certainty of the evidence was rated as moderate. Ten types of non-laboratory health-care workers performed nine types of point-of-care tests using 13 assays. Most studies included nurses. The primary outcome observed across most studies focused on the diagnostic accuracy of point-of-care testing performed by non-laboratory personnel (175).

Benefits and harm

The Guideline Development Group formulated a strong recommendation based on judgement of the overwhelming benefits of the intervention, including, but not limited to, the following.

• Most settings with limited resources and a high burden of HIV infection lack laboratory professionals.
• Decentralized and task-shared specimen collection expands access to testing (dried blood spot specimens for infant diagnosis and viral load).
• Point-of-care testing leads to more rapid testing, return of results to clinicians and patients and clinical action.
• Fewer health facility visits are needed for caregivers to receive results, and the timing of results is more reliable.

There was no major harm, but more extensive network support and maintenance were needed.

Feasibility, cost and cost–effectiveness

Overall, task sharing of specimen collection and point-of-care testing with non-laboratory personnel was feasible and acceptable. Task sharing would save costs with deployment of personnel with less training for diagnostic testing and sample collection. The most important cost will be training, ongoing supervision and remunerating non-laboratory personnel, albeit at a potentially lower cost compared with laboratory professionals. Decentralization will likely result in increased proportions of non-laboratory personnel required to perform the specimen collection and testing, requiring careful assessment and expansion of human resource capacity.

Equity and acceptability

Task sharing of specimen collection and point-of-care testing with non-laboratory personnel is likely to improve equity, since relying on specialized personnel favours populations in urban settings and increases the transport burden on rural populations, which generally have the lowest incomes. Task sharing may also increase access to testing for members of key populations, who may have difficulty in accessing traditional health services and facility-based services. Further, decentralizing specimen collection and testing, including at community-based sites, may increase access to diagnostics, especially including interventions and technologies capable of returning the results on the same day or more rapidly than laboratory-based testing.

In a systematic review, 58% of non-laboratory personnel indicated that preparing dried blood spot specimens for viral load was very easy, 43% indicated that collecting specimens was easy and 85% indicated that preparing dried blood spots was suitable for nonlaboratory personnel (175). Nurses had a 98% success rate of finger-prick blood specimen collection in South Africa. One study reported an ease-of-use score for task sharing point-of-care CD4 testing between 1.7 and 3 on a scale of 1 to 5 (5 being very difficult), and health-care worker trust in the test was measured at 82–100%. Another study found an odds ratio of 1.9 (95% CI 1.1–3.3) for more rational use of higher-level clinical personnel time when point-of-care CD4 testing operated by lower-level personnel was introduced instead. Further, 95% (95% CI 93–96%) of lay health-care workers rated the point-of-care CD4 technology favourably. All non-laboratory personnel found the point-of-care viral load testing to be easy or very easy to use, and 85% of the respondents indicated that point-of-care viral load testing was suitable or very suitable for non-laboratory personnel. Ninety per cent of non-laboratory personnel said that a syphilis rapid diagnostic test was easy to use, and antenatal care personnel scored the dual HIV and syphilis rapid diagnostic test 2.41 (with 3 being easiest) for ease of use and 2.27 (of 3) for ease of interpretation.

A study in Cameroon, Côte d’Ivoire, Eswatini, Kenya, Lesotho, Mozambique, Rwanda and Zimbabwe conducted structured interviews with health-care workers providing infant testing services and semistructured interviews with national and regional laboratory managers or early infant diagnosis programme managers before and after point-of-care infant testing was implemented (188). Health-care workers found point-of-care infant testing easy to use (74% said it was very simple to run the test), and 93% were very satisfied with the rapid turnaround time and ability to initiate treatment for infants living with HIV sooner.

Implementation considerations

Access to high-quality diagnostic testing should be continually expanded across HIV and other molecular testing needs, ideally combining laboratory-based and point-of-care technologies in an integrated laboratory network. Implementing a wide network of decentralized specimen collection and/or point-of-care testing requires centralized support from national laboratories and programmes to ensure adequate training, mentorship, service and maintenance, continuous quality assurance and accurate data entry at the point of care. In addition, decentralizing specimen collection and task sharing requires expanding human resource capacity. Legal and regulatory issues and policies may need to be adjusted in some countries to support the decentralization and task sharing of specimen collection and testing with non-laboratory personnel. Concurrently, scaling up and building human resource capacity, including strengthening laboratory personnel and capacity, will be critical to expanding diagnostic access. WHO has developed tools and guidelines for human resources for health and recommends an approach to systematically address the dynamics of the health workforce that includes assessing workload indicators among health-care providers.

Research gaps

Additional diagnostic accuracy studies directly comparing the performance of newer point-of-care technologies (infant diagnosis and viral load testing) between non-laboratory personnel and laboratory professionals would be valuable.

Background

Since 2016, WHO has recommended initiating ART to everyone living with HIV regardless of CD4 cell count, including pregnant and breastfeeding women. However, access to ART for pregnant and breastfeeding women living with HIV remains a challenge, as does providing essential HIV services to HIV-exposed uninfected and infected infants and ensuring that services for preventing mother-to-child transmission reach pregnant adolescent girls and young women, female sex workers and women who inject drugs.

Because many women living with HIV only access health services at the time of pregnancy, maternal and child health settings provide a key opportunity to provide access to ART (195,196). In most generalized HIV epidemic settings, maternal and child health services are provided at the primary care level, where pregnant women and children predominantly access health services. WHO recommends offering HIV testing services to pregnant women through provider-initiated approaches as an essential component of maternal, newborn and child health services. WHO also recommends couple and partner HIV testing for all pregnant women and their partners in maternal and child health-care services in generalized HIV epidemics and that such testing be considered for key populations in concentrated and low-level epidemics (9). In addition, in settings with a high burden of HIV infection, retesting is advised for all pregnant women with an unknown or HIV-negative status during late pregnancy (third trimester). Catch-up testing is needed if the first test or retest is missed or delayed. Countries with a high burden of HIV infection could consider an additional retest in the postpartum period for specific districts or regions with high HIV burden or incidence, women from key populations and women who have a partner living with HIV who does not have suppressed viral loads (9).

ART should be available in maternal and child health clinics or easily accessible in a linked model of service delivery. Countries with generalized epidemics may consider a phased approach to providing ART in maternal and child health settings, which may effectively transform such settings into ART sites, giving priority to facilities with the largest burden of HIV and building health systems to ensure uninterrupted ART, good adherence and retention to maintain viral suppression. All pregnant women, regardless of when they start ART, may require more intense monitoring of viral suppression, including conducting viral load testing at 34–36 weeks of gestation (or at the latest at delivery) to identify women who may be at risk of treatment failure and/or may deliver infants at higher risk of perinatal transmission. In addition, a viral load test is recommended for all breastfeeding women three months after delivery and every six months thereafter to detect viraemic episodes during the postnatal period (197).

Not all maternal and child health settings will have capacity to provide long-term HIV care and treatment for women, their partners and infants. These settings will need to assess and decide on the best time for transitioning and linking mothers and their infants to chronic HIV care and from chronic care into maternal and child health settings when the pregnant woman was already receiving ART at the time of conception. Providing choice for where a woman living with HIV receives ART care remains important and should not interfere with efficient provision of quality and person-centred antenatal care. Issues to consider in the assessment may include the capacity and quality of HIV care in the maternal and child health-care setting, acceptability and proximity of alternative HIV care settings and the burden of HIV infection.

Rationale and supporting evidence

A systematic review found one cluster-randomized trial and three observational studies which showed that integrated services improved uptake of ART and adherence to ART during pregnancy; outcomes for maternal mortality, morbidity, immune response, infant HIV testing uptake and mother-to-child transmission were comparable (198–203). Health-care providers thought that integrated services increased efficiency, decreased waiting time for clients and improved relationships between providers and patients, resulting in less stigmatization and improved adherence to treatment and care (204).

Background

The percentage of notified people with TB who had a documented HIV test result in 2019 was 69%, up from 64% in 2018. In the WHO African Region, the WHO region with the highest burden of HIV-associated TB, 86% of people with TB had a documented HIV test result. A total of 456 426 people coinfected with TB and HIV were reported, of whom 88% were receiving ART (205).

Since 2010, WHO has recommended ART for everyone with TB who is living with HIV, regardless of CD4 cell count. In 2021, WHO recommended that ART be initiated as soon as possible and within two weeks after starting TB treatment. Co-trimoxazole prophylaxis is also recommended for all people with both TB and HIV. TB infection control measures are crucial in HIV care settings to minimize the risk of nosocomial transmission of TB.

Rationale and supporting evidence

A systematic review evaluating the effectiveness of delivering ART in TB treatment settings identified 19 observational studies, many of which showed increased uptake and timeliness of ART initiation. However, the data on mortality and TB treatment success were inconsistent. The same systematic review identified five observational studies evaluating the effectiveness of delivering TB treatment in HIV care settings. Two studies reported decreased mortality and another showed comparable mortality rates. The TB treatment success rates and ART uptake were comparable across studies (206).

Background and rationale

Among the 1.9 billion women of reproductive age (15–49 years old) worldwide in 2019, 1.1 billion need family planning and 270 million have an unmet need for contraception. Across WHO regions, evidence indicates that sex workers have a greater unmet need for contraception than the general population, and reports indicate excessive reliance on using condoms alone instead of the recommended dual protection (207–210). The proportion of the need for sexual and reproductive health services, including contraception services, that was satisfied by modern methods was 76% globally in 2019, but this fell to less than 50% in western and central Africa. WHO emphasizes the importance of linking sexual and reproductive health and rights and HIV for adolescent girls and young women (211). Since women living with HIV face unique challenges and human rights violations related to their sexuality and reproduction within their families and communities and from the health-care institutions from which they seek care, creating an enabling environment is especially emphasized to support more effective health interventions and better health outcomes (212).

In 2016, WHO conditionally recommended that sexually transmitted infection and family planning services be integrated within HIV care settings (3). Since that time, additional evidence has been published supporting the integration of sexual and reproductive health and HIV. A systematic review published in 2019 that considered linkage and integration found that the proportion of women receiving an HIV test during the study period ranged from 35% to 99% for integrated services and from 20% to 95% for non-integrated services or services integrated at a lower level (213,214); the review summarized findings from several studies that included adolescent girls and young women. The proportion of women accessing HIV services using contraception ranged from 54% to 80% for integrated services and from 10% to 83% for non-integrated services or services integrated at a lower level (213,214). Integrating HIV testing services with sexual and reproductive health services is feasible and has potential for positive joint outcomes. The review included six studies – one cluster-randomized trial carried out in Uganda and five non-randomized cluster trials carried out in Kenya, eSwatini and the United States of America. Two studies found that integration favoured an increase in sexual and reproductive health services, including contraception; one study found an increase in the uptake of dual contraceptive methods. In the study that reported dual method use, the proportion of women using dual methods during the study period was 34% for integrated services and 0% for non-integrated services (215). The overall certainty of evidence for all outcomes was very low, and the available evidence is limited (214). In the other direction, another systematic review of 14 studies found that integrating family planning into HIV care and treatment settings was associated with higher levels of use and knowledge of modern methods of contraception among women living with HIV (216).

Benefits and harm

Overall, integration is associated with increased offers and uptake of sexual and reproductive health services, including contraception, which is likely to result in improved downstream clinical outcomes. Given the nature of the intervention, the Guideline Development Group considered that the benefits likely outweighed any possible harm. One fear of integration is that tasking providers with too many services may reduce the quality of these services. However, it has been reported that integration can positively affect service quality and client outcomes for contraceptive use, ART in pregnancy and HIV testing (217). Integrating HIV and sexual and reproductive health services has been found to improve accessibility, the quality of antenatal care and nurse productivity while reducing stigma and without compromising the uptake of care (218).

Feasibility, cost and cost–effectiveness

A study from Zambia found that integrated HIV testing and counselling and voluntary male medical circumcision services could be provided at a lower cost per client than segmented, vertical provision (219). A study from Kenya (220) found decreased consultation times when services were integrated (10 versus 30 minutes); another study from Kenya (221) highlighted the need for sustained systems and health-care worker support over time. Integration may lead to increases in service efficiency, but this is likely to be highly context dependent (222–224).

Equity and acceptability

A survey conducted among health-care providers and clients found that more than 90% of respondents considered that integration is important and feasible. Integration may improve access to sexual and reproductive health services, including contraception, among key populations. A study from Kenya found that access to sexual and reproductive health services, including contraception, for women who inject drugs can be improved by integrating contraceptive and other sexual and reproductive health interventions into existing outreach-based HIV prevention and harm-reduction programmes (225). Another study among female sex workers in Kenya found that integration improved access to the use of non-condom contraception methods, which is important for these people, who may have difficulty negotiating condom use (226). Integration also has the potential to reduce stigma. A survey of health-care providers in South Africa found that they considered integration important for reducing stigma and increasing access to and improving the quality of care (227).

Implementation considerations

Implementing comprehensive and integrated sexual and reproductive health and rights and HIV programmes to meet the health needs and rights of the diverse group of women living with HIV requires that interventions be put into place to overcome barriers to service uptake, use and continued engagement. In all epidemic contexts, these barriers occur at the individual, interpersonal, community and societal levels. They may include challenges such as social exclusion and marginalization, criminalization, stigma, gender-based violence and gender inequality. Strategies are needed across health system building blocks to improve the accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services for women living with HIV. If left unaddressed, such barriers undermine health interventions and the sexual and reproductive health rights of women living with HIV (212).

Focusing on improving investment in the overall health system is important to support the integration of sexual and reproductive health services, including contraception and HIV services. Laws and policy barriers to accessing sexual and reproductive health services, including for adolescents, need to be addressed (212). Although this applies to any integration effort, it is especially important since sexual and reproductive health programmes have historically been implemented as established vertical programmes within health systems. WHO strongly recommends that care for women experiencing intimate partner violence and sexual assault be integrated as much as possible into existing health services rather than being a stand-alone service (212).

Training on human sexuality may facilitate greater understanding of sexually diverse communities, especially people identifying as lesbian, gay, bisexual, transgender, queer or intersex (LGBTQI) and adolescents and young people seeking accurate sexual and reproductive health and rights information and services (67).

Since an increasing proportion of people living with HIV are receiving their HIV treatment through a differentiated service delivery model with extended ART refills and less frequent clinical visits, aligning the provision of sexual and reproductive health services, including contraception (WHO recommends providing one year of oral contraception and supports community delivery and self-management) and commodities, with differentiated service delivery for HIV treatment models should be considered.

Careful planning and coordination are important for both programme management and service delivery, including establishing integrated data systems and providing consistent cross-training of health-care providers. Moreover, political will and significant coordination, collaboration and integration across disease programmes will be important (228,229).

Research gaps

The evidence supporting approaches to integrating sexual and reproductive health services, including a range of contraception, with HIV services is limited. Research is encouraged to identify approaches to integration that lead to better uptake of sexual and reproductive health services, including contraception; such research should also consider integrating cervical cancer screening and human papillomavirus vaccination. Implementation research is encouraged to evaluate different strategies of integration in different health systems and social contexts, including providing contraception in the context of less frequent clinical and ART refill visits. In addition, research into the efficiency of integrating antenatal and postnatal care and differentiated HIV services outside the maternal and child health service delivery may advise on differentiated service delivery. This in turn would support evidence on the best times for transitioning between maternal and child health services and chronic care.

Background and rationale

Low- and middle-income countries are facing an increasing burden of noncommunicable diseases. Fifteen million people 30–69 years old die prematurely from noncommunicable diseases every year, and 85% of these people live in low- and middle-income countries. Diabetes and hypertension are the major cardiovascular risk factors for target organ damage of the brain, heart and kidneys. An estimated 425 million people in low- and middle-income countries currently have diabetes. This number is expected to increase to 629 million in 2045. The prevalence of hypertension in low- and middle-income countries is estimated to exceed 20% (230). Thanks to widespread access to ART, the life expectancy of people living with HIV has improved substantially, and this places them at risk of noncommunicable diseases that are common with increasing age. In addition to the elevated risks from modifiable factors for noncommunicable diseases such as smoking, poor diet and a sedentary lifestyle, people living with HIV have an independent increased risk of noncommunicable diseases (especially cardiovascular diseases, cervical cancer, depression and diabetes) related to HIV itself and to ART-related side effects (180,231).

In April 2019, WHO convened an expert scoping consultation on noncommunicable diseases and mental health conditions with policy-makers, academics and partners from the HIV, noncommunicable disease and mental health communities to review existing WHO norms and policies for preventing and managing major noncommunicable diseases and mental health conditions. Participants identified the need to establish effective approaches identifying for integrating hypertension, diabetes and HIV services (232).

A systematic review identified five studies – two interrupted time-series studies (233,234) and three cluster-randomized trials (235–237) – and found that integrated models of care that include hypertension or diabetes or multi-disease approaches may increase the number of people controlling both blood pressure and HIV. It also found that offering integrated care was unlikely to alter mortality (RR 0.90, 95% CI 0.79–1.02). The overall certainty of evidence was very low, and the available evidence is limited (238).

Benefits and harm

The Guideline Development Group concluded that offering integrated services for managing hypertension and diabetes with HIV services will have a small benefit and that any possible harm is small and related to increased workload that may affect the quality of services.

Feasibility, cost and cost–effectiveness

The feasibility of integrating diabetes and hypertension care with HIV services may vary based on the setting and health system factors and should be supported at the planning and policy levels. Involving the community may promote increased uptake of diagnostic, preventive, treatment and referral services for HIV and noncommunicable diseases (239). One study found that engaging regulatory authorities early, considering work culture and building the capacity of a robust interdisciplinary workforce were critically important (240). A comparative study in sub-Saharan Africa concluded that multi-disease services can be offered at relatively low marginal cost (241).

Equity and acceptability

Implementing this recommendation may increase access to routine hypertension and diabetes services among those living with HIV with limited access to primary preventive services. The results of a WHO survey conducted to support these guidelines indicate that most respondents considered integrating HIV and diabetes (83%) or hypertension (78%) care to be very important or important. A systematic review reported high acceptability of integrated adherence clubs for people receiving chronic medication for controlling both HIV and noncommunicable diseases (242). Another review found that most people would accept receiving noncommunicable disease services in an HIV care setting. HIV care providers were willing to provide noncommunicable disease services and recognized the potential benefits of doing so but highlighted concerns around space constraints, increased workload, training requirements, supply chain shortages and potential effects on other services as key factors to consider (239).

Implementation considerations

Focusing on improving investment in the overall health system will be important to support the integration of hypertension, diabetes and HIV services. Since an increasing proportion of people living with HIV are receiving their HIV treatment through a differentiated service delivery model with extended ART refills and less frequent clinical visits, aligning the provision of noncommunicable disease commodities with differentiated service delivery for HIV treatment models should be considered.

Careful planning and coordination are important for both programme management and service delivery, including establishing integrated data systems and providing consistent cross-training of health-care providers. Moreover, ensuring political will and significant coordination, collaboration and integration across disease programmes will be important.

Research gaps

The following research gaps were identified: long-term data on the health outcomes of people living with HIV who have noncommunicable diseases, cost–effectiveness data for various models of integrated care and implementation research on optimizing the supply chain. Research can help to define health promotion activities that encourage lifestyle changes and protect against noncommunicable diseases among people living with HIV, who may face stigma and other challenges in receiving health promotion through the usual channels. Research is also needed to inform how hypertension and diabetes care can be integrated with the common differentiated models of service delivery implemented for HIV. Qualitative research can inform the values and preferences of people living with HIV and noncommunicable diseases related to how care is delivered.

Background

These guidelines recommend the same ART eligibility criteria for all adults regardless of drug use behaviour. WHO recommends opioid substitution therapy (with methadone or buprenorphine) for treating opioid dependence combined with psychosocial support (243). Opioid substitution therapy should be integrated and administered in conjunction with ART for those who need it. Although some evidence suggests that opioid substitution therapy improves HIV treatment outcomes among people living with HIV who inject drugs, it should not be a prerequisite for initiating or maintaining ART.

Given the high incarceration rates of people who inject drugs, efforts should be made to ensure that ART is available as part of prison health services. Continuity of treatment and care need to be maintained through appropriate referrals when people return to the community.

Rationale and supporting evidence

A systematic review found one randomized trial and three observational studies evaluating the effect of delivering ART in settings providing opioid substitution therapy. Some studies observed trends of improved viral suppression and reduced mortality, whereas others found comparable rates of viral suppression and mortality (244–246). A more recent systematic review provided additional support for the use of opioid substitution therapy, and its integration with HIV services, to improve the HIV treatment and care continuum among people who inject drugs living with HIV (247). A review of qualitative studies found that convenience and the comprehensive nature of co-located care support acceptability but that health system challenges need to be addressed to deliver integrated services (248).

This recommendation supports expansion of ART by delivering the service in settings providing opioid substitution therapy. Opioid substitution therapy should be provided free of charge or covered by public health-care insurance and should be accessible to everyone who needs it, including in prisons and other closed settings. HIV programmes need to continue to work closely with other service providers to ensure successful implementation of this recommendation. Guidance on maintaining effective opioid substitution therapy programmes is available in the WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations (70).

Background and rationale

The aim of universal health coverage and related services is to deliver high-quality people-centred integrated service and care. Universal health coverage also emphasizes a fundamental shift in service delivery such that services are integrated and focused on the needs of people and communities. One intervention that shows promise in helping to achieve these goals is diagnostic integration. Significant unmet testing needs remain across diseases, including HIV, TB and related infections. Programmatic integration (both sharing devices and integrating networks) is a priority intervention within the universal health coverage agenda to optimize the use of limited resources and improve care.

In 2017, WHO developed guidance for countries on the key considerations of multi-disease testing (249). In 2019, WHO held a country consultation to share experiences and focus on some of the aspects to diagnostic integration (250): funding and resources; optimizing and mapping the diagnostic networks; integrating systems; and considerations related to patients.

Several countries across WHO regions are already moving forward with diagnostic integration. Some countries are also sharing devices and considering integrating HIV and TB diagnostic services and incorporating hepatitis C virus, human papillomavirus and emerging outbreak infections. Several technologies exist that can conduct multiple tests on their technology and can be considered for diagnostic integration or device sharing (251).

Priorities may have to be set among patients and tests to consider the utilization needs of all programmes and to continue to ensure that the host programmes in particular have full access to device capacity. To ensure more rational integrated testing, several countries have continued testing all people with presumptive TB, with the addition of infant HIV diagnosis and targeted HIV viral load testing; HIV volumes were generally small and ensured no overutilization. Careful consideration for test volumes across diseases and how to set priorities among patients for point-of-care and laboratory referral testing will be critical through network optimization and mapping exercises.

The following challenges have been identified through pilots and programmes.

• Focus is required to adjust the laboratory and clinic workflow on implementing additional assays on the integrated platform.
• Systems considerations need to be implemented to ensure that results are returned on the same day, especially for more urgent tests and results, such as infant HIV diagnosis.
• Adequate human resource capacity is needed to manage additional patient demand.
• Service and maintenance contracts are often limited or challenging (this was specific to the technology implemented during pilot projects).
• Significant support is necessary to ensure that adequate infrastructure is introduced.

Access to high-quality diagnostic testing should be continually expanded across testing needs, ideally combining laboratory-based and point-of-care technologies in an integrated diagnostic network without creating dependence on any one technology. Attention should also be paid to human resources, supply chain, quality assurance, monitoring and reporting and national regulatory components to develop sustainable and strong integrated networks. Careful planning and coordination are important for both programme management and service delivery. Moreover, ensuring political will and significant coordination, collaboration and integration across disease programmes will be important. Further, diagnostic integration and device sharing provide several potential mechanisms to reduce costs across assays, diseases and programmes (250).

Sharing costs between programmes could translate into cost savings for all programmes and more efficient use of resources. Costs can be shared between the host and beneficiary programmes under different allocation scenarios (such as by testing volumes, by allocating entire cost items to each respective programme or by accounting for already incurred investments). Costs are mainly saved by sharing device costs and service and maintenance costs (252). Leveraging existing device fleets with available capacity is a feasible approach to increase access to testing in a cost-effective manner. Tools exist to support countries in understanding the savings available and determining the most efficient and effective strategy.

A systematic review (253) found two observational studies reporting outcomes of integrating HIV and TB testing – one conducted by Médecins Sans Frontières in Zimbabwe (254) and another by the Clinton Health Access Initiative in Malawi and Zimbabwe (255). Both studies reviewed how integrating HIV testing with TB testing affected TB testing, the programme that procured and set up the technology.

Even with the addition of HIV infant testing and targeted HIV viral load testing, TB testing volume accounted for about 60% of the total after integration. Despite the increase in overall testing volumes, device use never exceeded 75%. Integration with HIV testing did not adversely affect the turnaround time for results or the outcomes. The time to return results and the proportion of people initiating TB treatment were the same before and after infant diagnosis testing and targeted viral load testing were added.

After integration with the TB-procured devices, HIV infant diagnosis and targeted HIV viral load testing experienced more rapid turnaround times and increased treatment initiation rates and increased probability of clinical action for infants living with HIV and people living with HIV receiving ART experiencing viraemia. Offering TB, HIV infant diagnosis and targeted HIV viral load through integrated testing increased device use without exceeding capacity or affecting TB services. Finally, these studies show that integrated testing was operationally feasible, with appropriate site selection to balance the expected demand. TB testing and treatment continued to be provided at the same rate.

Based on the available evidence and country experience, the Guideline Development Group determined that a good practice statement was indicated, since integrating diagnostic services across disease programmes is anticipated to result in a net overall benefit. The Guideline Development Group agreed that programmes should consider integrating their diagnostic services both for programmatic reasons and to ensure comprehensive care for people living with HIV. Increased efficiency is expected, and diagnostic integration and sharing of devices would enable more integrated health services and diagnostic networks.

Anticipated benefits include the potential to improve access to testing by increasing the device base; leveraging programmes’ knowledge; and shared operational costs. Diagnostic integration is also expected to create a more optimized, efficient network across diseases, improve patient care and reduce the costs generated in vertical programmes. Diagnostic integration is also expanded to ensure a more robust and reactive diagnostic network, especially positioned to respond to outbreaks and pandemics as they arise.

Knowledge gaps were identified that could benefit from further research, including measuring the impact of diagnostic integration across disease types (including HIV, TB, hepatitis, sexually transmitted infections, cervical cancer and disease outbreaks). Implementation research would be beneficial to generate best practices for diagnostic integration and quality assurance approaches for sustainable delivery of diagnostic integration.

Differentiated service delivery

Children who are established on ART are eligible for differentiated service delivery (see the WHO criteria for determining whether a child has been successfully established on ART in section 7.3). Differentiated service delivery for children, although child-centred, should be harmonized with differentiated service delivery for their caregivers in a family-centred approach. The following table summarizes the guidance for differentiated service delivery for children 0–9 years old.

There are several models for differentiated service delivery for children, with wide variability in implementation, including multi-month refills, flexible hours, family clinics and community models. An innovative model is virtual case management or virtual support, especially for caregivers and families who have access to telecommunication services. Robust evidence of long-term retention and viral suppression among children is needed as well as streamlined guidance on eligibility criteria and implementation.

Section 7.3 provides details of recommendations for differentiated service delivery.

Re-engagement into care

Strategies for actively tracing children who have dropped out of care, standard protocols that ensure rapid follow-up and procedural guidance on the mechanisms, including multidisciplinary approaches to support re-engagement, should be developed. To facilitate this, efforts to routinely obtain consent and accurate contact details for community follow-up from caregivers are essential. Approaches for tracing children include phone calls, text messaging, mail, email and in-person tracing or a combination of these. Upon re-engagement, efforts to support retention of children should be emphasized, including counselling, disclosure, psychosocial support, peer support groups for caregivers and enrolment into appropriate differentiated service delivery models.

Table 7.2

Differentiated service delivery for children.

Task sharing

Since 2013, WHO has recommended that trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain ART (190). In 2016, WHO specified that these recommendations apply to all adults, adolescents and children living with HIV (3). However, programme experience suggests that task sharing has not sufficiently extended to children. Across many settings, doctors continue to initiate treatment, especially for younger children in hospital settings. An evaluation of health-care worker values and preferences in task sharing for initiating and maintaining treatment for children undertaken by the PATA network in 2020 highlighted challenges inherent in task sharing, including complexities associated with advanced HIV disease, suboptimal formulations and dose adjustments that may undermine nurse and midwife competence and confidence. Task sharing is critical and urgent to accelerate ART coverage among children.

This entails revising the regulatory framework and investing in preservice and in-service training on ART for children for nurses and midwives, providing regular clinical mentoring and supportive supervision, remote support (virtual platforms and hotlines), delineating roles and ensuring harmonization across all the cadres and levels of care. Standard operating procedures should provide clear indications, pathways and systems for referral to mid- and senior level cadres such as clinical officers and doctors (63). Evidence for task sharing models in care for children is limited. More evidence on task sharing and the outcomes of children in various contexts needs to be generated to inform policy.

Peer programming

Using peer approaches, especially in programmes for preventing mother-to-child transmission, is a low-cost, effective and acceptable intervention for improving children’s health outcomes and timely presentation for early infant diagnosis and retention in care (294,295). Peer programming provides another opportunity for task-sharing. Provided with adequate training, supervision and tools, peers can support health-care workers and facilities to execute tasks, including caregiver education and psychosocial support, adherence support, community delivery of ART and community follow-up. Policies should clarify the roles and responsibilities of peers, consider formalizing them within the service delivery systems and establish mechanisms for retaining these cadres.

Monitoring and evaluation systems should establish task sharing and peer programming indicators specific to children and quality assurance mechanisms that monitor the quality of services provided for children by each cadre against established competency levels and standards developed. Job aids, including dosing charts, caregiver counselling and education guides, should be provided to facilitate task sharing. Section 7.7 provides details on the recommendations for task sharing.

Assisted disclosure

Disclosure enhances adherence to ART, but the emotional and mental effects of disclosure to children vary (296,297). Qualitative data suggest that caregivers need support and counselling on approaching disclosure to children (298). Interventions based on an education model have been used to improve the knowledge and skills of caregivers and health-care workers on disclosure (299). Most countries have policies for disclosing HIV status to children in place. Health-care workers and lay workers should be equipped with adequate skills and aids to support the disclosure process in children and to provide post-disclosure support. Children with adherence issues should be assessed for disclosure status and age-appropriate disclosure planned based on their capacity to understand basic HIV concepts, cognitive development and emotional maturity.

In summary, stronger evidence of high-impact service delivery models for children and their caregivers is needed, tailored to the epidemic context, through robust well-conducted operational research that documents experience of programmes in pilots and scale-up and that builds evidence for the interventions in context to inform implementation and policy.

Background

WHO recommends initiating ART among in all adolescents (10–19 years old) living with HIV regardless of CD4 cell count or clinical stage of disease. A growing cohort of 1.7 million adolescents living with HIV includes people infected from birth and those who acquired HIV later in childhood and adolescence (301,302). Although health outcome data for this age group remain limited, emerging evidence indicates that adolescents living with HIV are underserved by current HIV services and have lower access to and worse outcomes on ART than older age groups (303–305). Adolescents are at high risk of loss to follow-up both before and after initiating ART, with older adolescents, pregnant adolescents, adolescent mothers living with HIV and adolescent key populations being especially vulnerable (304,306–313). Peer-driven models of care have demonstrated impact on improving health-seeking behaviour and HIV treatment outcomes for adolescents living with HIV, such as linkage, adherence to ART, retention in care and viral suppression (314–316).

Rationale and supporting evidence

Adolescents, including those living with HIV, face significant barriers to accessing health services, such as inadequate health literacy, limited ability to navigate health systems, legal requirements for parental or caregiver consent and insufficient resources to pay direct and associated service costs (317,318). Adolescents face significant levels of stigma and discrimination, especially adolescents from key populations, among whom criminalization of behaviour such as sex work, drug use and same-sex activity further perpetuates social exclusion and hinders access to health and support services (319,320). The rapid developmental and social changes that occur during adolescence exacerbate the impact of such barriers and can profoundly affect how adolescents engage with health services (321).

Poor-quality services also limit adolescent engagement in health care. Adolescents often perceive health services as unacceptable because of concerns about confidentiality and negative attitudes of health-care providers (319,320,322). Services are often not organized to accommodate adolescent needs and routines and have inconvenient service schedules, inflexible appointments and unwelcoming environments (320,321). Without sufficient attention and support, adolescents can be lost between services for children and services for adults.

Because of their specific needs, adolescents require high-quality comprehensive services and care to support access, retention and adherence. This includes psychosocial support, sexual and reproductive health and mental health care (321,323). The principles of adolescent-friendly health services are outlined in the WHO-defined characteristics of adolescent-friendly health services (Box 7.7) (322,324).

A systematic review (3) was undertaken to assess the effectiveness of adolescent-friendly health services for adolescents living with HIV compared with the standard of care. Because of the limited evidence available, the review was expanded to include adolescents and young adults up to and including 24 years of age. Adolescent-friendly health services were defined according to the WHO characteristics and the global standards for high-quality health-care services for adolescents. Eleven randomized controlled trials (325–335) and eight observational studies (336–343) from four of the six WHO regions were identified. Four studies focused on adolescents living with HIV; the remainder focused on sexual and reproductive health, HIV prevention, mental health, diabetes, general health and smoking cessation. All studies included two or more of the WHO characteristics and global standards for high-quality health-care services for adolescents. Only one study included all WHO characteristics, and no study addressed all global standards.

Adolescent-friendly health services, approaches and interventions compared with standard care showed small but significant improvements in various outcomes, including health outcomes (lower pregnancy rates); health care utilization (presentation at a clinic for mental health, HIV counselling and testing and outpatient visits); uptake of services (HIV testing); knowledge (acquiring HIV and sexually transmitted infections, preventing pregnancy and sexual health); attitudes (towards sex and HIV testing); sexual risk-reduction behaviour (condom use); self-efficacy (condom use or diabetes management); and service acceptability. Outcomes related to healthy lifestyles and quality of life did not differ. Among young people living with HIV exposed to adolescent-friendly health services compared with the standard of care, there was improved short-term viral suppresion and long-term ART adherence. The overall certainty of evidence is low. The Guideline Development Group made a strong recommendation despite low-certainty evidence, citing the promising improvement in outcomes and the existing programme experience, evidence of feasibility and acceptability by the end-users (3).

Cost and cost–effectiveness

A cost modelling study and a retrospective cost analysis for adolescent-friendly health services in low- and middle-income countries reported that, although additional resources are required to ensure the delivery of high-quality adolescent-friendly health services, investments to implement and scale up these services – especially services providing multiple interventions – appear to have value and impact for adolescents (344,345).

Equity and acceptability

Adolescent-friendly approaches aim to ensure that all adolescents obtain the health services that they need, that policies and procedures are in place to facilitate the provision of health services to adolescents and that all health-care providers treat adolescents with equal care and respect regardless of HIV status or risk behaviour.

A global consultation of 470 young people living with HIV and a situational analysis of more than 200 facilities in the WHO African Region was undertaken (320,346); additional input from two unpublished multicountry longitudinal qualitative studies with 147 adolescents living with HIV was also considered (3). Key themes and suggested strategies for improving service delivery focused on empowered and solution-oriented information and support; opportunities for open and honest discussion; skills development on sexual and reproductive health and HIV disclosure from an early age; comprehensive care that addresses issues beyond HIV, including support for adolescents from key populations; flexible scheduling of clinic visits to accommodate school hours; services free of charge closer to home and community-based; dedicated hours and spaces for adolescents; peer-led interventions and services; and an adolescent-competent workforce.

Further, since adolescents living with HIV are a heterogeneous group with varying needs, expectations, preferences and vulnerabilities, care should be taken to ensure equity in service delivery across the age band, paying particular attention to especially vulnerable adolescents, including those from key populations. Relevant WHO guidance and tools are available to facilitate the equitable implementation of adolescent-friendly approaches and programmes, which should consider differentiated intensity and frequency of services for adolescents (21,347).

Feasibility

Programmatic and facility-level evidence suggests that providing adolescent-friendly health services is feasible. A situational analysis of over 200 health facilities in the WHO African Region found that 35% of facilities were attending to adolescents living with HIV separately from adults and/or children through dedicated schedules, staff and/or spaces (311). A case study of a government ART clinic in South Africa found that providing adolescent-friendly approaches in an HIV service setting is feasible. Although the financial costs were low, consideration needs to be given to ensure the engagement of stakeholders, including adolescents; adolescent-specific training for health-care providers and minimal rotation of providers; and adequate time for planning restructured services. A survey of national HIV programme managers highlighted a lack of appropriately trained health-care workers and the need for greater preparation of health-care services as key challenges in delivering HIV services to adolescents (3).

Experience in Zimbabwe has identified several requirements for scaling up adolescent-friendly HIV services, including a national, multisectoral, coordinated response; adolescent-sensitive policies and guidelines; meaningful involvement of adolescents; training and sustained mentorship of health-care providers; community system strengthening; linking community interventions with health facilities; and a national monitoring and evaluation framework with disaggregation and clear indicators for adolescents.

Implementation considerations

The WHO global standards for high-quality health-care services for adolescents provide an approach to improving the services provided to adolescents (72). Examples of how these standards can be adapted to HIV services are available (Box 7.8) (316). The standards are accompanied by an implementation guide that highlights the necessary steps at the national, district and facility levels to achieve the standards and assessment tools to measure implementation (72).

The implementation guide outlines further actions to implement the standards at the national, district and facility levels (72).

Adolescent peer-driven models and support are key implementation strategies towards the global standard of adolescent participation. The WHO technical brief on peer-driven adolescent HIV models of care (316) provides implementation considerations for adapting and scaling up peer-based, adolescent-friendly models and showcases five best-practice case studies based on country experience. The brief advises that peer support is best implemented alongside: routine assessments to monitor progress and quality; standardized peer counsellor recruitment; orientation, training and mentorship of peer counsellors and other stakeholders; deliberate and differentiated care of peer counsellors and health-care workers; and transition planning for peer counsellors ageing out of the programme.

Additional HIV-specific implementation considerations include:

• integrating HIV services for adolescents living with HIV with other adolescent health services, such as those for mental health and sexual and reproductive health;
• aligning approaches for HIV service delivery with WHO and national adolescent-friendly health service standards, protocols and activities;
• including the implementation of adolescent-friendly approaches in HIV health service supervisory and monitoring systems;
• ensuring training, research and personal development opportunities for health-care providers on adolescent HIV treatment and care;
• engaging service providers, adolescents and other key stakeholders to identify acceptable and feasible activities;
• implementing adolescent-friendly health service approaches in all HIV services accessed by adolescents, including antenatal care for pregnant adolescents living with HIV and adolescent mothers;
• establishing links and referral pathways to ensure a comprehensive continuum of care, especially for the transition from HIV services for children to those for adults; and
• addressing the needs and vulnerabilities of adolescents from key populations (70).

Relevant WHO guidance and tools are available (71,319,300,348,349–352).

Research gaps

Although examples of excellence in adolescent-friendly health services for adolescents living with HIV exist (317,353–355), programmes remain poorly documented, with limited scale, and quality and standards vary widely.

Research should contribute to improving understanding of how to implement adolescent-friendly health services within HIV services at a programmatic level and the cost–effectiveness of these approaches in resource-limited settings. Research on the service delivery needs of adolescents living with HIV should examine the minimum package of care; models of delivery at different service levels, including for key populations and pregnant adolescents living with HIV; integrating sexual and reproductive health into HIV services for adolescents; interventions to support safe disclosure; treatment literacy; interventions to address mental health; and the impact of provider training and peer interventions.

The WHO technical brief on peer-driven adolescent HIV models of care (316) advocates operational and implementation research to assess the effectiveness of and best practices within peer support programmes.

Supporting adolescent mental health and psychosocial well-being

Both the aforementioned WHO-defined characteristics of adolescent-friendly health services and the WHO global standards for high-quality health-care services for adolescents (72,322) highlight the importance of providing an appropriate package of services that fulfils the needs of adolescents. Almost 50% of all mental health conditions start before the age of 14 years, and up to one in five adolescents experience a mental disorder each year (356). Adolescents living with HIV are at increased risk of mental health disorders, such as depression and anxiety (356,357).

The WHO guidelines on mental health promotive and preventive interventions for adolescents provide evidence-informed recommendations on psychosocial interventions for adolescents 10–19 years old that can be implemented in schools, health-care settings, communities or through digital platforms (356) and are relevant within an HIV context.

Background and rationale

The 2016 consolidated HIV guidelines detailed the key elements of general care over the continuum of HIV care for people living with HIV (3). However, adolescents and young adults living with HIV face distinct and interlinked challenges as they navigate the health-care system, take on responsibility for managing their own care and treatment and confront issues relating to stigma and disclosure (316). Specific guidance is therefore necessary to ensure that interventions specific to adolescents and young people are identified and evaluated.

Adolescence entails biological, cognitive and social changes. It is a phase in the life-course of increased exploration of identity, vulnerability and experimentation, and navigating this phase can be especially complex (358). Adolescents and young adults living with HIV experience numerous mental and social issues, including depression, stigma, isolation, difficulties with treatment adherence and retention, sexual risk-taking practices and substance use (359). In addition, evidence indicates that these people are underserved by current HIV services and, compared with adults 25 years and older, have significantly worse access to and coverage of ART, worse suppression of viral loads and a high risk of loss to follow-up both before and after initiating ART (3).

Psychosocial interventions, which adopt psychological, social and/or behavioural approaches to developing skills and knowledge, have been introduced across a variety of sociodemographic settings, but these interventions have not been adequately explored as a whole.

A systematic review assessed the effect of psychosocial interventions on ART knowledge, linkage to care, adherence to ART, retention in care, viral load, sexual and reproductive health behaviour and knowledge and improved transitioning to adult services. Thirty randomized controlled trials of psychosocial interventions for adolescents and young adults were identified (360). Psychosocial interventions improved adherence to ART (standardized mean difference 0.39, 95% CI 0.11–0.68); reduction in viral load (standardized mean difference – 0.26, 95% CI –0.45 to –0.07) and led to increased viral suppression (odds ratio 1.9, 95% CI 1.0–3.8) and undetectable viral load (odds ratio =1.8, 95% CI 1.1–3.1). No undesirable effects were identified. The Guideline Development Group judged the certainty of evidence to be moderate.

The systematic review described the following psychosocial interventions:

• interventions that harnessed motivational interviewing, a collaborative, client-centred counselling style focused on increasing motivational readiness for behavioural change (361–366);
• interventions that involved adolescents and their caregivers: family-based interventions to promote mental health and prevent negative behaviour (such as nonadherence) among adolescents with HIV, which are designed to strengthen communication, problem-solving and negotiation skills for both adolescents and caregivers (367);
• interventions based around peer support and social networks, which are peer-driven interventions involving multiple intervention components to target adolescents and young adults living with HIV and improve outcomes, including adherence to treatment, retention in care and suppression of viral loads (314,368–370); and
• digital means used to introduce new information and deliver behaviour change skills (371–375).

Benefits and harm

Overall, the net effects on adherence and suppression of viral loads were positive. There were no undesirable effects, and the interventions improved adherence and viral load outcomes. The Guideline Development Group judged the benefits to be moderate and harm trivial.

Feasibility, cost and cost–effectiveness

Overall, psychosocial interventions for adolescents living with HIV were found to be feasible to implement (314,376,377). Many studies reported low attrition rates, indicating that interventions were feasible and well accepted (362,367,378,379). The location of the intervention also influenced feasibility, with interventions delivered digitally or at home considered more feasible because of convenience and flexibility (369,380).

Comprehensive training of existing or new personnel and integrating interventions into existing health-care settings were important for successful implementation (365,381,382). Other feasible interventions used existing support networks to improve engagement in care (368).

There is potential for digital interventions and delivering support through virtual platforms (383). There is an opportunity for delivering blended virtual and face-to-face psychosocial support to support access to equitable and wide-scale services.

Information on the resources used and the cost were extracted as part of the systematic review. Short-term increases in the costs of widespread implementation may offset the longer-term economic and social costs of failing to promote the suppression of viral loads for adolescents living with HIV (314). Psychosocial interventions designed to be implemented by lay counsellors or peer mentors are relatively inexpensive (367,376,378,384). Costs may be reduced by using digital strategies for delivery (371,379). The effects of digitally delivered interventions have been identified as being comparable to or even better than those of in-person interventions (378). Conversely, labour-intensive interventions are more costly (379). Training and employing new personnel to deliver interventions also involve costs. The Guideline Development Group judged the certainty of evidence on costs and resource requirements to be moderate.

Equity and acceptability

Psychosocial interventions are likely to improve equity, especially for more vulnerable groups such as adolescent girls and young women, pregnant adolescents, adolescent mothers and key population groups, and in contexts of high youth unemployment and persistent HIV stigma. The systematic review showed improvements in health equity when approaches are introduced to provide structural support and optimize the potential of peer support and networks and when considering gender preferences for psychosocial support interventions (385–387). The widespread provision of psychosocial services enables adolescents living with HIV to have a more equitable chance to benefit from optimal HIV outcomes by ensuring that each young person receives adequate support to enable them to live physically and mentally well with HIV. The Guideline Development Group judged that offering psychosocial interventions to adolescents and young adults living with HIV would probably increase equity.

A global consultation of adolescents and young adults living with HIV was conducted among 388 respondents across 45 countries, supplemented by 10 focus group discussions with 61 adolescents and young adults with HIV across 10 countries (63). There was near universal agreement (95–98% of respondents) that psychosocial support interventions would help substantially across the HIV cascade and a range of outcomes. Psychosocial support was considered critical to both the mental and physical health of adolescents and young adults living with HIV. The findings demonstrate that psychosocial support is desired and preferred and described as being potentially transformative across HIV treatment outcomes (diagnosis and initiating ART, adherence, retention in care, suppression of viral loads, mental health and sexual and reproductive health and rights). The findings show that adolescents and young adults living with HIV want to receive sustained psychosocial support at each stage of the HIV cascade (63).

Adolescents and young adults living with HIV prefer a varied package of psychosocial interventions, but they consider peer support especially important in managing their health. Interventions that focus on strengthening support from trusted family members and health-care workers are also desired.

Another survey was implemented among frontline health-care workers to assess a wide range of service delivery practices, gaps and enablers (388); 324 health-care workers from 30 countries, primarily in sub-Saharan Africa, participated. At each step in the treatment cascade, the health-care workers reported psychosocial issues as major challenges and recommended psychosocial support strategies more than any other type of intervention. The Guideline Development Group found no important variability on preferences and acceptability.

Implementation considerations

A package of services should be considered that is both acceptable and feasible within the context in which they are to be delivered. This package should be differentiated according to the needs and experiences of different subpopulations of adolescents and young adults living with HIV.

Some adolescents and young adults living with HIV may require adaptations to the content and/or delivery of psychosocial programming to meet their needs. These include adolescents and young adults: with disabilities; who are living with mental health conditions or substance use; who are in and out of school; who are orphans; who are members of ethnic minority groups; who are lesbian, gay, bisexual, transgender, queer or intersex (LGBQTI); who are pregnant; and who are living in contexts of adversity such as extreme poverty and/or humanitarian emergencies. In addition, differences in exposure to risks and protective factors depending on age, developmental stage, sex, health status, whether they belong to a key population and context need to be considered.

Evidence supports psychological approaches such as motivational interviewing and cognitive behavioural therapy. Programmes can include goal setting, problem solving, coping skills, healthy daily routines, interpersonal and communication skills, activating social support and other strategies. Interventions can be delivered through a range of delivery modalities and health-care workers, including clinic visits, home visits, support groups (including peer support and groups that link psychosocial support with ART delivery such as teen clubs), social media and telephone contact. These should be fully integrated within the package of clinical services to optimize impact. Facilitators should be able to develop supportive, trusting, non-judgemental relationships, to maximize engagement in programming; this requires investing in ongoing training, supervision and support for facilitators.

Interventions should be implemented in keeping with the global principles and standards for providing high-quality health-care services for adolescents. The highest ethical standards should be maintained, including voluntary participation, confidentiality, privacy and the best interests of each adolescent and young person. Failure to participate should not affect access to ART or other services.

Peer-driven approaches and the participation and engagement of adolescents are necessary facilitators. The meaningful involvement of adolescents and young adults living with HIV in planning, developing, implementing and evaluating interventions may promote the acceptability and uptake of interventions.

Community support and the involvement of parents, guardians, schools, and other community members in programmes may provide important support for programmes and promote their success.

Research gaps

Additional research is required to identify interventions that improve outcomes for different groups of adolescents and young adults living with HIV. Importantly, research is also needed on content and delivery strategies for interventions to involve parents and caregivers, for both younger and older adolescents, to assess the effectiveness of these programmes.

Further research is needed to inform feasible and effective training, supervision and implementation of support models at scale for facilitators of psychosocial interventions, including peer providers.

There is an ongoing need for research and programme evaluation from resource-limited settings on psychosocial interventions for this group, which would be further supported with more data on the costs and cost–effectiveness of interventions that are currently limited. To further inform implementation, intervention studies should aim to include methods to capture and report costs.

In addition, to enhance the comparability of study findings, intervention studies are encouraged to use standardized outcome definitions to report critical outcomes.

Lastly, follow-up beyond the immediate post-intervention period is needed to understand the long-term impact of psychosocial interventions.