Jose, Sophie; (2018) Assessing outcomes of people living with HIV in the UK in relation to the continuum of care framework. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

HIV is now a chronic illness, requiring long-term care and adherence to treatment. The continuum of care depicts the stages of the HIV care pathway, including diagnosis, Antiretroviral Therapy (ART) uptake and viral suppression. It is a widely used framework that monitors the success of HIV care and potential for transmission in a population. However, it has limitations and does not capture information on important health indicators, particularly mortality. The UK Collaborative HIV Cohort (CHIC) Study is an observational database of HIV-positive individuals accessing care. Linkage to HIV surveillance data is used to improve ascertainment of deaths, and, alongside additional data collected from participating centres, classify a principal cause of death. Late diagnosis occurs in approximately 56% of those aged ≥50 years, but 42% of those ≤50, and is associated with an increased rate of death in the subsequent year. Late ART initiation is associated with lower CD4 counts over time on ART, leaving individuals at a higher risk of clinical progression for longer. Engagement in care (EIC) during the first 5 years on ART correlates with life expectancy, but is generally high (median 93% of months in care). Unsuppressed viral load is highly predictive of age at death in those on ART. A longitudinal continuum of care provides information on person-time spent with unsuppressed viral load and incorporates additional outcomes of mortality and loss to follow-up. It has shown disparities in care across demographic subgroups in the UK, with younger HIV-positive individuals having lower levels of EIC and being slower to initiate ART than older individuals, who have higher mortality. Women and those of black ethnicity spend less time on ART with a suppressed viral load. Targeted improvements in testing rates, adherence and engagement support are needed in those identified at high risk of sub-optimal care engagement, to reduce mortality and achieve a good continuum of care for all people with HIV in the UK.

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