HIV continuum of care in Europe and Central Asia.

OBJECTIVES: The European Centre for Disease Prevention and Control (ECDC) supports countries to monitor progress in their response to the HIV epidemic. In line with these monitoring responsibilities, we assess how, and to what extent, the continuum of care is being measured across countries. METHODS: The ECDC sent out questionnaires to 55 countries in Europe and Central Asia in 2014. Nominated country representatives were questioned on how they defined and measured six elements of the continuum. We present our results using three previously described frameworks [breakpoints; Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; diagnosis and treatment quadrant]. RESULTS: Forty countries provided data for at least one element of the continuum. Countries reported most frequently on the number of people diagnosed with HIV infection (37; 93%), and on the number in receipt of antiretroviral therapy (ART) (35; 88%). There was little consensus across countries in their approach to defining linkage to, and retention in, care. The most common breakpoint (>19% reduction between two adjacent elements) related to the estimated number of people living with HIV who were diagnosed (18 of 23; 78%). CONCLUSIONS: We present continuum data from multiple countries that provide both a snapshot of care provision and a baseline against which changes over time in care provision across Europe and Central Asia may be measured. To better inform HIV testing and treatment programmes, standard data collection approaches and definitions across the HIV continuum of care are needed. If countries wish to ensure an unbroken HIV continuum of care, people living with HIV need to be diagnosed promptly, and ART needs to be offered to all those diagnosed.

Strategies for providing care and support to children orphaned by AIDS.

As a result of the severe HIV/AIDS epidemic in sub-Saharan countries such as Zimbabwe, where between 25-30% of the adult population are estimated to be infected, there are a growing number of orphans requiring care and support. Traditionally, orphans have been absorbed within the extended family but this is becoming more difficult because of the large number of young adults dying. The burden of care and support is falling on the very young and the very old. A number of strategies have been introduced to provide this care and support. Institutions, though popular, are very expensive to run, have limited capacity and only really cater for physical needs. Interventions which simply react to those who present to them may not reach the most needy and may encourage dependency. Community-based orphan care has been identified as the best and most cost-effective way of caring for orphans. An example of a community-based orphan visiting programme is presented. In the last six months of 1996, the FOCUS programme's 88 volunteers made a total of 9,634 visits to 3,192 orphans in 798 families at an average cost of US+1.55 per visit. The key elements of such programmes have been identified. They need to be implemented by a community-based organization (CBO) within a defined community. Volunteers should be selected from within the community. They need to be trained and supported as they enumerate orphans, identify the most needy and carry out regular visits. The volunteers should keep records of all their activities. These records can then be used as a basis for monitoring the programme. In order to cope with the increasing number of orphans in resource-poor settings like Zimbabwe, it is essential that such programmes be replicated and scaled up. This not only an economic necessity but is also a way of providing appropriate and effective services to those who need them.

PIP: In sub-Saharan African countries such as Zimbabwe, where 25-30% of the adult population is HIV-infected, a steadily increasing number of AIDS orphans are in need of care and community support. A study conducted in Zimbabwe's Manicaland province in 1992, found that 1 in 5 households contained orphaned children. The tradition of incorporating orphans into the extended family has broken down as HIV-infection rates have risen. Community-based orphan support programs that use volunteers to visit the most needy children have the potential to complement existing coping mechanisms in a cost-effective manner. Through a program operating in 4 rural sites in Manicaland (Families, Orphans, and Children Under Stress), 88 volunteers made 9634 visits to 3192 orphans in a 6-month period in 1996. The total cost of this program in 1996, was US$26,000 ($1.55/visit), 51% of which was spent within the affected communities. Key steps in establishing a community-based orphan support program include an organizational analysis, identification of catchment areas, selection and training of volunteers, client identification and registration, and program monitoring and evaluation. Despite the efficacy of community-based orphan programs, new child care institutions without links to the community continue to be established in sub-Saharan Africa and to attract scarce resources. Among the obstacles to more widespread implementation of a community-based strategy are the low priority given to problems that affect children, the sheer magnitude of the problem, a reluctance to acknowledge AIDS as a cause of death, and a lack of awareness on the part of politicians and planners of the potential of such programs.

Estimating coverage of a community-based home care programme.

The Family AIDS Caring Trust (FACT) was formed in Mutare, Zimbabwe's third largest city, in 1987. FACT's home care programme started in 1992. The programme operates in the urban area of Mutare which contains three townships with a population of 131,367. The area employs a trained nurse as a coordinator and four assistants, each assigned a zone within the city, who carry out the bulk of the visits. As part of an evaluation of the programme we attempted to estimate its coverage using different models. Using these models the FACT programme has a coverage of between 2.5%-23%. It is important that all home care programmes think in terms of coverage and do not simply strive to provide high quality services to a few patients.