Presenting a conceptual framework for an HIV prevention and care continuum and assessing the feasibility of empirical measurement in Estonia: a case study
Objective: We aim to show the feasibility of using an integrated prevention and care
continuum (PCC) model as a complete and improved tool for HIV control measurement
and programming. Alignment of prevention and care continua is essential to further
improve health outcomes and minimize HIV transmission risk.
Design: Cross-sectional study.
Methods: Data from 977 persons who inject drugs (PWID) collected in 2011-2016 in
Tallinn, Estonia, were used to construct an HIV PCC for PWID, stratified by risk for
acquiring or transmitting HIV infection and by coverage of combined interventions. We
also estimated the average protective effect of current levels of intervention provision.
Results: 74.4%, 20.3% and 35.2% of PWID were currently using needle and syringe
programmes (NSP), drug treatment and HIV testing, respectively. 51.1% of current
PWID were HIV seropositive and of those 62.5% were currently on antiretroviral
therapy (ART) and 19.0% were virally suppressed. Across the PCC, individuals moved
between categories of being aware and ever using drug treatment (resulting in -50%
“leakage”); from ever having used to currently using drug treatment (-59%); between
“ever testing” and “current (continuous) testing” (-62%); and from self-reported ART
adherence to viral suppression (-70%). Use of prevention services was higher among
those at risk of transmission (HIV positive). The overall reduction in acquisition risk
among HIV-negative PWID was 77.7% (95% CrI 67.8-84.5%), estimated by the
modelled protective effects of current levels of NSP, drug treatment and ART
compared to none of these services.
Conclusions: Our findings suggest that developing a cohesive model for HIV
prevention and treatment is feasible and reflects the bi-directional relationships
between prevention and care. The integrated continuum model indicates the major
factors which may predict the epidemic course and control response.