Human immunodeficiency virus care cascade among sub-populations in Rakai, Uganda: an observational study

Introduction: To assess progress towards the UNAIDS 90-90-90 initiative targets, we examined the HIV care cascade in the population-based Rakai Community Cohort Study (RCCS) in rural Uganda and examined differences between sub-groups. Methods: Self-reports and clinical records were used to assess the proportion achieving each stage in the cascade. Statistical inference based on a chi(2) test for categorical variables and modified Poisson regression were used to estimate prevalence risk ratios (PRRs) and 95% confidence intervals (CI) for enrolment into care and initiating antiretroviral therapy (ART). Results: From September 2013 through December 2015, 3,666 HIV-positive participants were identified in the RCCS. As of December 2015, 98% had received HIV Counseling and Testing (HCT), 74% were enrolled in HIV care, and 63% had initiated ART of whom 92% were virally suppressed after 12 months on ART. Engagement in care was lower among men than women (enrolment in care: adjPRR 0.84, 95% CI 0.77-0.91; ART initiation: adjPRR 0.75, 95% CI 0.69-0.82), persons aged 15-24 compared to those aged 30-39 (enrolment: adjPRR 0.72, 95% CI 0.63-0.82; ART: adjPRR 0.69, 95% CI 0.60-0.80), unmarried persons (enrolment: adjPRR 0.84, 95% CI 0.71-0.99; ART adjPRR 0.80, 95% CI 0.66-0.95), and new in-migrants (enrolment: adjPRR 0.75, 95% CI 0.67-0.83; ART: adjPRR 0.76, 95% CI 0.67-0.85). This cohort achieved 98-65-92 towards the UNAIDS 90-90-90 targets with an estimated 58% of the entire HIV-positive RCCS population virally suppressed. Conclusions: This cohort achieved over 90% in both HCT and viral suppression among ART users, but only 65% in initiating ART, likely due to both an ART eligibility criterion of <500 CD4 cells/mL and suboptimal entry into care among men, younger individuals, and in-migrants. Interventions are needed to promote enrolment in HIV care, particular for hard-to-reach subpopulations.