{"id":1265,"date":"2017-03-08T16:05:27","date_gmt":"2017-03-08T16:05:27","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=1265"},"modified":"2017-03-08T16:05:27","modified_gmt":"2017-03-08T16:05:27","slug":"the-prep-care-continuumcascade-how-would-it-look","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2017\/03\/08\/the-prep-care-continuumcascade-how-would-it-look\/","title":{"rendered":"The PrEP \u2018care continuum\/cascade\u2019: how would it look?"},"content":{"rendered":"

We take for granted the value of the care continuum<\/a> (or \u2018cascade\u2019), now increasingly seen as the key measure of health system response to HIV (Cassell (STIs editorial)<\/a>). \u00a0\u00a0The application of this model to HIV has provided a benchmark for evaluation in contexts as diverse as Moscow (Wirtz & Beyrer (STIs)<\/a>), South Africa (Schwartz & Baral (STIs)<\/a>) or the Netherlands (van Veen & van der Sande (STIs)<\/a>).\u00a0\u00a0 But could the same model also offer a means of evaluation in the case of other complex sexual health interventions such as PrEP (Pre-Exposure Prophylaxis)?<\/p>\n

An on-line soon-to-be-published paper by Nunn & Chan<\/a> (N&C), building on an earlier attempt by Kelley & Rosenberg<\/a> (K&R), does precisely this.\u00a0 An important difference from the earlier paper seems to be the more concrete definition of a larger number of steps (nine as against five) \u2013 especially in the central area of \u2018uptake\u2019 and engagement in care.\u00a0 Here K&R define three stages: \u2018need for awareness of PrEP and willingness to use it\u2019, \u2018need for good access to healthcare\u2019, and \u2018need for a prescription for PrEP.\u00a0 N&C replace these with a more concrete conceptualization of the process in five stages involving: an occasion where PrEP access is facilitated <\/strong>(4); an appointment arising from that occasion where the assessment is performed <\/strong>(5); the prescription of PrEP<\/strong>, where indicated (6); the actual initiation of PrEP<\/strong> (i.e. when the client starts taking the pills) (7).\u00a0 Also important is N&C\u2019s substitution of two final steps \u2013 adherence<\/strong> (8)) then retention<\/strong> (9) for K&R\u2019s single final step of \u2018adherence\u2019.\u00a0 N&C point out that, whereas, with ART, \u2018adherence\u2019 is once-and-for-all and secures the ultimate goal of viral suppression, in the case of PrEP, we can envisage multiple trajectories depending on whether PrEP continues to be indicated (e.g. the client may no longer be exposed to risk).\u00a0 Finally, K&R\u2019s first step \u2013 \u2018identifying at risk MSM\u2019 \u2013 gives way to three: identifying at risk individuals<\/strong> (1), enhancing HIV awareness<\/strong> (2), enhancing PrEP awareness<\/strong> (3).<\/p>\n

Is this nine-stage definition of a PrEP cascade overly \u201ccomplex\u201d (EECAAC2018<\/a>)?<\/p>\n

Answering such a question requires us to reflect on the function that the \u2018cascade model\u2019 is called upon to perform.\u00a0 If the model divides up the total course of an intervention into a series of staged tasks, this is presumably because the health benefit depends on the completion of the whole intervention, yet the accomplishment of each step is necessary to the achievement of subsequent ones.\u00a0 The idea of the cascade can provide a fair way of evaluating the progress of an intervention before its potential health benefits have been delivered \u2013 and can also identify the precise points at which the intervention is failing (i.e. where clients become \u2018disengaged\u2019).<\/p>\n

It follows that each step should correspond to a potential outcome that is not inferable from previous or later outcomes but is worthy of independent evaluation.\u00a0 If everyone who accesses PrEP (4) also attends an appointment at which suitability of PrEP is discussed (5), or everyone who adheres to PrEP (8) is also retained in PrEP (9), then steps (4) and (5), or steps (8) and (9), can be merged.\u00a0 This is not stated in so many words by the authors of the model.\u00a0 However, I would assume that it must lie at the basis of their thinking.<\/p>\n","protected":false},"excerpt":{"rendered":"

We take for granted the value of the care continuum (or \u2018cascade\u2019), now increasingly seen as the key measure of health system response to HIV (Cassell (STIs editorial)). \u00a0\u00a0The application of this model to HIV has provided a benchmark for evaluation in contexts as diverse as Moscow (Wirtz & Beyrer (STIs)), South Africa (Schwartz & […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4369,1642,4367,2380,1],"tags":[],"class_list":["post-1265","post","type-post","status-publish","format-standard","hentry","category-hiv-retention-in-care","category-hiv-testing","category-hiv-treatment-cascade","category-pre-exposure-prophylaxis","category-uncategorized"],"yoast_head":"\nThe PrEP \u2018care continuum\/cascade\u2019: how would it look? - Sexually Transmitted Infections<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/sti\/2017\/03\/08\/the-prep-care-continuumcascade-how-would-it-look\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The PrEP \u2018care continuum\/cascade\u2019: how would it look? 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