The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions.

Mugglin, Catrina; Kläger, Delia; Gueler, Aysel; Vanobberghen, Fiona; Rice, Brian; Egger, Matthias (2021). The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions. Journal of the International AIDS Society, 24(7), e25761. BioMed Central 10.1002/jia2.25761

Mugglin_JIntAIDSSoc_2021.pdf - Published Version
Available under License Creative Commons: Attribution (CC-BY).

Download (1MB) | Preview


The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade.


We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero.


Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care.


The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.

Item Type:

Journal Article (Review Article)


04 Faculty of Medicine > Pre-clinic Human Medicine > Institute of Social and Preventive Medicine (ISPM)

UniBE Contributor:

Mugglin, Catrina Andrea; Klaeger, Delia Corina; Güler-Kaya, Aysel and Egger, Matthias


600 Technology > 610 Medicine & health
300 Social sciences, sociology & anthropology > 360 Social problems & social services




BioMed Central


[4] Swiss National Science Foundation




Andrea Flükiger-Flückiger

Date Deposited:

28 Jul 2021 10:43

Last Modified:

29 Jul 2021 19:01

Publisher DOI:


PubMed ID:


Uncontrolled Keywords:

ART outcomes HIV care cascade sub-Saharan Africa virological suppression




Actions (login required)

Edit item Edit item
Provide Feedback