Michael Mugavero, MD, MHSc
Associate Professor of Medicine
University of Alabama at Birmingham

Among the 1.1 million Americans living with HIV infection in the United States, only 25% are virally suppressed. Depicted as the “treatment cascade,” individuals must navigate a series of steps starting with HIV testing and diagnosis, initial linkage to medical care among those who test positive and subsequent retention in care followed by antiretroviral therapy (ART) receipt and adherence to ultimately achieve viral suppression (Figure 1). The largest gaps in the cascade occur for the early steps of linkage and retention, with nearly 50% of persons diagnosed with HIV not engaged in medical care. So, how do we address the challenge (glass half empty), or is it the opportunity (glass half full), to improve linkage and retention in HIV?

A recent report from the CDC indicates dramatic gaps in linkage and retention are seen across age, gender, racial/ethnic, and risk transmission groups (CDC Fact Sheet). Failure to move across these early steps of the treatment cascade among roughly half of persons diagnosed with HIV precludes access to ART and attainment of viral suppression. This has profound implications for individual health outcomes and HIV prevention with positive initiatives (e.g., treatment as prevention). Because of current deficiencies, improving entry into and retention in care holds the greatest promise to maximally realize the individual and public health benefits afforded by viral suppression. So, what can we do?

Recently published guidelines to improve entry into and retention in care and ART adherence included five recommendations addressing engagement in medical care (Guidelines). Systematic monitoring of entry into care (recommendation #1) and retention in care (recommendation #2) are recommended for all persons with HIV. A range of data sources are available including public health surveillance, clinic based utilization and administrative claims data, with integration of systems a proven approach to enhance monitoring. Recent reports from the Institute of Medicine on monitoring HIV care in the US are valuable resources that include core indicators for linkage and retention and data systems available for monitoring (IOM reports: Monitoring HIV Care in the United States, Indicators and Data Systems, A Strategy for Generating National Estimates of HIV Care and Coverage).

Three recommendations in the guidelines focused on interventions with proven efficacy to improve entry into or retention in care. Among persons newly diagnosed with HIV, strengths-based linkage case management is recommended to facilitate entry into medical care (recommendation #3). Cost and resource limitations may preclude implementation and dissemination of this intervention approach for all newly diagnosed persons. Based upon HRSA Special Projects of National Significance, the final two recommendations are for intensive outreach (recommendation #4) and peer or paraprofessional patient navigation (recommendation #5) for persons tenuously connected to care. These latter two recommendations are to be considered on an individual basis, and not routinely recommended for widespread implementation. Resources like the in+care campaign provide additional, practical tools and guidance for HIV medical clinics interested in enhancing monitoring and intervention approaches to foster entry into and retention in care (in+care campaign).

Half of persons diagnosed with HIV in the US are not in care. This group represents the greatest challenge and opportunity for us to meaningfully impact the domestic HIV epidemic. What are you doing now? What are you going to do in the future?

Please join us for a webinar on January 16^th that will provide more details on these Guidelines; you can register here.  Also, the AETC NRC will sponsor a workgroup in 2013 focused on developing practical tools and manuals to support implementation of programs demonstrated to improve linkage and retention in care.

Figure 1.