Engaging in HIV Care: What We Learned From AIDS 2012

Edward M. Gardner, MD


August 29, 2012

In This Article

Retention in HIV care has received increasing attention in recent years. Retention is critically important for optimizing treatment outcomes for HIV-infected individuals, and poor retention represents one of the primary obstacles to successful "test and treat" strategies for HIV prevention.

At the XIX International AIDS Conference, known as AIDS 2012, multiple presentations and posters focused on issues relevant to engagement and, in particular, retention in HIV care. This article reviews some of the important discussions on those topics that took place at AIDS 2012.

Updates to the HIV Engagement in Care Cascade

In a late-breaking abstract, Dr. Irene Hall from the Centers for Disease Control and Prevention (CDC) presented an updated US HIV engagement in care cascade that included subgroup analyses based on demographic characteristics.[1] Data for the cascades were derived from 2 sources: The National HIV Surveillance System was used to estimate HIV prevalence and linkage to care, and the CDC-sponsored Medical Monitoring Project (MMP) was used to estimate retention in care, receipt of antiretroviral therapy, and HIV viral suppression to < 200 copies/mL.

Looking at the estimated 1,148,200 HIV-infected individuals who were living in the United States in 2009, of whom 207,600 (18.1%) were unaware of their HIV serostatus, I will focus on 2 subpopulations: (1) the proportion of all US HIV-infected individuals retained in HIV care, defined as individuals having at least 1 HIV clinic visit between January and April 2009, and (2) the proportion of all US HIV-infected individuals with viral suppression.

Overall, 37% of US HIV-infected individuals were retained in care, and 25% of all US HIV-infected individuals attained viral suppression.[1] As shown in the Table, when patients were stratified by gender, females had slightly better retention than but similar viral suppression to males; by race, rates of retention and suppression were highest for white persons, intermediate for Hispanic/Latino persons, and lowest for black persons. Rates of retention and suppression increased as age increased from 25-34 years to 55-64 years. Finally, when stratified by HIV transmission category, the highest rates of retention and suppression were in female injection-drug users and female heterosexuals; the lowest rates were in male heterosexuals.

Table. US Continuum of Care: Rates of Retention and Viral Suppression

Variable Rate of Retention Rate of Viral Suppression
  Higher Lower Higher Lower
Gender Female: 41% Male: 35% Female: 26% Male: 25%
Race White: 38% Hispanic: 37%


Black: 34%

White: 30% Hispanic: 26%
Black: 21%
Age 55-64 years: 46% 25-34 years: 28% 55-64 years: 36% 25-34 years: 15%
Transmission category Female IDU: 44%
Female heterosexual: 40%
Male heterosexual: 29% Female IDU: 28%
Female heterosexual: 25%
Male heterosexual: 19%
IDU = injection-drug user

The information presented by Dr. Hall and the CDC will be critical as we move forward to develop interventions to support individuals across all transitions in the HIV engagement in care cascade.

Three other presentations focused on measurements of engagement, using city-wide, region-wide, and nationwide data. Nanette Benbow from the Chicago Department of Public Health presented interesting data on engagement in care from 4 large metropolitan areas in the United States -- Chicago, Los Angeles County, Philadelphia, and San Francisco -- using local public health surveillance combined with MMP calculators.[2] The 2 California sites had the highest rates of retention, ranging from 54% to 57%, as well as the highest rates of viral suppression, ranging from 40% to 44%; at the other sites, retention rates ranged from 30% to 39% and suppression rates ranged from 21% to 23%. Females and black persons were less likely than their counterparts to have viral suppression.

Sarah Rowan from Denver Public Health presented data suggesting that current cascade estimates may in fact be underestimates.[3] In a well-defined cohort of more than 600 persons with newly diagnosed HIV in Denver, Dr. Rowan and colleagues used clinical data and public health HIV laboratory reporting databases to track engagement in HIV care. In the chart-review phase, which included about two thirds of patients who had accessed care in a study site, 14% had evidence of migration out of Colorado. Accounting for out-migration (along with mortality) led to an improvement in estimates of retention in care, from 50%-55% to 65%-70%, as well as improvements in estimates of viral suppression, from 36% to 48%. Even after the approximately 20% of individuals with undiagnosed disease were accounted for, 38% of patients represented by this cohort were virally suppressed.

Valerie Delpech from the Health Protection Agency in London presented data on the United Kingdom's national engagement in HIV care cascade.[4] Using both national surveillance and clinical data, they estimated that 24% of HIV-infected individuals were unaware of their infection status. Once diagnosed, 82% of individuals were linked and retained in care and were receiving antiretroviral therapy; 87% of these persons had viral suppression. Thus, it was estimated that 54% of all HIV-infected individuals in the United Kingdom have a suppressed viral load.

It is encouraging to see data from global treatment cascades, and hopefully more such data will be available in the future. Moving forward, it will be interesting to look at similarities and differences across national and regional cascades and to further study the effect of healthcare systems on the engagement in HIV care cascade.


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