Achieving Improvements across the HIV Treatment Cascade

A Clinical Management Algorithm Based on IAPAC's Entry Into and Retention in Care and Antiretroviral Therapy Adherence Guidelines

José M. Zuniga, PhD, MPH; Benjamin Young, MD, PhD


J Int Assoc Provid AIDS Care. 2013;12(1):15-17. 

Engagement in care is directly linked to achieving HIV viral suppression, yet over the past 2 years analyses of data related to the US HIV epidemic have revealed that many people living with HIV/AIDS are failing to successfully navigate the HIV treatment cascade, with only between an estimated 19% and 28% achieving the ultimate goal of antiretroviral therapy (ART): viral suppression. We propose a clinical management algorithm that captures key operational interventions recommended in recently published guidelines on entry into and retention in care and ART adherence.

Perhaps no other recent study has placed the lack of optimal engagement in HIV care in the United States into greater perspective than the much-cited 2011 review by Gardner and colleagues, which among other sobering findings reported poor engagement in care for HIV-positive individuals across the spectrum of care, and extrapolated that only 19% of the country's HIV-infected population is virologically suppressed.[1]

Just as the HIV treatment community began cogitating on the implications of the "Gardner Cascade," and almost every PowerPoint presentation served to remind us of our collective disappointment, the US Centers for Disease Control and Prevention (CDC) conducted its own analysis using various sources (eg, CD4 and viral load reports, surveillance data) to determine the extent of patient disengagement across the treatment cascade. What they found mirrored the Gardner findings, indicating that only 28% of Americans living with HIV/AIDS have managed to keep their virus under control while on antiretroviral therapy (ART).[2]

Various factors, including social determinants of health, have contributed to these significant gaps. Yet, in many respects, their underlying cause rests in the realms of clinical and behavioral practice. As such, recently published evidence-based guidelines focused on improving entry into and retention in care, as well as ART adherence,[3] offer a road map for achieving improvements across the treatment cascade. But achieving improvements in these areas requires taking recommendations from the published work into the clinic.

Recognizing a dearth of tools to assist providers in assessing and managing patients across the care continuum, we sought to create a simple clinical management algorithm that captures key operational interventions recommended in the guidelines (Figure 1), including:

Figure 1.

Improving entry into and retention in care and art adherence for persons with HIV.

  • monitoring of entry into care (eg, strength-based case management);

  • monitoring retention in care (eg, use of peer or paraprofessional navigators);

  • monitoring adherence (eg, self-reported adherence, pharmacy refill);

  • antiretroviral strategies for treatment-naive and -experienced patients;

  • education and counseling (eg, one-on-one ART education and adherence support); and

  • adherence tools (eg, reminder devices and interactive communication technologies).

Clearly, interventions in these areas need to appreciate the unique social and clinical context existing in each care environment. As such, for some settings certain aspects of the algorithm may be more important or relevant than others. Operationalizating many of the guidelines' recommendations should be accompanied by robust evaluation to identify what works and where. We thus believe there is a pressing need to validate the recommended interventions through both implementation science and operational research.

With fewer than 1 in 3 Americans living with HIV achieving the goal of virologic suppression, many are not fully benefiting from the promise of long-term AIDS-free survival that ART—optimally prescribed by clinicians and adhered to by patients—has been proven to deliver.[4–6] As the authors of the CDC analysis[2] rightly conclude:

Only with success at each step in the continuum of HIV care (ie, identifying those with HIV, linking them to and retaining them in care, and ensuring they receive optimal treatment and prevention services) can the ultimate goals of improving health, extending lives, and preventing further HIV transmission be achieved.