The proportion of people living with HIV linked to and retained in HIV care varies considerably
between individual US states and jurisdictions and is generally well below
target levels, investigators report in the Journal
of Acquired Immune Deficiency Syndromes. The authors studied data from 19
jurisdictions with full reporting of CD4 and viral load test results and also
found that only 43% of patients had an undetectable viral load.
“Our analysis is
one of the first explorations of state-level data to identify gaps in the
continuum of care,” write the authors. “Additional analyses are needed at the
state-level that further investigate the continuum by demographic and
behavioral characteristics, as well as social determinants of health.”
The past decade
has witnessed remarkable improvements in HIV treatment and care. The prognosis
of many people living with HIV is now normal and an undetectable viral load –
the aim of antiretroviral therapy for almost all patients – is associated with
a near-zero risk of HIV transmission.
But not all
patients are benefiting fully from treatment.
that approximately a quarter of people newly diagnosed with HIV in the US are not
linked to care. Moreover, attrition throughout the care continuum means that
only 36% of people with HIV in the US have a suppressed viral
The US National
HIV/AIDS Strategy has set a number of targets relating to engagement with care to be achieved by 2015. These include: increasing the proportion of
newly diagnosed patients who are linked to care from 65 to 85%; the proportion
retained in care from 73 to 80%; and the rate of virological suppression in
HIV-diagnosed gay and bisexual men, Hispanic people and black people by 20%.
A team of
investigators wanted to determine state-level differences in engagement with
care and virological suppression. They therefore examined data collected from
states and jurisdictions with full reporting of CD4 cell count and viral load
through to the end of 2012. These 19 jurisdictions included San Francisco and
Los Angeles counties in California, New York State and the District of
A total of 15,449
individuals were newly diagnosed in the 19 jurisdictions during 2011. Of these,
79% were linked to care within three months. However, linkage to care differed between
jurisdictions, ranging from 72% of patients in Georgia to 100% in North Dakota.
Seven jurisdictions met or surpassed the 2015 goal of 85% and several others
were within 5%.
A total of 338,959
people were living with diagnosed HIV infection in the 19 jurisdictions by
the end of 2010. Of these, 63.4% were in care in that year. The percentage
differed between states, from 41% in Illinois to 75% in Iowa.
Just over a half
(50.9%) of patients were in continuous care in 2010, the percentage ranging
from 25% in Illinois to 59% in Iowa. Overall, there was a 12.5% difference
between the percentage of patients in care and the percentage in continuous
care. The largest difference was in West Virginia (54-33%), followed by North
Dakota (62-42%) and Michigan (69-51%).
Some 43.4% of
patients were virally suppressed at the end of 2010. By jurisdiction, the
proportion ranged from 14% in Delaware to 56% in California. Overall, there was
a 7.5% difference in the percentage in continuous care and the percentage with
viral suppression. The biggest difference was in Delaware (28-14%), followed
by Georgia (44-32%) and New York (58-47%).
highlight the importance of analyzing data by jurisdiction to tailor
interventions that are appropriate at a local level,” conclude the authors.
“Healthcare providers, state and local health departments, and government
agencies can collaborate to build the infrastructure and services needed to
promote linkage to and retention in care, and to re-engage persons into care
who have fallen out of care. Services can include patient information about the
benefits of HIV medical care and adherence to treatment for improving
individual health outcomes and preventing HIV transmission.”