Big gaps in engagement with HIV care and virological suppression between US states

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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.


virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

continuum of care

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 


The prospect of survival and/or recovery from a disease as anticipated from the usual course of that disease or indicated by the characteristics of the patient.

But not all patients are benefiting fully from treatment.

Research suggests 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 load.

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 Columbia.

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%).

“These data 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.”


Gray KM et al. Jurisdiction level differences in HIV diagnosis, retention in care, and viral suppression in the United States. J Acquir Immune Defic Syndr 65: 129-32, 2014.