Black people have low levels of engagement and retention in HIV care in the US

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Intensified efforts are needed to improve engagement by black people in the HIV care continuum in the United States, according to data published in the 7 February edition of Morbidity and Mortality Weekly Report.  

In 2010, an estimated 75% of black, HIV-positive adults were linked to care, 48% were retained in care, 46% were taking antiretrovirals and 35% had an undetectable viral load. These outcomes are well below the goals of the National HIV/AIDS Strategy and the HIV Care Continuum Initiative. Engagement with care was especially low among male and younger people.

“These data demonstrate the need for implementation of interventions and public health strategies that increase linkage to care and consistent ART among blacks,” comment the investigators. They note achievement of the goals of the national HIV strategy and HIV care continuum require 85% of black people diagnosed with HIV to be linked to care, 80% to be retained in care, and the proportion with an undetectable viral load to increase by a fifth.


linkage to care

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

retention in care

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

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. 

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.



Black people are the racial group most affected by the HIV epidemic in the US, comprising 44% of all new infections and 44% of all people living with HIV. Control of the US HIV epidemic therefore requires high levels of engagement among black people with all stages of the HIV care continuum.

Investigators used data collected from the National HIV Surveillance System and Medical Monitoring Project to assess engagement with HIV care and antiretroviral treatment outcomes among black people in 2010.

Three-quarters of black people diagnosed with HIV in 2010 were linked to HIV care within three months of diagnosis. The rate of linkage to care was higher among females than males (81 vs 72%). People aged 13 to 24 years had the lowest rate of linkage to care of any age group (69%); linkage increased with age group (e.g., over 55 years = 81%). As regards transmission category, individuals in the men who have sex with men risk group had the lowest rate of linkage to care (72%), and the women in the injecting drug use and heterosexual risk categories had the highest rates of linkage (82 and 81%, respectively).

Overall, 48% of black people were retained in care. A higher proportion of women were retained in care than men (51 vs 47%, respectively). Retention in care was lower in younger age groups compared to older age groups. Analysis by transmission category showed the rate of retention in care was lowest among male injecting drug users (44%) and highest among women infected via drug use or heterosexual contact (both 51%).

Well under half (46%) of black people were prescribed HIV therapy. Women were more likely than men to be utlitising antiretroviral treatment (51 vs 44%, respectively). The prevalence of antiretroviral useage increased with age, from 21% among the 18 to 24 age group, to 57% among those aged over 55 years. Males infected via injecting drug use were the risk group least likely to be taking HIV treatment (34%), whereas useage was highest among heterosexual women (51%).

Just over a third (35%) of black people had an undetectable viral load. The rate of virological suppression was higher in women than men (40 vs 33%, respectively) and increased with age. Only a fifth of male injecting drug users had an undetectable viral load compared to 41% of female heterosexuals.

“Blacks with HIV might not seek, receive, or adhere to HIV care or achieve viral suppression for reasons including lack of health insurance, poverty and stigma,” suggest the authors. “HIV programs that focus on care and treatment for blacks might strengthen these efforts to link and retain HIV-infected persons in care and promote adherence to medication to achieve optimal health outcomes.”

They suggest that interventions are especially needed for male and younger people. “Focusing prevention and care efforts on populations that bear a disproportionate burden of HIV disease could lead to reductions in HIV incidence and health inequalities and help achieve the goals of the National HIV/AIDS Strategy.”


Whiteside YO et al. Progress along the continuum of HIV care among blacks with diagnosed HIV – United States, 2010. MMWR 63(5), 85-89, 2014.