The treatment cascade in the United States – good in Ryan White programmes, but overall picture for gay men is poor

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People living with HIV in the United States who receive their care through the Ryan White HIV/AIDS Program have good rates of retention and virological suppression, investigators report in the online edition of Clinical Infectious Diseases. Of the patients seen at least once in 2011, some 82% were retained in care and 73% achieved virological suppression.

These outcomes dwarf those seen for most people living with HIV in the US – previous reports have estimated that as few as 40% were retained in care and 19% had achieved virological suppression.

A second new report focuses on gay, bisexual and other men who have sex with men, demonstrating that outcomes continue to be unacceptably poor in this group. Of those who have ever been diagnosed with HIV, 51% were retained in care and 42% achieved virological suppression.


retention in care

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

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.

Ryan White HIV/AIDS Program

In the United States, the largest federally funded programme providing HIV-related services to low-income, uninsured, and underinsured people with HIV/AIDS.

linkage to care

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


Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

However, both new studies found that outcomes were poorer in younger people, African American people and some other ethnic groups.

Thanks to improvements in antiretroviral therapy, many people living with HIV have an excellent life expectancy. The best outcomes are seen in people with good engagement with the HIV treatment cascade: prompt diagnosis, linkage with care, retention in care, initiation of HIV therapy according to guidelines and achievement of an undetectable viral load (virological suppression).

While very good levels of retention in care and virological suppression have been achieved in western Europe, US outcomes are much more worrying.

Ryan White HIV/AIDS Program

Services funded through Ryan White provide HIV treatment and care to people who cannot otherwise pay for their care. Investigators used programme data for 2011 to calculate rates of retention in care and virological suppression. They also looked at the factors associated with these outcomes.

Approximately 513,000 people received at least one Ryan White service. Almost two-thirds (62%) had a least one HIV medical care visit. Of these, 82% had at least two follow-up appointments at least 90 days apart and were therefore defined as retained in care.

Rates of retention in care ranged from 76% in people aged between 19-24 years to 88% for those aged under twelve. When retention was examined according to ethnicity, rates were lowest among American Indian/Alaskan Native people (78%) and highest among individuals of Asian background (85%). Retention also differed according to gender categories, from 83% in female patients to 80% in transgender patients.

Viral suppression was achieved by 73% of patients retained in care. Outcomes varied according to demographic characteristics. Only 49% of people in the 19-24 age group achieved suppression, compared to a rate of 87% in people aged 65 or older. Suppression rates were lower among black/African American patients (67%) compared to patients of Asian race/ethnicity (83%).

There are no analyses according to sexuality in this report.

The authors believe their findings are better than expected, especially as the programme “serves a predominantly poor population that would be expected to have significant health disparities and worse outcomes than the overall HIV-infected population.” But they stress “an urgent need to focus on retention in medical care and outcomes achievement among youth and young adults.” Concern is also expressed about disparities in outcomes for different ethnic groups.

An accompanying editorial notes that there are “gaps and limitations” in outcomes, and calls for targeted interventions to improve outcomes in these populations.

Men who have sex with men

Six-in-ten of people newly diagnosed with HIV in the United States are gay, bisexual and other men who have sex with men (MSM). The study on this group reflects individuals with differing degrees of access to health care – included are men who receive Ryan White services, men with private health coverage and men who are not currently enrolled in any programme.

The data come from the National HIV Surveillance System and the Medical Monitoring Project. Some analyses include data from across the United States, while others are based on 19 states which collected more detailed information.

  • Among MSM diagnosed during 2010, 77.5% were linked to care within three months of diagnosis.
  • Among all MSM who had ever been diagnosed with HIV and were still alive, 50.9% received HIV medical care at least twice during 2010.
  • Among all MSM who had ever been diagnosed with HIV and were still alive, 49.5% were prescribed anti-HIV drugs in 2010.
  • Among all MSM who had ever been diagnosed with HIV and were still alive, 42.0% achieved viral suppression in 2010.

For each of these measures, outcomes were poorer for younger men. For example, just 25.9% of men under the age of 25 had an undetectable viral load, compared to 60.8% of those aged over 55.

Similarly, outcomes were consistently poorer for black and African American men, with 37.0% achieving viral suppression.

The authors note that lack of health insurance, stigma and discrimination might influence men’s uptake of medical care.

“The findings in this report highlight the need for continued expansion of prevention, care, and treatment efforts for achieving improvement in linkage to care, retention in care, and viral suppression for MSM, particularly MSM aged <25 years and black/African American MSM,” they conclude. 


Doshi RK et al. High rates of retention and viral suppression in United States HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011. Clin Infect Dis, online edition, 2014.

Saag MS et al. Fixing a hole in the HIV safety net. Clin Infect Dis, online edition, 2014.

Singh S et al. Men Living with Diagnosed HIV Who Have Sex with Men: Progress Along the Continuum of HIV Care — United States, 2010. MMWR, 26 September 2014.