Considering the HIV Care Continuum on World AIDS Day

Guest post by Cathy Maulsby

Tremendous progress has been made in the fight against HIV since the first World AIDS Day in 1988. Thanks to advancements in antiretroviral therapy (ART), HIV can now be a manageable chronic disease, and in the U.S., the average life expectancy for people living with HIV (PLWH) continues to increase towards that of the general U.S. population. However, significant work remains to be done to reach the goal of ending HIV in this country. Today, approximately 1.2 million people in the U.S. are living with HIV, and certain populations (including gay, bisexual and other men who have sex with men, Black women and men, Latino men and women, people who inject drugs, youth aged 13 to 24, and transgender women) continue to be disproportionately affected. Additionally, of the 1.2 million PLWH in the country, far too many lack access to ART—the lifesaving drugs that reduce HIV transmission by lowering the level of virus in the blood (viral suppression).

In the field of HIV, we refer to the HIV care continuum—a model of the consecutive stages of HIV medical care, from initial diagnosis to achieving viral suppression—to identify gaps in services and improve engagement in care and health outcomes for PLWH. The Centers for Disease Control and Prevention (CDC) estimates that among PLWH, only 41% are retained in HIV care, 36% are prescribed ART, and 28% are virally suppressed. This means that the majority of PLWH do not have access to regular HIV medical appointments (approximately 60%), and even more (approximately 70%) are not virally suppressed. Clearly, there is significant work to be done to reduce these gaps across the continuum of care.

In July 2015, the White House released an updated National HIV/AIDS Strategy (NHAS) to guide the nation’s response to the epidemic through 2020. The updated NHAS sets specific goals to achieve the vision of a country where new HIV infections are rare, and every person living with HIV has access to high-quality care. If we are to meet these goals, it is critical that HIV programs combine effective behavioral and biomedical programs to boost linkage and retention in HIV care. Evidence-based program models—such as patient navigation, coordinated care teams, and strengths-based case management—save lives by providing the tools and support to maintain regular HIV care engagement, but reimbursement and coverage for these services needs to be expanded. In addition, there is a dearth of information on how to implement these interventions in real-life practice settings, and too few evidence-based interventions exist for some of the populations most heavily impacted by HIV, such as Black gay, bisexual and other men who have sex with men.

Through research that my colleagues and I conducted on Improving Access to HIV Care, a national HIV linkage and retention in care program funded through AIDS United with generous support from the Corporation for National and Community Service, M·A·C AIDS Fund, and Bristol-Myers Squibb, we found that a lack of support services—such as long waitlists for housing and insufficient resources for mental health and addiction services, and employment-related services—created a significant barrier to HIV program implementation. And while case management reimbursement through the federal Ryan White HIV/AIDS program provides much needed support, the demand for these services often far surpasses the available resources.

Scientific advances have given us the tools to effectively prevent HIV infection and disease progression. But HIV is a social disease, and the root causes—and the largest barriers to HIV medical care and HIV medication adherence for many PLWH—are the complex and competing needs, such as housing insecurity, addiction, mental health conditions, incarceration and unemployment. To realize the full benefit of the tools available to fight HIV, coverage for much needed case management and social support services must be expanded, and we must address, at the systems-level, the social factors that place individuals at increased risk for HIV transmission. Otherwise, the disparities we see today across the HIV continuum of care are likely to persist.

Cathy Maulsby is an assistant scientist at the Johns Hopkins Bloomberg School of Public Health and co-author of Improving Access to HIV Care: Lessons from Five U.S. Sites, which JHU Press will publish early next year.

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