In 2015, an estimated 36.7 million people worldwide were living with HIV.1 In the United States, HIV affects 1.2 million people.2 Although the annual number of new HIV diagnoses declined by 19% over the last decade2 the condition remains a major public health problem that was addressed by President Obama in 2013 through the establishment of the HIV care continuum. It prioritized the establishment of national indicators for HIV care and was updated in 2015 to include “quantifiable five-year goals for 2020.”3 The emphasis on “continuum” is central to this model.4
Traditionally, universal HIV testing and viral suppression have represented two ends of the continuum.4 However, the steps in the middle of the continuum are essential in “securing optimal health outcomes.”4 The national estimates of persons living with HIV (PLWH) show that, while 86% of all PLWH in the US know that they are HIV-infected, only an estimated 35% actually achieve viral suppression, suggesting inadequate management of the steps between diagnosis and successful treatment.4
The HIV treatment continuum is sometimes referred to as a “cascade.” However, a recent article by Kay et al distinguishes between the two. “Continuum” refers to “dynamic and bidirectional navigation of the spectrum of HIV care engagement at an individual level,” while “cascade” “usually represents a unidirectional series of five steps, including HIV diagnosis, LTC engagement/retention in care, ART initiation and adherence, and viral suppression.4 The true nature of HIV care is often “nonlinear,” and improvement in one step may not lead to positive outcomes, “underscoring how imperative it is to facilitate efficient and effective passage of PLWH through each step.”4
Video: Origins of HIV in the U.S.
Step 1: Diagnosis
The first step in the treatment continuum is diagnosis. Current CDC guidelines recommend that every patient between ages 13 and 64 years be offered an HIV test at least once.5,6 The US Preventative Services Task Force (USPSTF) issued similar guidelines.7
Despite these guidelines, an estimated one in eight HIV-positive individuals are unaware of their serostatus.2 One of the key goals set forth by the 2020 NHAS is to increase the number of PLWS who are aware of their status to 90%.3 The Joint United Nations Programme on HIV/AIDS (UNAIDS) referred to their international 2020 target as “90-90-90”—ie, increasing the number of PLWS who know their serostatus to 90%; increasing the percentage of those diagnosed and treated with ART to 90%; and increasing those diagnosed, treated, and successfully maintaining viral suppression to 90%.8
In the US, the most common source of health coverage for low-income individuals is Medicaid.4 The initial proposal of the ACA was to make routine HIV testing a universally covered preventive screening measure. Unfortunately, however, unequal Medicaid expansion has led to state-by-state variation in reimbursable HIV testing, with 34 states covering routine testing, and 16 states—including those with the highest HIV infection rates—covering only “medically necessary” testing.4