Step 5: Viral Suppression
The primary goal of HIV treatment and public health interventions is viral suppression through ART. PLWH are considered to be virally suppressed if their most recent viral load, measured within the past year, is <200 copies/milliliter (c/mL).9 An estimated 70% of US PLWH are not virally suppressed.9 But for PLWH who are diagnosed, retained in care, and adherent with ART—ie, those who have completed each step of the HIV care continuum—90% have achieved viral suppression in the US. 15 To achieve the NHAS goal of increasing the total number of PWLH with viral suppression to 80% by 2020, providers must work to link and retain PLWH in care.4
Healthcare Policy and Access Across the Continuum
The ACA expanded eligibility for health insurance to all populations, including PLWH. However, the Health Resources and Services Administration’s Ryan White HIV/AIDS Program (RWHAP) will remain a “valuable payer of last resort” for PLWH with low income.4 This program currently services over half a million PLWH who are either uninsured or underinsured, providing supportive and direct medical services to patients with HIV, including access to ART via the AIDS Drug Assistance Program.16,17 A quarter of PLWH in the US still lack health insurance, which underscores the need for continued funding of this program. Current literature urges HIV providers to advocate for this current funding, which has not been reauthorized since 2013 and relies on yearly appropriations from Congress.19-22 Moreover, changes proposed by President-elect Donald Trump may put the ACA in jeopardy.23 AIDS United, a major HIV/AIDs policy/advocacy and research organization, noted that Mr. Trump has not made specific statements regarding HIV.24 It remains to be seen what impact the new administration will have on HIV treatment.
The HIV treatment cascade is “a straightforward, helpful guide for healthcare providers working with PLWH.”4 The authors recommend “concerted collaboration” between policymakers, HIV providers, and other key stakeholders in improving outcomes at each step of the continuum, at a population level.
1. UNAIDS. Fact Sheet November 2016. Available at: http://www.unaids.org/en/resources/fact-sheet. Accessed: November 24, 2016.
2. Centers for Disease Control and Prevention (CDC). HIV in the United States at a glance. Available at: http://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed: November 24, 2016.
3. Office of National AIDS Policy. National HIV/AIDS strategy for the United States: Updated to 2020; 2015. Available at: https://www.whitehouse.gov/sites/default/files/docs/national_hiv_aids_strategy_update_2020.pdf. Accessed: November 24, 2016.
4. Kay ES, Batey DS, Mugavero MJ. The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future. AIDS Res Ther. 2016 Nov 8;13:35. eCollection 2016.
5. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, Clark JE. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morb Mortal Weekly Rep (MMWR) 2006; 55(14): 1–17. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed: November 25, 2016.
6. Centers for Disease Control and Prevention. HIV infection: detection, counseling, and referral. 2015. Available at: http://www.cdc.gov/std/tg2015/hiv.htm. Accessed November 25, 2016.
7. U.S. Preventive Services Task Force. Final recommendation statement: human immunodeficiency virus (HIV) infection: screening. 2013. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-screening. Accessed: November 24, 2016.
8. Joint United Nations Programme on HIV/AIDS. 90–90–90: an ambitious treatment target to help end the AIDS epidemic; 2014. http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf. Accessed: November 25, 2016.
9. Centers for Disease Control and Prevention (CDC). Understanding the HIV care continuum. 2014. Available at: http://www.cdc.gov/hiv/pdf/dhap_continuum.pdf. Accessed: November 23, 2016.
10. Institute of Medicine. Monitoring HIV care in the United States: indicators and data systems. Washington (DC): National Academies Press (US); 2012.
11. Chandler RK, Kahana SY, Fletcher B, Jones D, Finger MS, Aklin WM, Hamill K, Webb C. Data collection and harmonization in HIV research: the seek, test, treat, and retain initiative at the National Institute on Drug Abuse. Am J Public Health. 2015;105(12):2416–22.
12. Kim JJ, Maulsby C, Kinsky S, Riordan M, Charles V, Positive Charge Intervention Team, Jain K, Holtgrave DR. The development and the implementation of the national evaluation strategy of access to care, a multi-site linkage to care initiative in the United States. AIDS Educ Prev.2014;26(5):429–44.
13. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis. 2013;57(8):1164–71.
14. Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, Orrell C, Altice FL, Bangsberg DR, Bartlett JG, Beckwith CG, Dowshen N, Gordon CM, Horn T, Kumar P, Scott JD, Stirratt MJ, Remien RH, Simoni JM, Nachega JB. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care Panel. Ann Intern Med. 2012;156(11):817–33.
15. Bradley H, Hall I, Wolitski RJ, Van Handel MM, Stone AE, LaFlam M, Skarbinski J, Higa DH, Prejean J, Frazier EL, Patel R, Huang P, An Q, Song R, Tang T, Valleroy LA. Vital signs: HIV diagnosis, care, and treatment among persons living with HIV—United States, 2011. Morb Mortal Weekly Rep (MMWR). 2014; 63(47):1113–1117. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm?s_cid=mm634 a5_w. Accessed: November 24, 2016.
16. Health Resources and Services Administration. Ryan White HIV/AIDS Program Annual Client-Level Data Report 2014. Availble at: http://hab.hrsa.gov/data/servicesdelivered/2014RWHAPDataReport.pdf. Accessed: November 24, 2016.
17. Cahill SR, Mayer KH, Boswell SL. The Ryan White HIV/AIDS program in the age of health care reform. Am J Public Health. 2015;105(6):1078–85.
18. Martin EG, Meehan T, Schackman BR. AIDS Drug assistance programs managers confront uncertainty and need to adapt as the Affordable Care Act kicks in. Health Aff. 2013;32(6):1063–71.
19. Martin EG, Strach P, Schackman BR. The state(s) of health: federalism and the implementation of health reform in the context of HIV care. Public Admin Rev. 2013;73(Suppl 1):S94–103.
20. Hazelton PT, Steward WT, Collins SP, Gaffney S, Morin SF, Arnold EA. California’s “Bridge to Reform”: identifying challenges and defining strategies for providers and policymakers implementing the Affordable Care Act in low-income HIV/AIDS care and treatment settings. Plos ONE. 2014;9(3):e90306.
21. Sood N, Juday T, Vanderpuye-Orgle J, Rosenblatt L, Romley JA, Peneva D, Goldman DP. HIV care providers emphasize the importance of the Ryan White Program for access to and quality of care. Health Aff. 2014;33(3):394–400.
22. Johnson JA, Heisler EJ. US Congressional Research Service. The Ryan White HIV/AIDS Program: overview and impact of the Affordable Care Act (Report No. R44282); 2015. https://www.fas.org/sgp/crs/misc/R44282.pdf. Accessed: November 24, 2016.
23. Sparer M. Maintaining insurance access under Trump—a strategy. N Engl J Med. November 16, 2016.
24. AIDS United. Candidates Position on HIV/AIDS. Available at: http://www.aidsunited.org/2016-Elections-Center/Candidate-Positions-on-HIV002FAIDS.aspx. Accessed: November 24, 2016.