Significance of HIV Continuum Care Retention



The term continuum is used to refer to the dynamic bidirectional process of HIV care at an individual level. In 2013, the US government through Executive Order by the then President Barrack Obama formed the HIV care continuum initiative which prioritized the establishment of a set of national indicators for HIV care. This continuum involves five basic steps. The HIV Continuum Care is thus an internationally recognized standard that represents the five sequential steps undertaken in HIV care.

These steps progress systematically from testing to the engagement in medical care, therapy (ART) treatment, and the ultimate suppression of the virus. Even though the Centers for Disease Control and Prevention (CDC) place emphasis on the importance of universal HIV testing at one end of the continuum and viral suppression at the other, researchers indicate that the steps in the middle of the continuum guarantee optimal health outcomes. The combination of all the five steps, therefore, forms the comprehensive HIV Continuum Care.


This is the initial step in the HIV Continuum Care. CDC guidelines recommend that medical professionals carry at least one test to every patient between the ages of 13 and 64 years. This move aims at making HIV screening a routine practice rather than a risk-based practice. In the recent years, HIV testing has been made more efficient since test results are made available in less than half an hour. This has facilitated the integration of HIV testing into ordinary healthcare routine visits (Yehia, 2015).

Additionally, patients are now able to carry out HIV testing at home using modern equipment. Statistics indicate that one in every eight HIV-positive individuals is not aware of their serostatus. This poses a public health risk since it raises the probability of persons living with HIV unknowingly transmitting HIV to others. Moreover, it is detrimental to the infected individual since late diagnosis makes management of HIV quite difficult. About 91.5 percent of all new infections are attributed to persons living with AIDS who remain undiagnosed (Heffernan, 2016).  Therefore, more emphasis should be laid down on domestic HIV testing and diagnosis.

Linkage to care (LTC)

This is the second step in the HIV care continuum and it is the period between documentation of diagnosis and commencement of medical treatment. According to the Centers for Disease Control and Prevention (CDC) and the Institute of Medicine (IOM), Linkage to care is the period extending up to three months. Use of a standard indicator ensures proper coordination among data tracking systems as well as effective policy analysis. However, variations in state reporting practices for reporting HIV diagnosis in the US makes an establishment of a standard baseline for measuring purposes difficult. Comparing rates of Linkage to care among different countries is compounded by the presence of multiple statistical back-calculation methods which are used to establish the estimates of numbers of undiagnosed people living with HIV (Mugavero, 2011).

A number of studies have come up with modalities of facilitating Linkage to care. For instance, they seek, test, treat, and retain (STTR) data collection and harmonization initiative is an HIV care model that can be applied to many susceptible populations. The success of this model stems from the fact that it is based on a specific group of drug users and is centered on the collaboration of an interdisciplinary team. Use of standard surveys and modes of data collection on matters such as drugs and alcohol abuse, mental health and HIV testing history ensures proper data management. Standardization of data collection and measurement techniques ensures that the STTR initiative conducts an organized research that enables identification of the populations at risk so as to avail care to them (Johnson, 2015).

The multi-site access care initiative, on the other hand, targets people living with poverty and helps in extending the HIV care continuum to more vulnerable groups. A part of using quantifiable indicators, the multi-site access care initiative also conducts qualitative case studies to adequately capture the diverse experiences of different staff members in distributed program sites. Both the STTR and multi-site access care initiative show how the Linkage to care strategies may be designed to meet the needs of the target population while taking into consideration the need to maximize the resources available at the provider’s site (Hallett, 2013).

Retention in Care (RiC)

There is no established standard of measuring retention in HIV care. The Center for Disease Control and Prevention (CDC), for instance, describes HIV retention in care (RiC) as the proportion of the people living with HIV who have made more than two visits for routine medical care in the previous 12 months (Colasanti, 2016). It’s therefore recommended that any measure of RiC includes at least two indicators. One of the indicators is kept for appointments while the other indicator takes care of the missed appointments. In this regard, the two indicators provide complementary information. Studies indicate that the number of missed appointments leads to higher viral loads and lower CD4 counts. However, this trend has also been linked to other factors. For instance, a study has established that African Americans have a lower proportion of viral suppression compared to other racial communities.

When compared with other high-income regions, the US has been found to have the lowest proportion of people living with HIV who are still retained in the care. In British Columbia, 57 percent of the people living with HIV is retained in the care. Denmark and Australia have a proportion of 75 percent and 76 percent respectively (Skarbinski, 2014).

Antiretroviral therapy (ART) adherence

According to Reveles, et al. (2015), there is no established standard indicator for use by healthcare providers to confirm that patients stay out of ART medication. This poses a challenge to the requirement by the International Association of Physicians in AIDS Care (IAPAC) which recommends that health providers use patient self-report as a measurement of ART adherence.

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Whereas the number of persons living with HIV who subscribed to ART in the US ranges between 24 to 37 percent, going by estimates, the number of those who are consistently adherent to prescribed regimens remains unclear. The US performs marginally as per international standards on this measure. Estimates in other high-income areas such as British Columbia and Australia are 44 percent and 66 percent respectively. Monitoring adherence is compounded by the fact that it is not easy to quantify since it is only based on the patient self-report (Colasanti, 2016).

Viral suppression

This is the final step in the continuum. It represents the basic goal of HIV treatment and public health intervention. It involves viral suppression through ART. According to the CDC, persons living with AIDS are considered virally suppressed if their most recent viral load is less than 200 copies per milliliter. Apparently, there is no international standard for gauging the level of viral suppression, making comparison difficult (Thompson, 2012).

In the US, 90 percent of the persons living with AIDS who have adhered to ART have achieved viral suppression. Recent studies indicate an error in simple, cross-sectional measures of viral suppression. Going by RiC, patients often transition between suppressed and non-suppressed states within less than one year period (Barnabas, 2014).


HIV Continuum Care is a very useful guide for healthcare providers working with persons living with HIV since it provides practical steps in a systematic approach from diagnosis to viral suppression. The progress made by CDC and UNAIDS towards standardization of international quantitative indicators is set to improve efficiency in measurement, monitoring, and provision of HIV care.  Despite the progress made by various agencies which deal with HIV management, a large number of persons living with HIV have not adequately accessed the HIV care continuum. In order to achieve the goals of HIV Continuum Care comprehensively, it is vital to examine all steps in the HIV care continuum at an individual level. More attention needs to be given to the linkage and retention stages which have received inadequate attention. This requires the concerted efforts of policymakers as well as HIV providers so as to bolster the outcomes of each stage.

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  10. Yehia, B. (2015). HIV Research Network. The HIV care continuum: changes over time in retention in care and viral suppression. Plos ONE. 2015; 10(6):e0129376.
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