HIV Care Continuum
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What Is the HIV Care Continuum?
The HIV care continuum is a public health model that outlines the steps or stages that people with HIV go through from diagnosis to achieving and maintaining viral suppression (a very low or undetectable amount of HIV in the blood) through care and treatment with HIV medicine called antiretroviral therapy or ART.
The steps are:
- diagnosis of HIV infection
- linkage to HIV medical care
- receipt of HIV medical care
- retention in medical care
- achievement and maintenance of viral suppression
Viral suppression is defined as having less than 200 copies of HIV per milliliter of blood by consistently taking HIV medicine. HIV medicine can also make the viral load so low that it doesn't show up in a standard lab test. This is called having an undetectable viral load.
Reaching and maintaining HIV viral suppression or an undetectable viral load is a primary goal of HIV treatment. Treatment with HIV medicine is recommended for all people with HIV, regardless of how long they’ve had the virus or how healthy they are.
Why Is the HIV Care Continuum Important?
The HIV care continuum is useful both as an individual-level tool to assess care outcomes, as well as a population-level framework to analyze the proportion of people with HIV in a given community who are engaged in each successive step. This helps policymakers and service providers better pinpoint where gaps in services might exist and develop strategies to better support people with HIV to achieve the treatment goal of viral suppression.
Supporting people with HIV to move through the steps of the continuum to achieve and maintain viral suppression or an undetectable viral load is critically important. Research shows that people with HIV who get and keep an undetectable viral load can live long and healthy lives and will not transmit HIV to their HIV-negative partners through sex. This is sometimes called “Undetectable = Untransmittable” or U=U.
For individuals with HIV to gain these benefits, they need to be aware that they have HIV, be connected to and engaged in regular HIV care, and receive and adhere to treatment with HIV medicine. However, there are obstacles that can contribute to poor engagement in HIV care and treatment, substantially limiting the effectiveness of efforts to improve health outcomes for those with HIV and reduce new HIV transmissions.
Knowing where the gaps are most pronounced and for what populations is vital to knowing how, where, and when to intervene to break the cycle of HIV transmission in the United States and improve health outcomes for people with HIV.
What Does the HIV Care Continuum Show?
Prevalence-based continuum. This HIV care continuum chart is based on the prevalence of HIV in the U.S. in 2019. Published in May 2021, this is the latest available prevalence-based HIV care continuum data from CDC. Prevalence describes the number of people with HIV at a given time, regardless of when they acquired HIV or whether they have received a diagnosis. (Some people may have HIV but not know it). Prevalence data is useful for planning and resource allocation, as it reflects the number of people—diagnosed and undiagnosed—who currently need HIV testing, care, and treatment services. Prevalence rates are also useful for comparing HIV disease between populations and for monitoring trends over time. (Read more about the prevalence-based approach to monitoring the HIV care continuum and how it is used.)
According to CDC, an estimated 1.2 million people aged 13 and older had HIV in the United States at the end of 2019. Of those 1.2 million people:
- Diagnosis—An estimated 87% were diagnosed. That means that 13% of people with HIV (nearly 1 in 7) did not know they had HIV and were therefore not accessing the care and treatment they need to stay healthy and prevent transmitting the virus to their partners.
- Receipt of Care—Approximately 66% had received HIV medical care. CDC measures receipt of care as the percentage of persons with diagnosed HIV who had at least one CD4 or viral load test run by a health care professional in a given year. Once in medical care, people can start HIV medicine to help them stay healthy and protect their partners. Initiating ART is recommended for all people with diagnosed HIV.
- Retention in Care—Approximately 50% were retained in care. CDC measures retention in care as the percentage of persons with diagnosed HIV who had two or more CD4 or viral load tests, performed at least three months apart. People with HIV who have ongoing, regularly scheduled medical care have been shown to have better health outcomes and increased safer sexual behaviors.
- Viral Suppression—An estimated 57% had achieved viral suppression. CDC measures viral suppression as a viral load test result of <200 copies/mL at the most recent viral load test during measurement year.
- Linkage to care—According to CDC, of those who received an HIV diagnosis in 2019, 81% were linked to care within one month. This figure is calculated differently from other steps in the continuum, so it cannot be directly compared. CDC defines linkage as having one or more documented CD4 or viral load tests within 30 days (1 month) of HIV diagnosis. The denominator is limited to the number of people receiving an HIV diagnosis in a given year, rather than the total number of people with HIV that is used in the calculations for the other continuum steps. Rapid linkage to care is important because it can shorten the time to viral suppression, which helps people stay healthy and prevents sexual transmission of the virus.
Diagnosis-based continuum. Different analyses present the steps or stages of the HIV care continuum in different ways. For example, CDC also offers a diagnosis-based continuum, which shows each step as a percentage of the number of people with diagnosed HIV. According to CDC data published in 2022, of the 944,247 people ages 13 and older with diagnosed HIV in the U.S. during 2020, 74% had received some HIV medical care, 51% were retained in care, and 65% were virally suppressed. In addition, among the 28,422 individuals who received an HIV diagnosis in 2020 in the 46 jurisdictions with complete reporting of laboratory data to CDC, 82% were linked to medical care within one month of diagnosis. (CDC cautions that data for 2020 should be interpreted with caution due to the impact of COVID-19 on access to HIV testing, care-related services, and case surveillance activities in states and local jurisdictions.) (Read about the diagnosis-based approach to monitoring the HIV care continuum.)
How Is the HIV Care Continuum Being Used?
Federal, state, and local health departments, community-based organizations, health care providers, and people with HIV continue to use the HIV care continuum to measure progress toward HIV goals as well as to pinpoint where gaps in services may exist in connecting individuals with HIV to sustained, quality care and treatment. Knowing where drop-offs are most pronounced and for which populations helps policymakers, public health officials, and health care providers implement system improvements to support all persons with HIV so they are able to successfully navigate the continuum and achieve and maintain viral suppression.
Take a Closer Look
To learn more about the HIV care continuum in the U.S. and how the steps are defined and measured, see these resources: