Description After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). ART adherence is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. Methods A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. Recommendations Recommendations are provided for monitoring of entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

The National HIV/AIDS Strategy and the promise of treatment as prevention have garnered considerable attention from the policy, practice, and scientific communities, with the treatment cascade becoming the sentinel image illustrating the domestic human immunodeficiency virus (HIV) epidemic. The cascade depicts prevalence estimates for sequential steps from HIV diagnosis through viral suppression, the most striking of which is that >50% of persons diagnosed with HIV are not in medical care. This heterogeneous group includes individuals not linked to medical care following HIV diagnosis and those entering care who are not retained, requiring reengagement from a range of community settings. This review synthesizes the state of engagement in HIV care in the United States, focusing on research, practice, and policy considerations. Included are conceptual frameworks, a review of health implications, measurement, monitoring, and evidence-based intervention approaches, and a look to the future in addressing the greatest challenge and opportunity facing our domestic HIV epidemic.

IntroductionEvery new HIV infection is preventable and every HIV-related death is avoidable. As many jurisdictions around the world endeavour to end HIV as an epidemic, missed HIV prevention and treatment opportunities must be regarded as public health emergencies, and efforts to quickly fill gaps in service provision for all people living with and vulnerable to HIV infection must be prioritized.DiscussionWe present a novel, comprehensive, primary and secondary HIV prevention continuum model for the United States as a conceptual framework to identify key steps in reducing HIV incidence and improving health outcomes among those vulnerable to, as well as those living with, HIV infection. We further discuss potential approaches to address gaps in data required for programme planning, implementation and evaluation across the elements of the HIV prevention continuum.ConclusionsOur model conceptualizes opportunities to monitor and quantify primary HIV prevention efforts and, importantly, illustrates the interplay between an outcomes-oriented primary HIV prevention process and the HIV care continuum to move aggressively forward in reaching ambitious reductions in HIV incidence. To optimize the utility of this outcomes-oriented HIV prevention continuum, a key gap to be addressed includes the creation and increased coordination of data relevant to HIV prevention across sectors.

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In this issue of JAMA Internal Medicine, Feldman and colleagues 1 report that Medicare spending on insulin for patients with diabetes was an estimated $7.8 billion, which is $4.4 billion more than the Centers for Medicare & Medicaid Services might have spent by using the prices negotiated by the US Department of Veterans Affairs and their formulary restrictions. Even if the $4.4 billion figure overestimates the potential savings, the potential for lower prices would substantially increase many patients' access to life-saving insulin products. The report by Feldman et al 1 is one of several studies that JAMA Internal Medicine has recently published illustrating the opportunities for savings of billions of dollars annually in the Medicare Part D prescription drug program. For the top 50 oral drugs dispensed based on Medicare spending, Venker et al 2 estimated that by using US Department of Veterans Affairs medication prices, Medicare could have saved up to $14.4 billion in 2016 of the estimated $32.5 billion spent. For angiotensin-converting enzyme inhibitors and angiotensin-II-receptor blockers alone, Growdon et al 3 estimated potential Medicare savings in 2016 and 2017 at $676 million of the total $754 million spent by using generic substitution and therapeutic interchange. For inhaler prescriptions, Feldman et al 4 previously estimated potential Medicare savings in 2017 of up to $4.2 billion of the $7.3 billion spent through use of negotiated prices and a defined formulary. These studies have a consistent and clear message. At present, the issue for the federal government is not the ability to easily save billions of dollars each year in Medicare Part D spending. Rather, the issue is the political will in Washington, DC, to facilitate savings through legislation and regulatory changes, such as measures that would allow price negotiations, benchmark pricing, and formulary restrictions, and in states to remove prescribing barriers, such as those for generic substitution and therapeutic interchange.