Continuous Retention and Viral Suppression Provide Further Insights Into the HIV Care Continuum Compared to the Cross-sectional HIV Care Cascade

Abstract

Continuous retention is a critically important measure of long-term success in HIV treatment and the crucial component of successful treatment-as-prevention but is infrequently evaluated. Single cross-sections may overestimate successful retention and virologic outcomes. A longitudinal HIV care continuum provides greater insight into long-term outcomes and exposes disparities not evident with traditional cross-sectional care continua.

An Exploratory Study to Assess Individual and Structural Level Barriers Associated With Poor Retention and Re-engagement in Care Among Persons Living With HIV/AIDS

“…Comparative analyses explored individual and systemic level barriers and facilitators to care engagement. This study supports the notion that success along the care continuum cannot be marked by achievement of viral suppression alone, as most of the unretained patients had previously achieved virologic suppression but at the time of returning to care few remained virologically suppressed [7]. Furthermore, these churning populations have been shown to contribute significantly to the community viral load [37], which may have implications for ongoing HIV transmission in the community [38].…”

“…Despite the evidence that retention is associated with positive HIV disease specific outcomes, retention is the step of the HIV care continuum where the largest drop-off occurs [5, 6]. Even among patients who meet standard definitions of retention in care at a single point in time, maintaining that retention over time remains a challenge [7–9]. In addition, progression along the HIV care continuum can be neither linear nor stable and patients may cycle in and out of care, a phenomenon referred to as “churn” [10–12].…”

Sex, Race, and HIV Risk Disparities in Discontinuity of HIV Care After Antiretroviral Therapy Initiation in the United States and Canada

“…Retention in care and HIV disparities research have been linked through numerous studies describing the relationship between clinical engagement, access to and initiation of therapy, continuity of care, and viral suppression and other markers of HIV disease progression in various populations and settings, both in resource-rich and resource-limited settings. 12,13,15,16,18,[29][30][31] In fact, the relationship between retention disparities and lack of viral suppression alone merits close attention as viral suppression is a priority outcome in the NHAS, implicating improved individual outcomes and reduced HIV transmission. 5,8,[29][30][31] Few studies, however, have followed a cohort as large as the NA-ACCORD population over such a long period of time after ART initiation, a long enough period to directly observe the median times of first discontinuity of retention in care.…”

“…27,28 This retention measure has also been noted to correlate strongly with several other metrics and to be independently associated with negative clinical outcomes such as lack of viral suppression. 1,5,[29][30][31] This retention definition was anchored to calendar time to create estimates comparable with other studies and cliniclevel reports applying the indicator in regular reporting intervals. Disruption of continuous retention (discontinuity) was defined as the first instance of failing to meet the IOM indicator definition in any calendar year after ART initiation and before study follow-up ended.…”

The Perilous Road from HIV Diagnosis in the Hospital to Viral Suppression in the Outpatient Clinic

“…This reaffirms the tremendous difficulty in maintaining retention and VS for extended periods of time. 23 The phenomenon of patients cycling in and out of care (at times retained and at times not) has been termed ''churn. '' 24 In our analysis, the length of follow-up is not long enough to classify patients into ''churn,'' but the concept of poor longitudinal rates compared with cross-sectional rates is evident.…”