The HIV Engagement in Care Cascade

Edward Gardner, MDAssociate Professor of Medicine

Denver Public HealthUniversity of Colorado Denver

Test and Treat

Models made sense…

But it seemed a lot needed to happen in between

We were thinking more like Test and Link and Retain and Re-engageand Treat and Persist and Adhere andRe-engage …

HIV Care Continuum

Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2Cheever LW Clin Infect Dis 2007;44:1500-2

Not in HIV Care Engaged in HIV Care

Unaware of HIV infection

Aware of HIV infection (not in care)

Receiving some medical care but

not HIV care

Entered HIV care but lost to

follow-up

Cyclical or intermittent user

of HIV care

Fully engaged in HIV care

Test and Treat for HIV Prevention

Das M et al. PLoS One 2010;5:e11068

Treatment as Prevention – HPTN 052

NEJM 2011;365:493-505.

HPTN-05296% reductionIn HIV incidence

CDC Cascade

MMWR December 2, 2011 / 60(47);1618-1623

Review Search Strategy• PubMed search - cross-match of HIV or AIDS with

– Prevalence United States– Incidence United States– Late diagnosis– Linkage to care– Retention in care– Engagement in care– Adherence– Persistence– Resistance

• Bibliographies of pertinent articles were reviewed• Emphasis was based on population based studies

over cohort or single institution studies

Linkage to HIV Care• Original Cascade estimated about 75% linkage• Marks et al.1 meta-analysis found 72% linkage

in studies after 2003• MMWR2 estimated 77% linkage• Dombrowski et al.3 showed 88% linkage in 3

months in Seattle/King County Washington• Denver Public Health Data (unpublished):

• Final Estimate: 72 – 88%1AIDS 2010, 24:2665–2678, 2MMWR 2011 / 60(47);1618-1623, 3AIDS 2012, 26:77-86.

Retention in HIV Care• Original Cascade estimated 50% retention• Marks et al.1 meta-analysis – 59% retention• MMWR2 – 51%• Torian et al.3, New York City – 46% (regular care)• Hall et al.4, 13 U.S. areas – 59% (1 visit/year)• Tripathi et al.5, South Carolina – 50%• Dombrowski et al.6, Seattle – 66%• Final Estimate: 46 – 66%

1AIDS 2010, 24:2665–2678, 2MMWR 2011 / 60(47);1618-1623, 3AIDS Pt Care STDs 2011;25:79-88, 4JAIDS 2012;60:77-82, 5AIDS Res Hum Retrovir 2011;27:751-58, 6AIDS 2012, 26:77-86.

Attainment of an Undetectable Viral Load• Original Cascade estimated 60% undetectable• Marks et al.1: 62% < 75 cps/ml, 73% < 400

cps/ml• MMWR2: 77% • Hall et al.3: 73%• Dombrowski et al.4: 65%• InCare Campaign5: 70%• Final Estimate: 62 – 77%

1AIDS 2010, 24:2665–2678, 2MMWR 2011 / 60(47);1618-1623, 3AIDS Pt Care STDs 2011;25:79-88, 4AIDS 2012, 26:77-86, 5www.incarecampaign.org

Simulations of the Engagement in HIV Care Spectrum to Account for Inaccuracy in our Engagement Estimates

66%

21%28%34%22%19%

0

200000

400000

600000

800000

1000000

1200000

Current Dx 90% Engage 90% Treat 90% VL<50 in 90% Dx, Engage,Tx, and

VL<50 in 90%

(a) (b) (c) (d) (e) (f)

Num

ber o

f Ind

ivid

uals

Un-Diagnosed HIVNot Linked to CareNot Retained in CareART Not RequiredART Not UtililzedViremic on ARTUndetectable Viral Load

Denver Cascade over Time

76%70%

62% 61%55% 55% 54% 54% 58% 54%

9%16% 17% 22% 23% 21% 21% 18% 21%

17% 12% 11% 9% 9% 8% 8% 8% 7% 6%

5% 7% 9% 11% 10% 11% 14% 13% 14% 14%

2% 2% 2% 2% 3% 3% 3% 3% 2% 4%

21%29% 32%

37% 35% 33% 35% 37% 37% 36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6 12 18 24 30 36 42 48 54 60

Months After HIV Diagnosis

% in care %not retained %not linked

%out of state %expired % VL<200cps/ml

IAS 2012 Poster MOPDC0305

Denver Cascade over Time Censoring Out-Migration and Death

IAS 2012 Poster MOPDC0305

Limitations

• Different definitions of linkage and retention in different studies

• Overlap in the stages of engagement in HIV care– Cross-sectional depiction of a longitudinal process

• The review applies to the U.S. and not to resource-poor settings

• Unable to assess the impact of financial barriers to HIV care in the U.S.

Conclusions• Engagement in care is critical to the successful

management of HIV infection– For the individual– For the population

• Deficiencies in the spectrum of engagement in care present formidable barriers to HIV care and ‘test and treat’ for HIV prevention:– Failure to diagnose– Failure to link to care– Failure to be retained in care– Failure to receive and adhere to antiretroviral therapy

• Research is needed on ways to improve transitions across all steps in the engagement in care cascade

Comments

• Universal Treatment is the “Treat” of Test & Treat

• Data quality on engagement steps is improving• Engagement in Care research in HIV is likely

applicable to other chronic illnesses• Cascade formats could be standardized and

used worldwide as a snapshot of HIV Care

Thank You

Talk Supported by AIDS United

Questions?