Step 2: Linkage to Care (LTC)

LTC is defined as “a period of three months or less between documentation of diagnosis and initiation of medical treatment with an HIV care provider/prescriber.9,10 Because only 59% to 80% of those diagnosed are linked to care within 3 months,9 the new 2020 goal is 85% of PLWH linked to care within 1 month of diagnosis.3

The seek, test, treat, and retain (STTR) data collection and harmonization initiative is “organized around a specific subgroup and involves the collaboration of an interdisciplinary, multi-site team.”4,11 Data interoperability is ensured through use of standardized surveys and questionnaires. Because of standardized data collection and measurement, the STTR Initiative facilitates coordinated research, helping to identify at-risk populations and link them with care.11

The multi-site access to care (A2C) focuses on LTC in PLWH living in poverty.12 A2C collects qualitative case studies and cost-analysis components. The authors comment, “The STTR and A2C programs exemplify how LTC strategies may be developed in such as way that they address the needs of the target population, while also maximizing the resources available to the provider site(s).”4

Step 3: Retention in Care (RiC)

There is no consensus regarding how best to measure retention or continuity in HIV care.4 The IOM, NHAS, and CDC define HIV RiC as the proportion of PLWH who have “two or more visits for routine HIV medical care in the preceding 12 months, at least three months apart.”10 However, this definition encompasses only adherence to scheduled medical appointments and does not account for missed or cancelled appointments.13 Additional recommended information adds two indicators—one for kept appointment and one for missed appointments—since this provides complementary information.4 The number of missed appointments is a significant predictor in measuring clinical outcomes.4 PLWH may transition in and out of care over time (a process referred to as “churning”), thereby increasing the error margin of estimates. For this reason, there is a “need for coordination among service providers, so that data reporting can be timely and accurate.”4


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Step 4: ART Adherence

There is currently no standard indicator for confirming that patients consistently stay on ART medication.4 Therefore, although estimates for the number of PLWH prescribed ART in the US range from 24% to 37%, it is actually unknown how many are consistently adherent with prescribed regimens.2 Adherence is difficult to measure, as it relies largely on patient self-report. Moreover, self-report tools may provide only a “snapshot” rather than a longitudinal record, and therefore should be interpreted “with caution.”4 ART adherence is critical, as it is the primary determinant of viral suppression, reducing by 96% the chance that PLWS will transmit the virus. Moreover, it helps prevent the development of ART-resistant strains of the virus.4 Although the standard HIV care model places ART adherence after the retention stage, it is possible that this “unidirectional” is oversimplified, since PLWH may seek intermittent care.4

An expert panel of the International Association of Physicians in AIDS Care recommends ART to PLWH immediately after diagnosis, regardless of CD4 count, because lower CD4 counts weaken the immune system and increase the risk of opportunistic infections, AIDS-related diseases, and even non-AIDS-related diseases caused by chronic inflammation.14

This article originally appeared on MPR