The HIV Care Continuum: A Tool for Driving Systematic Change to Support Better Engagement in Care Jeffrey S. Crowley Distinguished Scholar/ Program Director National HIV/AIDS Initiative O'Neill Institute for National and Global Health Law Georgetown Law

Engagement in HIV Care (United States and Puerto Rico, 2012) Source: Applying Public Health Principles to the HIV Epidemic—How Are We Doing?, Frieden et al, NEJM, 12/01/15.

HIV Transmissions Along the HIV Care Continuum (United States and Puerto Rico, 2012) Source: Applying Public Health Principles to the HIV Epidemic—How Are We Doing?, Frieden et al, NEJM, 12/01/15.

Changes in US HIV Transmission Patterns Using 2006 data, CDC estimated: 25% of HIV+ unaware of infection responsible for more than half of all new HIV infections Using 2012 data, CDC now estimates: 13% of HIV+ unaware are responsible for only 23% of new infections; nearly half of HIV+ are diagnosed and not in care accounting for nearly 70% of new infections Are these new estimates good or bad news?

Comparing the US to the Netherlands Virally Suppressed Transmissions by unaware US (2012) (ALL HIV+)30%23% Netherlands (2013) (MSM)91%71% Netherlands has long had universal access to health coverage; other countries reported nearly comparable rates of viral suppression; presumably has fewer financial and other barriers to care Netherlands has a much smaller HIV population: 11,863 HIV+ MSM compared to more than 600,000 HIV+ MSM in US; many fewer transmissions Places in the US with near universal access to insurance also believe they have lowered incidence (MA, SF, etc.) My take-away: Hard to address transmissions from unaware, but by achieving high rates of viral suppression, Netherlands has demonstrated the effectiveness of treatment as prevention— showing large number of preventable transmissions in the US if we can get more people virally suppressed Source: Sources of HIV infection among men who have sex with men and implications for prevention, Ratmann et al, Science Translational Medicine, 01/06/16.

Letting science speak SMART (Strategies for Management of AntiRetroviral Therapy Study) Published in 2006, tested toxic side-effects, involved participants from 33 countries Study found a 160% higher risk of death for people in group not receiving continuous ART HPTN 052 (HIV Prevention Trials Network 052 Study) Published in 2011, examined whether viral suppression could prevent forward transmission by comparing serodiscordant couples in nine countries assigned to immediate and delayed ART Study showed a 96% decline in transmissions for the immediate tx group START (Strategic Timing of Antiretroviral Treatment Study) Published in 2015, examined the clinical impact of immediate versus delayed treatment in 35 countries People in the immediate treatment group were 57% less likely to develop serious illness or die than those in the deferred treatment group “The science has spoken. There can now be no excuse for inaction.” Anthony Fauci and Hilary Marston, NEJM, “Ending the HIV-AIDS Pandemic—Follow the Science, 12/03/15

What does all of this mean? We have the tools to end the HIV epidemic. Recent studies prove that, when properly implemented, effective prevention, screening, care, and early and sustained ART can improve outcomes and dramatically reduce HIV transmission In the US, many benefit from best care and latest treatments, but longstanding health inequities, discrimination, and other barriers prevent many others from benefitting from effective treatment The US health system does a fairly good job at supporting people with HIV who are retained in care, but historically, it has not focused on diagnosis, linkage, and retention—the stages of the continuum where most people stop engaging in care Structural changes in the health system, starting with expanded access to insurance and getting insurers to focus on the early stages of the continuum, can reduce health disparities, and help us to achieve the promise of better health for all people with HIV and fewer new HIV infections

How do we move forward? Better Monitoring We need to work to ensure that all health plans and providers monitor core HIV quality metrics; build quality improvement systems that include persons “not in care” Actively Intervening We need the health system to adopt practices to systematically improve engagement, this includes: EMR and other methods to routinize HIV screening, making active referral the standard practice, tracking missed clinic visits as a sentinel indicator, actively re-engaging people in care, and addressing financial and other barriers to care Working for Policy Change We need to expand Data to Care to every state, improve prevention and care coordination, and better engage the broader health system in HIV monitoring and care delivery