1. The HIV Engagement in Care Cascade Edward Gardner, MD Associate Professor of Medicine Denver Public Health University of Colorado Denver

2. 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-engage and Treat and Persist and Adhere and Re-engage …

3. HIV Care Continuum Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2 Cheever LW Clin Infect Dis 2007;44:1500-2

4. Test and Treat for HIV Prevention Das M et al. PLoS One 2010;5:e11068

5. Treatment as Prevention – HPTN 052 NEJM 2011;365: 493-505. HPTN-052 96% reduction In HIV incidence

6. CDC Cascade MMWR December 2, 2011 / 60(47);1618-1623

7. 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

10. Linkage to HIV Care Original Cascade estimated about 75% linkage Marks et al. 1 meta-analysis found 72% linkage in studies after 2003 MMWR 2 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linkage Dombrowski et al. 3 showed 88% linkage in 3 months in Seattle/King County Washington Denver Public Health Data (unpublished): Final Estimate: 72 – 88% 1 AIDS 2010, 24:2665–2678, 2 MMWR 2011 / 60(47);1618-1623, 3 AIDS 2012, 26:77-86.

12. Retention in HIV Care Original Cascade estimated 50% retention Marks et al. 1 meta-analysis – 59% retention MMWR 2 – 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% 1 AIDS 2010, 24:2665–2678, 2 MMWR 2011 / 60(47);1618-1623, 3 AIDS Pt Care STDs 2011;25:79- 88, 4 JAIDS 2012;60:77-82, 5 AIDS Res Hum Retrovir 2011;27:751-58, 6 AIDS 2012, 26:77-86.

14. Attainment of an Undetectable Viral Load Original Cascade estimated 60% undetectable Marks et al. 1 : 62% < 75 cps/ml, 73% < 400 cps/ml MMWR 2 : 77% Hall et al. 3 : 73% Dombrowski et al. 4 : 65% InCare Campaign 5 : 70% Final Estimate: 62 – 77% 1 AIDS 2010, 24:2665–2678, 2 MMWR 2011 / 60(47);1618-1623, 3 AIDS Pt Care STDs 2011;25:79- 88, 4 AIDS 2012, 26:77-86, 5 www.incarecampaign.org

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

17. Denver Cascade over Time IAS 2012 Poster MOPDC0305

18. Denver Cascade over Time Censoring Out-Migration and Death IAS 2012 Poster MOPDC0305

19. 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.

20. 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

21. 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

22. Thank You Talk Supported by AIDS United Questions?