1. Michael J. Mugavero, MD, MHSc Associate Professor of Medicine University of Alabama at Birmingham Birmingham, Alabama Elements of the Care Continuum FORMATTED: 12/09/15 New Orleans, Louisiana: December 15-17, 2015

2. National HIV/AIDS Strategy: 2020 Goals Increase linkage to care w/in 1 month of Dx to at least 85% Increase HIV serostatus awareness to at least 90% Increase retention among persons diagnosed to at least 90% Increase proportion of persons diagnosed with viral suppression to at least 80% Ulett et al. AIDS Pt Care STDs 2009;23:41-49, Mugavero et al. Clin Infect Dis 2011;52(S2). Slide 10 of 38

3. Skarbinski et al. JAMA Intern Med 2015;175 ~90% of HIV Transmissions in 2009 in the US Slide 13 of 38

4. MeasureMissed visit data? Ease of calculatingFollow-up time Missed visitYesEasy~1 day Appointment adherence YesModerate~1 yr No-show rateYesModerate~1 yr Constancy: Visit per 3, 4 or 6 mo intervals NoModerate~1 yr GapsNoEasy~1 yr HRSA/HABNoModerate-to-difficult 1 yr DHHSNoModerate-to-difficult 2 yrs Adapted from: Giordano TP (2012) Measuring retention in HIV care. www.medscape.com. Slide 21 of 38

5. Thompson MA et al. Ann Intern Med 2012;156 Guidelines: Monitoring ART Adherence Recommendation Strength/Quality Self-reported adherence IIA Pharmacy refill data (MPR) IIB NOT drug concentrations IIIC NOT pill counts IIIC NOT electronic devices (MEMS)IC Plasma HIV RNA (viral load) is the biological correlate of the adherence behavior, NOT a screening tool for adherence! Slide 30 of 38

6. Engagement across the continuum of HIV care is dynamic and impacts individual & population health Systematic monitoring of engagement in care and ART adherence is foundational  Prognostic value of missed visits  Predictive value of self-reported NON-adherence Evidence-based interventions for engagement in care and ART adherence amenable to clinical settings Partnerships with public health and community agencies essential to improve continuum outcomes Take Home Points Slide 38 of 38