Despite significant scale-up of HIV care and treatment across the world, overall effectiveness of HIV programs is severely undermined by attrition of patients across the HIV care continuum, both in resource-rich and resource-limited settings. The care continuum has four essential steps: linkage from testing to enrollment in care, determination of antiretroviral therapy (ART) eligibility, ART initiation, and adherence to medications to achieve viral suppression. In order to substantially improve health outcomes for the individual and potentially for prevention of transmission to others, each of the steps of the entire care continuum must be achieved. This will requirethe adoption of interventions which address the multiplicity of barriers and social contexts faced by individuals and populations across each step, a reconceptualization of services to maximize engagement, and ambitious evaluation of program performance using allor-none measurement

Margaret L Mcnairy

Wafaa M El-Sadr

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QAD 203038OPINIONThe HIV Care Continuum:No Partial Credit Given
Margaret L. Mcnairya,b,c and Wafaa M. El-Sadra,bCopyright © 
aICAP, Columbia
University, New Y
Correspondence t
Tel: +212 304 54
Received: 29 Mar
DOI:10.1097/QAD
ISDespite significant scale-up of HIV care and treatment across the world, overall
effectiveness of HIV programs is severely undermined by attrition of patients across
the HIV care continuum, both in resource-rich and resource-limited settings. The care
continuum has four essential steps: linkage from testing to enrollment in care, deter-
mination of antiretroviral therapy (ART) eligibility, ART initiation, and adherence to
medications to achieve viral suppression. In order to substantially improve health
outcomes for the individual and potentially for prevention of transmission to others,
each of the steps of the entire care continuum must be achieved. This will requirethe
adoption of interventions which address the multiplicity of barriers and social contexts
faced by individuals and populations across each step, a reconceptualization of services
to maximize engagement, and ambitious evaluation of program performance using all-
or-none measurement.  2012 Wolters Kluwer Health | Lippincott Williams & WilkinsAIDS 2012, 26:000–000Keywords: adherence, HIV, retentionScale-up of HIV testing, care, and treatment across the
world, particularly in sub-Saharan Africa (SSA) where the
majority of people living with HIV (PLWH) reside, has
been extraordinary with millions of individuals tested for
HIV, over 11 million enrolled in HIV care, and more than
6 million initiated on antiretroviral therapy (ART) [1,2].
The impact of this effort is evident in the decrease in HIV-
related deaths and rates of mother-to-child-transmission
in high prevalence countries as well as in the notable
decrease in HIV incidence in several countries in SSA [2–
4]. However, the overall effectiveness of HIV programs is
severely undermined by attrition of patients across the
HIV care continuum, both in resource-rich and resource-
limited settings. In studies from the US, only19–28%
percent of PLWH are estimated to achieve viral load
suppression [5,6]. In SSA, insufficient data are available on
overall viral load suppression given it is not routinely
available, but less than one-third of individuals who test
HIV positive are estimated to be retained from time of
testing through ART initiation [7,8].Lippincott Williams & Wilkins. Unau
University, New York, NY, bDepartment of Epid
ork, NY, and cDepartment of Medicine, Weill C
o Margaret McNairy, ICAP, Columbia University
83; fax: +212 342 1824; e-mail: Mm3780@colu
ch 2012; revised: 7 May 2012; accepted: 11 Ma
.0b013e328355d67b
SN 0269-9370 Q 2012 Wolters Kluwer HCompletion of the entire care continuum is essential for
optimal health outcomes for PLWH. This continuum
begins with HIV testing and continues through multiple
steps on the path to viral suppression for those initiated on
ART (Fig. 1). The first step is linkage from where a patient
received HIV testing to HIV clinics where counseling,
clinical and laboratory monitoring for disease progression
can be done on an ongoing basis to determine ART
eligibility, the second step in the continuum. The sub-
sequent step is prompt ART initiation based on prevailing
guidelines. Upon initiation of ART, similar monitoring
and counseling is needed to achieve and maintain viral
suppression, a critical outcome necessary for attaining
individual benefits from treatment [9]. Viral suppression in
PLWH has also been associated with a decrease in risk of
HIV transmission to sexual partners, an additional benefit
from effective completion of the continuum [10].
No single step in the care continuum appears to be the
sole bottleneck in the achievement of the entirethorized reproduction of this article is prohibited.
emiology, Mailman School of Public Health, Columbia
ornell Medical College, New York, NY
, 722 W. 168th Street, 712, New York, NY 10031
mbia.edu
y 2012.
ealth | Lippincott Williams & Wilkins 1
Co
CE: ; QAD/203038; Total nos of Pages: 4;
QAD 203038
2 AIDS 2012, Vol 00 No 00continuum. Linkage from testing to care has not been
routinely reported by programs, but limited data suggest
that it is poor across diverse settings. In the US, only 48%
of PLWH in South Carolina and 77% in New York City
linked to care within 3 months of receiving an HIV
positive test result [11,12], as compared to the target of
85% recommended by the US National AIDS Strategy
[13]. In SSA, median linkage is 59% across an analysis of
28 studies [7]. Determination of ART eligibility and
initiation of ART for eligible patients is also suboptimal.
In the US only half of PLWH, once enrolled, remained in
care and 89% of those eligible were prescribed ART [5].
Results are similar in SSA where less than half of PLWH
receive a CD4þ count test resultor clinical staging–—two
critical assessments required to determine ARTeligibility
[7]. Approximately two-thirds of PLWH who are eligible
for ART remain in care to ART initiation [7,8] and 70%
of patients on ARTare retained in care at 24 months [14].
Improvements in each step of the continuum must be
achieved simultaneously to improve outcomes such as
achievement of viral load suppression, decreased mother-
to-child transmission, and HIV-related mortality. To
improve viral suppression in PLWH in the US, it has been
noted that only when each step in the continuum is
completed with 90% fidelity would the proportion of
viral suppression increase from current 19% to 66% [6]. In
the context of the programs for prevention of mother-to-
child transmission (PMTCT), programs need to perform
with 90–95% effectiveness across the various steps in the
continuum in order to achieve the ultimate desired
mother-to-child-transmissionrate of less than 5% [15].
There are multiple reasons for the failure to achieve
optimal linkages and retention including structural,
biomedical and behavioral barriers. In a meta-analysis
of 17 studies evaluating loss to follow-up in ART
participants, the most common reasons reported were
lack of money, improving or deteriorating health, and
transfer to another HIV care site [16]. In a study from
Uganda, reported reasons for loss to follow-up included
lack of transport (50%), lack of money (35%), work (27%)
or childcare (22%), and deteriorating health (6%) [17].
Stigma also continues to be a barrier, particularly in
marginalized populations such as men who have sex with
men (MSM), and has been associated with non-disclosure
of HIV status and poor retention [18,19]. To address these
challenges, interventions such as use of point-of-care
CD4þ cell count testing at time of receipt of positive
HIV test result [20,21], case managers [22], counseling,
mobile technology [23,24], and financial incentives [25]
offer encouraging results for enhancing various steps in
the continuum; however, no single intervention to date
has been able to substantially impact all steps in the
continuum. Combination approaches which evaluate the
feasibility of multiple intervention sare being explored
with a focus on overall adherence with all steps in the
continuum [26]. However, interventions be tailored topyright © Lippincott Williams & Wilkins. Unauthothe social context and characteristics of the specific
patient populations they serve. For example, MSM in
resource-rich settings are likely to face different barriers
as compared to pregnant women in resource-limited
settings.
In addition to the interventions listed above, a
reconceptualization of how HIV services are organized
may also be needed to achieve desired health outcomes.
For example, HIV testing and HIV care and treatment
services have historically been organized and operated
separately in disparate physicallocations, operated by
different staff members sometimes working in parallel and
isolation of each other. New models of integrated HIV
care should be developed to create networks of testing and
care with agile referral systems. Another example is the
current organization of HIV services for pregnant HIV-
infected women. These services are traditionally based on
having PMTCT interventions during pregnancy and
delivery provided separately from HIV care and treatment
services required by the pregnant HIV-infected women
and their infants beyond delivery. Recent studies have
shown alarmingly high rates of loss to follow-up for these
women, particularly in the transition after delivery,
between PMTCT and lifelong HIV care services [27–
29]. Integrated HIV care, including provision of ARTand
antenatal services, whether within antenatal clinics or
preferably in primary care clinics that provide continuity
care for HIV-infected women and their children may
need to be considered.
In addition to the organization of services, another issue
that needs particular attention is the manner in which
program performance is evaluated. To date, performance
indicators largelymeasure activities within each service, or
step, rather than throughout the continuum. For
example, HIV testing sites report the numbers of tests
conducted or individuals tested rather than the ultimate
disposition of those found to be HIV positive. Similarly,
HIV care and treatment programs are largely evaluated by
the number of individuals enrolled in care or who
initiated ART rather than whether individuals were
retained across the entire HIV care continuum. Likewise,
PMTCT programs have focused on achieving HIV
testing in a high percentage of pregnant women attending
antenatal care clinics and the number of women and
infants who received antiretroviral regimens for PMTCT,
rather than based on whether the HIV-infected pregnant
women were retained in care beyond delivery and
whether their infants were appropriately followed in care
until their HIV status is confirmed.
The time is right for HIV programs to be evaluated
ambitiously based on the proportion of PLWH who
receive a full package, or bundle, of HIV services across
the continuum, i.e. in an all-or-none manner with ‘‘no
partial credit given’’ for achievement in one step of the
continuum [30]. Success would be determined by therized reproduction of this article is prohibited.
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QAD 203038
The HIV Care Continuum Mcnairy and El-Sadr 3
Fig. 1. ????.proportion of patients who received all the steps, or all of
the care components, for which he or she is eligible. In a
2006 article, Nolan and Berwick articulated the
advantages of an ‘‘all-or-none’’ measurement as a
patient-centered approach and as a tool to ensure quality,
and as a means of promoting a systems perspective [30].
All-or-none measurement is particularly appropriate for
chronic disease management, as in the case of HIV
disease, given the importance of retention over time and
the need for receipt of multiple interventions. In order to
operationalize this concept, country and program leader-
ship as well as funders must embrace this approach, while
at the same time appropriate data elements must be
collected and data management capacity strengthened.
The historic global response to the HIV epidemic has
demonstrated the feasibility of establishing large-scale
HIV programs in some of the poorest countries in the
world. To realize the potential ofthis extraordinary
investment and to enable meeting the remaining
challenges will require attention to every step of the
HIV care continuum. The loss of program effectiveness is
particularly tragic at a time of tremendous potential,
immense needs and constrained resources. Attention to
the fullcare continuum coupled with the implementation
of creative integrated models of care and ambitious
performance measures can go a long way to achievement
of an AIDS free generation.Acknowledgements
Conflicts of interest
None declared.
Disclaimers and Disclosures: none.
Sources of support for this work: none.Copyright © Lippincott Williams & Wilkins. UnautAuthor’s Role: MM and WES co-authored all drafts of
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The HIV care continuum: No partial credit given

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The HIV care continuum: No partial credit given

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