Deeper Look: The HIV Care Continuum

The HIV care continuum is a public health model that outlines the stages of care that people living with HIV go through from diagnosis to achieving and maintaining viral suppression. Guiding an individual through the care continuum is key to helping them achieve viral suppression, which not only helps them experience better health outcomes but also reduces their risk of transmitting HIV to others.

The HIV care continuum is vital in assessing individual care outcomes and population-level progress towards ending the HIV epidemic. Data on the HIV care continuum helps determine if people living with HIV in a given community are engaged in each successive step and where they may be facing barriers and falling out of care. This helps policymakers and service providers better determine where resources and strategies are needed to support people living with HIV to achieve the goal of viral suppression and live long, healthy lives.

People living with HIV who achieve and maintain an undetectable viral load—in the U.S. it is considered less than 200 copies/mL of HIV in the blood—by taking antiretroviral therapy (ART) daily as prescribed cannot transmit the virus to others and experience better health outcomes.

At a community level, a high rate of viral suppression indicates a lower chance of HIV transmission among members of the community. This is often referred to as the “Treatment as prevention” strategy (TasP). A high rate of viral suppression can only be achieved by diagnosing individuals and engaging them in HIV care and treatment. A Centers for Disease Control and Prevention (CDC) analysis shows that nearly 80% of new HIV infections in the U.S. in 2016 came from the nearly 40% of people who either did not know they had HIV or who received a diagnosis but were not receiving HIV care and treatment.

Status Neutral

There is also a growing movement among those working in HIV for a new kind of continuum that can be applied to everyone regardless of their HIV status. The New York City Department of Health and Mental Hygiene (NYC DOHMH) has been a leader in proposing this type of paradigm, which it refers to as the HIV Status Neutral Prevention and Treatment Cycle. This model suggests a sequence that starts with HIV testing. If an individual is diagnosed with HIV, they move into the classic HIV care continuum and start treatment as soon as possible with the goal of achieving viral suppression.

If the individual tests negative, they move into an HIV prevention continuum, which consists of understanding their risk of HIV exposure, learning about PrEP, and discussing with a healthcare provider whether it is an appropriate medication for them. Following those discussions, some people will start using PrEP, while others may be guided toward other prevention methods, such as condom use and more frequent HIV testing.

The goal of an HIV status-neutral cycle, however, is to be able to apply the model to the population more broadly so that everyone can take next steps to protect themselves and their partners. This model recognizes that, to reach the ultimate goal of ending HIV transmission, everyone needs to remain engaged in prevention and care efforts. The hope is that an HIV status-neutral cycle can also help reduce stigma around HIV and HIV testing because it presents testing as something everyone should be doing to protect their health—not limited to those deemed “at risk” of getting HIV.

Last, another important characteristic of the HIV status-neutral cycle is that it is viewed as continuous without a set beginning or end. This nonlinear representation more closely aligns with the experiences of people who are living with HIV as well as those who are at risk of getting it. Both groups benefit from an ongoing relationship with a healthcare provider whether they need HIV care and treatment or PrEP and regular HIV testing. It also recognizes that there is no real endpoint to HIV care or prevention as both are continuous throughout people’s lives.