HIV Spotlight on Center on Caring for the Newly Diagnosed Patient

Testing, Linking, Retaining: An HIV Clinician's Perspective

An Interview With Michael J. Mugavero, M.D.

Summer 2011

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Working Toward a Seamless Continuum of Care

Mascolini: When I was doing research for these articles on testing, linkage, and retention, I saw that many studies are done by people on the policy side or in epidemiology or other non-clinical fields. You're one of a handful of HIV clinicians who have studied these issues closely. What was your motivation for getting into this area of research?

Mugavero: From 2003 to 2006, when I was an infectious diseases fellow working on expanding HIV testing, I began to realize the challenges beyond HIV testing and started thinking about the obstacles to ensuring a continuum of care. Much of my research focused on testing, and then in the clinic I was caring for a lot of people with HIV, but I realized that many barriers and challenges lay between those two points. It became clear that the folks I was seeing in clinic were just a subset of those I was trying to reach with the testing efforts.

To me this continuum seemed a natural progression of the focus on medication adherence. If large numbers of individuals are unaware of their infection, or not linked to care or retained in care, the impact of successful treatment and adherence interventions on a population is greatly diminished.

In the last 3 to 5 years we've seen a dramatic expansion in emphasis on linkage and retention in care. A lot of that is driven by the test-and-treat paradigm or TLC-Plus: test, link to care, plus treatment.21 This approach -- expanded HIV testing plus quick linkage to care and treatment -- should have benefits both for the individual and at the population level because identifying infected people and treating them quickly will lower "community viral load" and limit HIV transmission. We saw this in HPTN 052, an international randomized trial that ended early when antiretroviral therapy begun at a higher CD4 count for the positive partner in a discordant couple lowered the risk that the negative partner would become infected by 96%.22 Those results should stimulate even more interest in the test-and-treat concept.

Figure 2

Figure 2. This simplified scheme of HIV care from diagnosis through antiretroviral therapy and retention in care indicates that care should be viewed as a seamless continuum, not a series of discrete steps.

I always stress that we need integrated approaches not just from a research perspective, but also from a practical perspective across this continuum of care (Figure 2). A newly diagnosed person doesn't think, "Now I'm going to go to my outreach intervention. Now I have to hop over to linkage to care. Now that I've made it to clinic, I'm going to focus on risk reduction, then on starting therapy, then on adherence."

Our approaches to these interventions often focus on one piece at a time, and we do need to focus on each element. But ultimately, if we really want to have impact, we need integrated approaches that map to the lived experience. Someone should go seamlessly from testing positive to getting into care, developing early behaviors around starting therapy, having good adherence to visits and to medicines -- all in a matter of months. Although test-and-treat and TLC-Plus focus on secondary prevention and population health, I think they have incredible potential to improve individual health outcomes.

Mascolini: Before we close, would you like to make any other points related to any of these issues?

Mugavero: I think the key message is that improved HIV care is going to require integration at multiple levels -- both scientifically and in practice. And over the past few years we have seen more and more integration, at the funding level and in local service delivery between medical providers, AIDS service organizations, community-based organizations, and health departments. The overriding idea is that we need approaches from testing through outcomes that match the individual's experience. People with HIV don't seek services piecemeal in discrete steps; there should be a seamless transition from one facet of care to the next.

With TLC-Plus21 and other studies, we need to determine the best way to integrate efforts and meet individuals' needs. Right now we're losing too many HIV-positive people at each step along that cascade who are not diagnosed, not linked, not retained. We must redouble our efforts to focus on helping people navigate this continuum of care as seamlessly as possible.


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  2. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1-17. Accessed March 25, 2011.
  3. Althoff KN, Gange SJ, Klein MB, et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis. 2010;50:1512-1520.
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  7. Delpierre C, Dray-Spira R, Cuzin L, et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS. 2007;18:312-317.
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  9. Keruly JC, Moore RD. Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clin Infect Dis. 2007;45:1369-1374.
  10. Mugavero MJ, Norton WE, Saag MS. Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system. Clin Infect Dis. 2011;52(suppl 2):S238-S246. Accessed May 2, 2011.
  11. Craw JA, Gardner LI, Marks G, et al. Brief strengths-based case management promotes entry into HIV medical care: results of the Antiretroviral Treatment Access Study-II. J Acquir Immune Defic Syndr. 2008;47:597-606.
  12. Craw J, Gardner L, Rossman A, et al. Structural factors and best practices in implementing a linkage to HIV care program using the ARTAS model. BMC Health Serv Res. 2010;10:246.
  13. Mugavero MJ, Lin HY, Allison JJ, et al. Failure to establish HIV care: characterizing the "no show" phenomenon. Clin Infect Dis. 2007;45:127-130.
  14. Mugavero MJ. Improving engagement in HIV care: what can we do? Top HIV Med. 2008;16:156-161. Accessed May 10, 2011.
  15. HIV Medicine Association (HIVMA). Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:651–681. Accessed May 19, 2011.
  16. Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793-800.
  17. Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009;48:248-256.
  18. Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44:1493-1499.
  19. Tripathi A, Youmans E, Gibson JJ, Duffus WA. The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study. AIDS Res Hum Retroviruses. 2011 Jan 15. Epub ahead of print.
  20. Ndiaye B, Ould-Kaci K, Salleron J, et al. Characteristics of and outcomes in HIV-infected patients who return to care after loss to follow-up. AIDS. 2009;23:1786-1789.
  21. HPTN 065. TLC-Plus: A study to evaluate the feasibility of an enhanced test, link to care, plus treat approach for HIV prevention in the United States. Accessed May 19, 2011.
  22. National Institute of Allergy and Infectious Diseases (NIAID). Treating HIV-infected people with antiretrovirals protects partners from infection: findings result from NIH-funded international study. May 12, 2011. Accessed May 19, 2011.
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