An Interview With Michael J. Mugavero, M.D.
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
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. 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
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.
- Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in
the United States at the end of 2006. J Acquir Immune Defic Syndr. 2010;53:619-624.
- 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.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed March 25, 2011.
- 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.
- Mugavero MJ, Castellano C, Edelman D, Hicks C. Late diagnosis of HIV infection: the role of age and sex.
Am J Med. 2007;120:370-373.
- Lanoy E, Mary-Krause M, Tattevin P, Perbost I, Poizot-Martin I, Dupont C, Costagliola D; ANRS C004 French
Hospital Database on HIV Clinical Epidemiological Group. Frequency, determinants and consequences of delayed
access to care for HIV infection in France. Antivir Ther. 2007;12:89-96.
- Delpierre C, Cuzin L, Lauwers-Cances V, Marchou B, Lang T; NADIS Group. High-risk groups for late diagnosis
of HIV infection: a need for rethinking testing policy in the general population. AIDS Patient Care STDS. 2006;20:
- 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.
- Sobrino-Vegas P, Garcia-San Miguel L, Caro-Murillo AM, et al. Delayed diagnosis of HIV infection in a multicenter
cohort: prevalence, risk factors, response to HAART and impact on mortality. Curr HIV Res. 2009;7:224-230.
- 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.
- 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. http://cid.oxfordjournals.org/content/52/suppl_2/S238.full.pdf+html.
Accessed May 2, 2011.
- 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.
- 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.
- 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.
- Mugavero MJ. Improving engagement in HIV care: what can we do? Top HIV Med. 2008;16:156-161.
www.iasusa.org/pub/topics/2008/issue5/156.pdf. Accessed May 10, 2011.
- 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;49:651681. http://cid.oxfordjournals.org/content/49/5/651.full.
Accessed May 19, 2011.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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. www.hptn.org/research_studies/hptn065.asp. Accessed May 19, 2011.
- 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.
www.niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspx. Accessed May 19, 2011.