Optimizing the HIV Care Environment

What Is the HIV Care Environment?

Antiretroviral therapy (ART; see Fact Sheet 403) can reduce the risk of serious illness, death or transmission of HIV. ART is now recommended for all people living with HIV (PLHIV) in a strategy called “treatment as prevention” (TasP).

Yet, only half of people living with HIV (PLHIV) around the world are aware of their status. Among those who know their HIV status, many do not receive ART in a timely manner, fail to stay engaged in care, or do not achieve sustained viral suppression.

The HIV care continuum is a way of describing the steps in the care and treatment of PLHIV which include:

  • Diagnosis (HIV testing; Fact Sheet 102)
  • Getting into medical care
  • Staying in medical care
  • Prescription of ART
  • Achieving viral suppression (undetectable viral load; see Fact Sheet 125)

The care continuum can help communities and health programs understand how well PLHIV receive care and treatment, improve health and prevent new infections.

What Are the IAPAC Guidelines?

The International Association of Providers of AIDS Care (IAPAC), through a multidisciplinary panel of international advisors, developed the first comprehensive, evidence-based guidelines for optimizing the HIV care continuum, with an aim to increase HIV testing coverage, linkage to care, treatment coverage, engagement and retention in care, and viral suppression for adults and adolescents.

The panel reviewed the scientific literature on the HIV care continuum and made 36 recommendations in six subject areas:

Recommendations for Optimizing the HIV Care Environment:

  1. Laws that criminalize the conduct of or exert punitive legal measures against MSM, transgender individuals, substance users, and sex workers are not recommended and should be repealed where they have been enacted. (A IV)
  2. Laws that criminalize the conduct of PLHIV based on perceived exposure to HIV, and without any evidence of intent to do harm, are not recommended and should be repealed where they have been enacted. (A IV)
  3. HIV-related restrictions on entry, stay, and residence in any country for PLHIV are not recommended and should be repealed where they have been enacted. (A IV)
  4. Strategies to monitor for and eliminate stigma and discrimination based on race, ethnicity, gender, age, sexual orientation, and/or behavior in all settings, but particularly in health care settings, using standardized measures and evidence-based approaches, are recommended. (B II)
  5. Proactive steps are recommended to identify and manage clinical mental health disorders (eg, anxiety, depression, and traumatic stress) and/or mental health issues related to HIV diagnosis, disclosure of HIV status, and/or HIV treatment. (A II)
  6. Enabling PLHIV to take responsibility for their care (eg, self-management, user-driven care) is recommended. (B I)
  7. Shifting and sharing HIV testing, dispensing of ART, and other appropriate tasks among professional and paraprofessional health worker cadres is recommended. (A I)
    1. Use of lay health workers to provide pretest education and testing and to enhance PLHIV engagement in HIV care is recommended. (B I)
    2. Task shifting/sharing from physicians to appropriately trained health care providers, including nurses and associate clinicians, is recommended for ART initiation and maintenance. (B II)
  8. Community engagement in every step across the HIV care continuum is recommended. (B II)

What's the Bottom Line?

The HIV care continuum describes how many people living with HIV know their status, engage in medical care, receive ART and achieve undetectable HIV viral loads.

The IAPAC guidelines are the evidence-based recommendations to improve the care environment for PLHIV. In many places, laws criminalize people at risk of HIV or make it illegal to migrate to or live there. These guidelines recommend that such laws be repealed. Monitoring for and eliminating stigma and discrimination, especially in health care settings is recommended. Enabling PLWHIV to take responsibility for their care and community engagement across the care continuum is recommended.