Comment On the Stages of HIV Care Continuum: considering treatment for secondary prevention among patients ‘retained in care’ Considering Treatment For Secondary Prevention Among Patients ‘retained in Care’ - Comment On the Stages of HIV Care Continuum: considering treatment for secondary prevention among patients ‘retained in care’ Considering Treatment For Secondary Prevention Among Patients ‘retained in Care’ - Open Access Pub

DOI 10.14302/issn.2324-7339.jcrhap-12-128 In July 2012, the Centers for Disease Control (CDC) presented new data at the XIX International AIDS Conference indicating only 25% of Americans with HIV had a suppressed viral load.1 Viral suppression has been associated with reduced individual morbidity and mortality as well as reduced risk of transmission to sexual partners. The CDC study further reported on the proportion of Americans in each Stage of HIV Care: 1) testing and diagnosis, 2) linkage to care, 3) retention in care, 4) provision of antiretroviral therapy (ART), and 5) viral suppression. Their findings suggested that of all people living with HIV in the United States, 82% had been diagnosed, 66% had been linked to care, 37% were retained in care, 33% were prescribed antiretroviral therapy (ART), and 25% had achieved viral suppression. These Stages of Care results are consistent with previous estimates2, 3that suggest many HIV-infected individuals drop-off as they progress through the continuum, leaving only a minority of individuals who reach the final stage of viral suppression. The Stages of Care continuum was first described by Gardner et al3 (March 2011) and is currently being used by federal, state, and local agencies to quantify the engagement of HIV-infected individuals in each stage of care and target resources accordingly. Achievement of viral suppression by adherence to ART is the model’s primary outcome for all people with HIV, and thus the model is alternatively referred to as the “treatment cascade.” The rationale for viral suppression as the cascade’s outcome is sound: 1) viral suppression is an expected result of adherence to ART, 2) viral suppression benefits the individual through improved clinical outcomes, and 3) viral suppression provides the public health benefit of reduced risk of transmission to others. Treatment guidelines were updated in March 2012 to recommend initiation of ART in all HIV-infected patients,4 but this does not mean all patients will receive ART. Patients may refuse or postpone treatment, and providers may opt to defer therapy on a case-by-case basis. For example, the strength of the recommendation for early initiation varies by patient CD4 count as there is limited evidence to demonstrate a clear clinical risk-benefit ratio for asymptomatic patients with CD4 counts over 500. However, there is strong evidence to support the use of early ART to prevent sexual transmission of HIV. Results from the HPTN 052 trial demonstrated a 96% reduction in heterosexual transmission associated with early ART.5 Based on