Getting to Zero and the HIV Care Continuum

Robert Carroll

Recent research has shown that early HIV treatment decreases the risk of transmission, as well as improves the health of infected individuals.

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More than 25 years ago, I was a freshman in nursing school and working as a health aid in one of the Nation’s first dedicated HIV hospices, Rosehedge House in Seattle, Washington. This was long before the advent of antiretroviral medications and their revolutionary life-extending benefits, so I spent the bulk of my time supporting those whose lives were rapidly ebbing away amidst a tide of opportunistic infections and malignancies.

I worked the night shift at Rosehedge House, and while my role was to assist with feeding, bathing, toileting, and transporting patients, more often than not I found myself comforting those who were facing their mortality far too early, or sitting quietly in the dark of night with those who were moving on from their pain and suffering. It was difficult work, humbling and often depressing, but work that forged in me a career-long commitment to HIV nursing.

Since then, the landscape of HIV testing, prevention, treatment, and care has changed dramatically, and HIV disease is now regarded more as a chronic—albeit still life-threatening—illness, rather than as the death sentence it once was. With the advent of antiretroviral medications in 1996, and the continuing expansion and improvement of HIV treatment and medication options, the numbers of those living with HIV continue to rise, while those deaths associated with AIDS continue to fall, for many groups.

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Recent research has shown that early HIV treatment decreases the risk of transmission, as well as improves the health of infected individuals. Given this evidence, and because of a number of exciting new treatment and prevention approaches, the Centers for Disease Control and Prevention (CDC) has declared HIV prevention in the United States a “Winnable Battle.” In fact, the refinement and expansion of HIV treatment has now effectively reduced to zero the number of new transmissions from mother to child, as well as vastly diminished the number of infections attributed to occupational exposure, through the administration of Post-Exposure Prophylaxis (PEP). Also, nonoccupational post-exposure prophylaxis (N-PEP), when properly and expeditiously administered, now provides an additional protective option for those exposed to HIV outside a clinical setting, most notably following unprotected sex. Finally, those at highest risk for HIV infection now have access to Pre-Exposure Prophylaxis (PrEP), a once-daily, single pill medication that has been proven to prevent infection among those engaging in unprotected, high-risk sexual activities.

The National HIV/AIDS Strategy (NHAS), developed through the White House Office of National AIDS Policy, aspires to support the “Winnable Battle” against HIV through three key goals: 

  • Reducing HIV incidence
  • Increasing access to care
  • Optimizing health outcomes for all through the reduction in HIV-related health disparities

Moreover, implementation of the NHAS has transformed HIV prevention efforts, with increased attention now focused on helping individuals living with HIV navigate the continuum of care, shown below, through testing, engagement in care, adherence, and maintenance of viral suppression (i.e., the absence—or relative absence—of circulating HIV in an infected person’s bloodstream).

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The continuum is based on recent CDC data and provides a visual roadmap to understanding where improvements are needed to link more people to care and keep them in the care system. Scrutiny of the numbers of people engaged with the HIV care system, at each of the five continuum stages, helps us to identify gaps in the system in order to prevent drop-offs from care and improve strategies that keep people moving forward toward long-term viral suppression.

Specifically, we can see that although more than 80% of those persons living with HIV in the United States have been tested and diagnosed, only 30% have been linked to and retained in care and achieved viral suppression. From these data, we can further extrapolate that by increasing testing and diagnosis, linking to care, and achieving viral suppression, we can significantly decrease the number of persons with highly infectious levels of virus, and thus decrease the potential for transmission, since research has shown that early HIV treatment decreases the risk of transmission, as well as improves the health of infected individuals.

Consequently, we now understand that in addition to behavioral approaches that aim to prevent HIV transmission, we must also focus our energies on engaging in care those already living with HIV. This approach, known as “Treatment as Prevention,” is perhaps our strongest tool to date in the myriad of HIV prevention approaches at our disposal, and aims to drive up to 100% the numbers of those persons living with HIV who are virally suppressed, and “Getting to Zero” the numbers of new infections.

Today, my work has taken me far from those long, dark nights sitting vigil at Rosehedge House, and the futility that marked those years has been replaced with hope. We can see a future generation without AIDS and a time when the rates of new infections get nearer to zero. But we are now at a new turning point, when we must apply to prevention science and messaging the same innovative exuberance we previously employed in the discovery of new and emergent antiretroviral treatments.

​Please check back for future postings, where we will continue to examine the dynamically evolving field of HIV prevention and care, as well as explore the ways in which innovations in health communication and health technologies are driving the goal of “Getting to Zero.”

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