Editorial Commentary: A Tale of 2 Realities: What Are the Challenges and Solutions to Improving Engagement in HIV Care?

“It was the best of times, it was the worstof times . . . we had everything before us,we had nothing before us....” [1]. Inshort, the period Charles Dickens de-scribed is reminiscent of the current stateof the human immunodeﬁciency virus(HIV) epidemic in the United States andthroughout the world. There is now con-crete evidence that, as never before, weare in the “best of times” for the HIVepi-demic. Over the past 2 decades, dramaticimprovements in HIV treatment have ledto signiﬁcant declines in HIV-relatedmortality in the United States, from apeak of 50876 deaths in 1995 to 8369 in2010 [2].Globally, the scale-up of antire-troviral therapy (ART) has led to similarreductions in mortality [3]. Finally, therecognition that suppression of HIV rep-lication to below the limit of detectionwith ART reduces the risk of HIV trans-mission by nearly 100% [4] provides aroadmap to effective control of the epi-demic. However, approximately 20% ofAmericans and close to 50% of the globalpopulation who are infected with HIV donot know their status. Moreover, themajority of those diagnosed with HIVare not engaged in care [5]. Despite datademonstrating that “treatment is preven-tion,” there continue to be about 50000new infections per year in the UnitedStates and >2 million globally with evi-dence of increasing incidence amongmen who have sex with men in thiscountry, suggesting that enormous chal-lenges remain ahead and that it may benaive or at least premature to be talkingabout the “End of AIDS” [6]. In fact, thismay be the “worst of times” for ultimateepidemic control.In an article by Mugavero et al, pub-lished in this issue of Clinical InfectiousDiseases [7], the authors review thecurrent state of engagement in care inthe United States, propose existingevidence-based interventions to improvecare outcomes, and call for increasing theresearch agenda to study strategies toimprove linkage, engagement, and reten-tion in care. There is a wide array ofreasons why some HIV-infected patientsare not effectively linked or retained intocare, ranging from untreated depressionto unstable living conditions, to stigma,to active substance abuse. Because theUS epidemic disproportionately affectspeople of color, structural issues, such asperceived racism and medical mistrust ofhealthcare providers, may also impairoptimal linkage and retention in care.There is an increasing array of evidence-based interventions that can result inimproved clinical outcomes, rangingfrom case management that links peopleinto care after diagnosis [8], to improvedscreening for the diagnosis and treatmentof concomitant mental health and sub-stance abuse conditions [9], to the useof peer health system navigators thatassist patients to efﬁciently access neededservices [10].The Mugavero paper is particularlytimely as we are currently at a criticaljuncture in healthcare in the UnitedStates that may create a perfect storm forpatients with HIV. At a time of increas-ing hope, we are also facing a healthcaresystem with decreasing resources. In thecurrent ﬁscal environment, the congres-sional sequestration has already impactedmany programs through its automatic5.1% cuts in funding, translating intoabout 424000 fewer HIV tests that theCenters for Disease Control and Preven-tion can provide to health departmentsandcommunity-basedorganizationscom-pared to prior years and 7400 peoplenotbeingabletoaccessantiretroviralmed-ication through the federal AIDS DrugAssistance Program. Medicaid expansion,critical forprovidingcare for those most atneed as part of the Affordable Care Act(ACA), is opposed by governors and/orlegislatures in some of the most affectedstates in the southern United States [ 11].These are only a few examples of theimpact of sequestration. Furthermore,although full implementation of the ACA