Patching a leaky pipe: the cascade of HIV care

Purpose of review We reviewed recent literature on the cascade of HIV care from HIV testing to suppression of viral load, which has emerged as a critical focus as HIV treatment programs have scaled up. Recent findings In low-and middle-income countries, HIV testing and diagnosis of people living with HIV (PLHIV), although rapidly expanding, are generally relatively low. Linkage and retention in care are global challenges, with substantial attrition between diagnosis, laboratory or clinical staging, and antiretroviral therapy (ART) initiation, and additional substantial attrition on ART due to loss to follow-up and death. ART coverage is rapidly expanding but is still relatively low, especially when considered as a percentage of all PLHIV. Adherence is also suboptimal and virological suppression is incomplete. Summary Taken together, the attrition at each step of the cascade of care results in overall low levels of viral load suppression in the total population of PLHIV. More robust monitoring from the facility to global levels and implementation of established and emerging interventions are needed at each step of the cascade to enhance HIV diagnosis, linkage to and retention in care, ART use, and adherence, and ultimately reduce viral load, improve clinical outcomes, and reduce HIV transmission.