The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

Antiretroviral therapy (ART) for human immunodeficiency vims (HIV) prevents ilness and death from HIV disease and transmission of HIV infection. To encourage global scale-up of ART, the Joint UN Program on HIV/AIDS (UNAIDS) issued the "95-95-95"targets for the HIV "cascade of care."These targets state that by 2030, 95% of individuals living with HIV will know their HIV status, 95% of people with diagnosed HIV infection will receive ART, and 95% of those taking ART will have achieved suppression of the virus. • While tremendous progress has been made toward achieving these targets, substantial gaps remain. The challenge of closing the final gaps requires reconsideration of the cascade itself. • The 95-95-95 HIV care cascade depicts a linear and unidirectional continuum of care with one starting point (HIV diagnosis) and one ending point (treatment discontination or death). This simplification of the cascade oversimplifies the complex cycle of engagement, disengagement, temporary disuptions, reengagement, and transitions in care experienced by many people living with HIV (PLHIV). • As the proportion of PLHIV who reinitiate ART after previously starting and stopping increases, we propose to update the HIV cascade of care to better reflect actual experiences of PLHIV. The new cascade makes the cycle of engaging and reengaging in HIV care both explicit and expected. • The revised cascade will inform and prioritize efforts by communities, healthcare workers, implementers, program managers, policymakers, and donors to prevent missed clinic visits, overcome barriers to care reentry, and minimize onset of advanced HIV disease. It will also emphasize that morbidity, mortality, and onward transmission can be minimized by focusing interventions on anticipating, and then reducing, the duration of gaps in care. © 2021 Ehrenkranz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.