Back HIV/AIDS HIV/AIDS Topics HIV Treatment Cascade of Care Only 30% of People with HIV in U.S. Have Undetectable Viral Load

Only 30% of People with HIV in U.S. Have Undetectable Viral Load


Less than one-third of people living with HIV in the U.S. are on antiretroviral therapy (ART) with full viral suppression, which is key to good health and reduced risk of transmission, according to the latest CDC Vital Signs report. In 2011, out of an estimated 1.2 million people living with HIV, just 4 in 10 were receiving HIV medical care and only 3 in 10 had undetectable viral load. "The bottom line is HIV care and treatment not only work to improve health and prolong lives, but also prevent transmission," said CDC director Tom Frieden. "You can save your life and save the life of someone else."

The report, published in the November 28 Morbidity and Mortality Weekly Report, updates the care continuum or "cascade of care," a representation of how many people living with HIV are lost at each successive step from testing and diagnosis, to linkage to care, to starting ART and achieving viral suppression.

For 2011, the care continuum data showed that of the 1.2 million people living with HIV in the U.S:

  • 86% had been diagnosed with HIV;
  • 40% were engaged in HIV medical care;
  • 37% were prescribed ART;
  • 30% achieved viral suppression.

The percentage of people diagnosed with HIV shows improvement over the widely cited 80% figure reported in a 2011 Vital Signs report. The proportion of people engaged in care was about the same, while the percentage with viral suppression rose slightly, from 26% in 2009 (also cited as 25% and 28% in other related reports) to 30%.

The improvement in diagnosis may reflect better screening, suggested Jonathan Mermin, director of CDC's National Center for HIV/AIDS, during a November 25 media briefing. All adults should undergo HIV screening as part of routine medical care at least once, and those at increased risk should be tested more frequently. "An HIV test should be as easy to get as a cholesterol test," he said.

Of the 15,449 people newly diagnosed with HIV in 2011, 80% were linked to HIV medical care within 3 months. Here, the proportions were lowest for the youngest age group (13-24 years) at 73% and for blacks at 76%.

The latest data revealed no notable differences in the likelihood of viral suppression according to sex, race/ethnicity, or transmission category (e.g., men who have sex with men, heterosexuals, injection drug users). Viral suppression rates were 28% for blacks and 32% for whites -- not a statistically significant difference.

However, young people (age 18-24) were only about one-third as likely to have undetectable viral load as the oldest group (age 65 and older): 13% vs 37%, respectively. Viral suppression rates increased steadily with age, from 23% for people age 25-34, to 27% for those age 35-44, to 36% for those age 55-64.

Frieden emphasized that much of the drop-off was attributable to the large proportion of people who had been diagnosed with HIV but did not go on to receive further care.

"Too many are not getting the care they need mainly because they are not staying in care," he said. "Most of those who are in care do receive ART."

Among the 70% of people with HIV -- nearly 840,000 individuals -- who did not have viral suppression:

  • 20% did not yet know they had HIV;
  • 66% had been diagnosed but were not engaged in regular HIV care;
  • 4% were engaged in care but not prescribed ART;
  • 10% were prescribed ART but did not achieve viral suppression.

Within the youngest age group, however, a higher proportion of people without viral suppression -- about half -- had not yet been diagnosed.

"It’s alarming that fewer than half of HIV positive young adults know they are infected," said Eugene McCray, director of CDC’s Division of HIV/AIDS Prevention. "Closing that gap could have a huge impact on controlling HIV -- knowing your status is the first critical step toward taking care of your own health and avoiding transmission to others."

When used consistently, ART can keep HIV suppressed to very low levels, allowing people with HIV to live longer, healthier lives and reducing the likelihood they will transmit HIV to others, the CDC stated in a press release announcing the findings. ART has been shown to reduce HIV sexual transmission by 96% percent, and U.S. clinical guidelines now recommend that everyone diagnosed with HIV receive treatment, regardless of CD4 T-cell count or viral load.

"For people living with HIV and AIDS, it's not enough to know -- you also have to go for health care," Frieden said during the briefing. He added that for providers, it's not enough to diagnose patients, they also have to provide sensitive and culturally appropriate care. Doctors have to take responsibility in the clinic and public health officials have to take responsibility for everyone in their jurisdiction, he added.

As to why some people with HIV may not access or stay in care, Mermin acknowledged that "it can be difficult for people without health circumstances can make it more difficult, poverty, sometimes homelessness, substance abuse -- many factors can deter people from seeking and remaining in HIV care."

Among the strategies that could help increase the likelihood that people with HIV would seek and receive ongoing medical care, the Vital Signs authors suggested strengths-based case management, provider notification systems, co-located medical and support services, clinic materials promoting engagement in care, clinic staff with expertise serving affected populations such as young people and gay men, and patient navigation and outreach services.

"State and local health departments, community-based organizations, and health care providers play essential roles in improving outcomes on the HIV care continuum that increase survival among persons living with HIV and prevent new HIV infections," the authors concluded. "The greatest opportunities for increasing the percentage of persons with a suppressed viral load are reducing undiagnosed HIV infections and increasing the percentage of persons living with HIV who are engaged in care."



H Bradley, HI Hall, RJ Wolitski, et al. Vital Signs -- HIV Diagnosis, Care, and Treatment Among Persons Living with HIV -- United States, 2011. Morbidity and Mortality Weekly Report 63(47):1113-1117. November 28, 2014.

CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data -- United States and 6 Dependent Areas -- 2012. HIV Surveillance Report. Supplemental Report 19(3). November 2014.

Other Sources

CDC. HIV Care Saves Lives: Viral Suppression is Key. Vital Signs. November 2014.

CDC. Only 3 in 10 People with HIV Have the Virus in Check. Press release. November 25 2014.