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International Association of Providers of AIDS Care
Reviewed February 3, 2017

Fact Sheet 114

Increasing retention in care, ART adherence and viral suppression


Antiretroviral therapy (ART; see Fact Sheet 403) can reduce the risk of serious illness, death or transmission of HIV. ART is now recommended for all people living with HIV (PLHIV) in a strategy called “treatment as prevention” (TasP).

Yet, only half of people living with HIV (PLHIV) around the world are aware of their status. Among those who know their HIV status, many do not receive ART in a timely manner, fail to stay engaged in care, or do not achieve sustained viral suppression.

The HIV care continuum is a way of describing the steps in the care and treatment of PLHIV and include:
• Diagnosis (HIV testing; fact sheet 102)
• Getting into medical care
• Staying in medical care
• Prescription of ART
• Achieving viral suppression (undetectable viral load; see Fact Sheet 125)

The care continuum can help communities and health programs understand how well PLHIV receive care and treatment, improve health and prevent new infections.


The International Association of Providers of AIDS Care (IAPAC), through a multidisciplinary panel of international advisors, developed the first comprehensive, evidence-based guidelines for optimizing the HIV care continuum, with an aim to increase HIV testing coverage, linkage to care, treatment coverage, engagement and retention in care, and viral suppression for adults and adolescents (see Fact Sheet 110).

The panel reviewed the scientific literature on the HIV care continuum and made 36 recommendations for interventions in six subject areas:

Optimizing the HIV care environment (Fact Sheet 111)

Increasing HIV testing coverage and linkage to care (Fact Sheet 112)

Increasing HIV treatment coverage (Fact Sheet 113)

Increasing retention in care, ART adherence, and viral suppression (Fact Sheet 114)

Adolescents (Fact Sheet 115)

Metrics for and monitoring of the HIV care continuum (Fact Sheet 116)

The recommendations are graded by strength and quality of the body of evidence as follows: Strong (A); Moderate (B); Optional (C); Excellent (I); High (II); Medium (III); Low (IV).



1. Systematic monitoring of retention in HIV care is recommended for all patients. (A II)
a. Retention in HIV care should be considered as a quality indicator. (B III)
b. Measuring retention in HIV care using electronic health record and other health system data is recommended. (BII)
c. Use of clinic databases/surveillance systems for HIV clinical monitoring and population-level tracking is recommended. (B II)


2. Routine ART adherence monitoring is recommended in all patients. (A II)
a. Viral suppression is recommended as the primary adherence monitoring metric. (B II)
b. Routine collection of self-reported adherence data from patients is recommended. (A II)
c. Pharmacy refill data are recommended for adherence monitoring. (B II)

3. Information and communication technologies aimed at supporting patient self-care are recommended. (B II)
a. Mobile health technology using weekly interactive components (eg, 2-way text messaging) is recommended. (B I)
b. Alarm devices are recommended as reminders for PLHIV with memory impairment. (A I)

4. Patient education about and offering support for medication adherence and keeping clinic appointments are recommended. (A I)
a. Pillbox organizers are recommended, particularly for HIV-infected adults with lifestyle-related barriers to adherence. (B II)

5. Neither directly administered nor directly observed ART is recommended for routine clinical care settings. (A I)
a. Directly administered ART is recommended for people who inject drugs and released prisoners at high risk of ART non-adherence. (B I)

6. Proactive engagement and reengagement of patients who miss clinic appointments and/or are lost to follow-up, including intensive outreach for those not engaged in care within 1 month of a new HIV diagnosis, is recommended. (B II)
a. Case management to retain PLHIV in care and to locate and reengage patients lost to follow-up is recommended. (B II)
b. Transportation support for PLHIV to attend their clinic visits is recommended. (B II)


The HIV care continuum describes how many people living with HIV know their status, engage in medical care, receive ART and achieve undetectable HIV viral loads.

The IAPAC guidelines are the evidence-based recommendations to improve retention in care, ART adherence and viral suppression for PLHIV.


Full text of the IAPAC guidelines is available at

Reviewed February 3, 2017

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