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OBJECTIVES

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Objectives

  • Describe the current state of HIV among underserved and vulnerable populations in the United States.

  • Understand the importance of testing, diagnosing, linking to and retaining in care, and managing HIV along all stages of the HIV care continuum.

  • Review groups at highest risk for morbidity and mortality of HIV/AIDS.

  • Describe challenges to patient care including patient, provider, system, and disease factors.

  • Identify interventions to improve HIV prevention efforts.

  • Identify interventions to improve care for vulnerable patients with HIV or AIDS.

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INTRODUCTION

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Don Sloan is a 34-year-old recently unemployed truck driver who is brought to the emergency department following an alcohol-related automobile collision. No serious traumatic injuries are found and he is medically stable. Prior to discharge he is informed of the laboratory test results, including an HIV test he had been told would be done as part of routine testing unless he refused. The emergency department attending tells him his HIV test is positive, orders a confirmatory HIV test, and refers Mr. Sloan to the outpatient HIV clinic.

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Major advances in treating human immunodeficiency virus (HIV) have shifted HIV from a terminal illness to a manageable chronic disease. The collaborative efforts of patients, advocates, and the medical community have rapidly advanced access to highly effective treatment. Consequently, individuals who learn they are HIV infected and take antiretroviral drugs (ARVs) daily have excellent health outcomes and a low risk of passing HIV to others. Globally, however, HIV is still the world’s leading killer due to an infection.

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In the United States, HIV/AIDS is still found disproportionately among people of color, especially African Americans and Latinos, men who have sex with men (MSM), injection drug users (IDUs), those with mental illness, and the poor. New infections continue to occur at alarming rates, especially among young MSM of color. Disparities in new infections and in care characterize the global epidemic as well, with gender inequity driving the growth of infections in women and girls.

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This chapter reviews critical elements of prevention and treatment of HIV/AIDS, including strategies for improving care for vulnerable populations with a focus on populations in the United States.

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THE HIV CARE CONTINUUM

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The causes of HIV infection have not changed significantly since it was first reported in the early 1980s. HIV is primarily transmitted through sexual exposure, injection drug use, and less commonly through mother-to-child transmission (especially in the United States). Persons with HIV infection may be asymptomatic and unaware of their infection for many years. However, a person infected with HIV can transmit the infection from the time he or she becomes infected. Medications that effectively suppress viral load (the amount of HIV virus circulating in the bloodstream) can significantly decrease and possibly eliminate infectivity.1 Suppressing the virus therefore both treats the disease in an individual and prevents disease transmission to others.

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