Approximately 50 000 new human immunodeficiency virus (HIV) infections develop in the United States each year.1 How many of these people know of their HIV infection? How many are engaged in HIV care? How many are successfully treated with antiretroviral therapy (ART)? Surprisingly, until very recently, the answers to these simple questions regarding HIV care were unknown.
In 2011, the HIV field was shocked to learn that only about a quarter of individuals living with HIV were successfully receiving HIV treatment.2 The steps to effective treatment, often referred to as the HIV care continuum or cascade—testing, linkage to care, retention in care, ART initiation, and achievement of an undetectable viral load—often operated more like an obstacle course than a smoothly paved road. Hurdles to successful HIV care include factors that are structural (eg, poverty, lack of health insurance), psychosocial (eg, stigma, substance use, mental illness), and clinic based (eg, the patient-provider relationship).3