Retention in care: is it still a clinically useful indicator for monitoring long-term engagement in HIV care in the treat-all era?

OBJECTIVES: Describe changes in visit frequency by viral suppression (VS) vs. non-VS among people with HIV (PWH) in the US treat-all era. DESIGN: Observational cohort study. METHODS: We defined six period-cohorts of PWH in U.S. clinical cohorts of the NA-ACCORD who had initiated antiretroviral therapy and were retained in clinic (attended ≥1 visit in 9 months [mo]) prior to January 1, 2012, 2014, 2016, 2018, 2020, and 2022 (n = 42 389-54 655). We estimated the proportions of PWH retained in clinic, having gaps in visits of >9-15mo or >15mo, and returned to clinic after gaps by time-updated VS status (< vs. ≥200 copies/ml) over 2 years of follow-up using multi-state models, standardized to the 2012 cohort. RESULTS: PWH in 2012 cohort had a median age of 51 years (IQR: 43-58); 85% were cismen; 43% were non-Hispanic Black; 15% were Hispanic; 84% had VS at baseline. The proportions of PWH having >9-15mo gaps with prior VS increased from 2012 (3.8%; 95% CI: 3.6%, 3.9%) to 2022 (6.9%; 95% CI: 6.5%, 7.3%). The proportions of PWH having >15mo gaps with prior VS increased from 2012 (6.6%; 95% CI: 6.4%, 6.8%) to 2022 (10.7%; 95% CI: 10.2%, 11.2%). The proportions of PWH with >9-15mo and >15mo gaps with non-VS remained low from 2012 to 2022. The majority of PWH returned to clinic after gaps. CONCLUSIONS: Over the past 12 years, PWH with prior VS had more gaps in visits that did not meet a minimum of 6-mo visit frequency consistent with standard retention indicators. Better indicators are needed to optimally direct resources for care engagement and VS.