To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013–2017.This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression.As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61–0.98) but more likely among those newly diagnosed from 2014–2017 , compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients . As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not . Those less likely to be suppressed were 20–29 vs. 60 years or older , had public vs. private insurance  and public vs. private housing .Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators. An estimated 1.04 million persons were living with HIV (PLWH) in the United States (U.S.) in 2018, with a prevalence of 374.6 per 100,000 population ), housing , income based on the federal poverty limit (FPL) for one person in 2017,  Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1:YesReviewer #2:Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1:YesReviewer #2:Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1:YesReviewer #2:Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1:YesReviewer #2:Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1:This is a well written and well articulated research work on an important topic in HIV management. However, the authors are invited to consider some clarification to further improve the understanding of the work.Title: The authors could consider a review of the title to "Retention in care and viral suppression among HIV patients in Peter Ho Clinic"Abstract: Line 36-37 What are the comparison group?Method section:The authors need to provide information on the study setting to help the readers understand the context of the clinic and its operational environment. There is need for more details about the patients management in the hospital and the total number of patients receiving HIV care in the hospital.line 89-91 : How long had the newly diagnosed patients been on treatment? Were they excluded because they did not experience virologic failure or because they were not eligible for the test as at the the time the analysis were conducted? Could the authors provide more information about how many patients were excluded from the analysis and for what reasons in a flow diagram?Line 98: Remove "The definition of"line 98-100: In defining the annual and durable retention, what was the starting point? The start of study or the point the patient commenced on ART? There is need to clarify on this further for ease of reproducibility. It is also important because retention rate vary with the duration on care from commencement of ART. This is same for viral suppression.line 109: How about 18 and 19 years of age?line 121: How did you handle those that did not have insurance "none"? The constituted 21% of the total respondents.line 129-132: Could the authors provide more details about the model development? How did they handle multiple collinearity? How were factors selected for the final model?Results section:Line 134: Were these all PLWH? Where they new enrollment within the period, all previously enrolled prior to this period or both new and old enrollments? This could have been explained in the method section for more clarity.Table 2: Please check the figures, the total number of new in Table 1 is 157 and is 158 in Table 2. Also, the current was 1229 in Table 1 and 1230 in Table 2. Were there additions? If anything the numbers should be less if some died within the period. Kindly cross check the figures.How was those without insurance handled. One would expect a footnote here explaining the merging of the cells in table 1.line 160: "patient" statusTable 4:The authors should consider rephrasing the title of table 4. I understand that these were the initial 935 patients that ever reported virologic failure whose latest results showed some changes probably after an adherence intervention and a follow up test. It should read factors affecting viral suppression among those that reported an earlier virologic failure at PHC 2013-2017Discussion:The authors should resist the urge of repeating the results in the discussion section. They should rather discuss the implication of their finding to practice and situated it in the body of knowledge. They can also provide unique context to help the readers understanding the findings and why they may defer from other well known findings.Line 221:The authors could do more search on longitudinal retention in care among PLWH in literature, what is described as durable retention here. Here some literature to considerhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289300/https://link.springer.com/article/10.1007/s10461-019-02450-7?shared-article-rendererhttps://academic.oup.com/cid/article/62/5/648/2462795Line 271: Was this a cohort study?Reviewer #2:This paper reports a 14-percentage-point increase in HIV viral suppression over five years in the HIV-focused Peter Ho Clinic in urban New Jersey, without consistent increases to retention in care. These findings are inspiring, but the paper should frame them more compellingly, more clearly describe analytic decisions, and highlight and analyze their suppression initiative more.AbstractPlease see comment below about conveying your unique angle and relevance throughout the paper, including in the abstract.IntroductionLines 52-54: Please make the statistics about viral suppression comparable in both sentences, i.e., both among (or not among) persons retained in care.Why this set of years and why this clinic? What unique questions of broad relevance were you able to ask and answer? Share things that will help the reader see how this analysis informs not only where this leaves PHC patients and policies but also other populations and health care systems. For example, PHC is the first and largest HIV clinic in NJ, it is set within a large medical center that also provides social services, it accepts public insurance and is supported by federal Ryan White funding and many patients are low-income, NJ and Newark are racially and ethnically diverse and have a relatively high prevalence of HIV, etc. The particular angle and relevance of your paper should shine not only in the introduction but also the abstract and discussion.MethodsLine 110: “Gender ” needs to be changed. Please specify if this is gender identity or sex assigned at birth. If the former, the terms “man” and “woman” are more appropriate, and it would also be helpful to state whether and how non-binary and transgender persons were ascertained and classified.Your analyses used multiple outcomes, denominators, inclusion criteria, and time periods. This section needs to more clearly convey what exactly the analyses were and who was in each one. Places to insert expansions on this may be around lines 88-89 ; and lines 82-83 .Lines 95-97 . A medical encounter was defined as a97 medical visit with a prescribing provider or an HIV viral load test…”): Guidelines have been shifting to permit once-yearly testing for persons with durable suppression. Especially since you also have a durable retention measure, did you consider looking at retention as being at least once in the year? Or did clinic policy, prescribing practices, or the HIV/AIDS Bureau guidelines sway you to only look at twice-annual? See also my comments on the first paragraph of the Discussion.Lines 98-100 : The durable retention definition seems unclear. How is the length of the period determined? Might be more standard to just pick one and justify it based on the literature, federal guidance, or the interest and practices of your clinic. Later when I go to the figure, I sort of understand what you’ve done – you calculated as many of the durable measures as you could for each person according to their amount of… enrollment or follow-up time? – and it would be helpful to describe that in the methods.Line 84 : Yes, every HIV clinic should be doing this internally. But again, what about your clinic, analysis, or findings makes this publishable because it’s of interest to a broader audience? Expand on this to tell the reader how the findings will illuminate broader truths about HIV care and suppression among attendees of an urban US HIV clinic.ResultsTables 1 and 2: How come the patient status (current / new / reengaged) breakdown of the 1,000 persons retained in care in Table 2 seems inconsistent with that for the 1,000 2017 persons in Table 1? Are 705 persons current, or 908?Lines 183-184 , 2014 (76%), 2015 (80%), 2016 (81%) and 2017 (87%).”): What a substantial and exciting increase. Congratulations! You are almost at 90%. What changed to make this happen? Was it clinic practice, medication changes, the slight shift in patient load toward persons with fewer financial barriers to adherence? This could be the angle for your entire paper. With a patient population with as many challenges as yours re substance use, mental illness, and poverty, many would want to know how you worked with your patients to achieve an increase to 87% suppression.Table 4: Are there any other characteristics about the care itself or contact with PHC or the suppression initiative that you’d want to include in a model? Or do you take the retention measure generally as a proxy for contact with the initiative? Could potentially break out retention differently to be more explicit about the nature of the care, e.g., instead of not retained vs. retained, could instead do something like not retained vs. retained but no case manager / nurse contact vs. retained and had a session with case manager / nurse.DiscussionLines 207-208 : Are these statistics comparable? Seems like the 71% nationally may be among all PLWH, whereas PHC patients are inherently connected with a provider and were in care during at least one point in the last five years.Lines 211-220: Given your attention to findings about suppression among persons not meeting the HAB criteria for retention in care , why not also look at this, potentially with a single-visit measure of retention? As it is, this first paragraph feels a bit like it goes off on a tangent here. Maybe you could explore suppression among persons not retained, at this length, in later paragraphs and, in the first paragraph, highlight several of your most important findings, such as that you’re hitting 90-90-90 targets for retention and suppression, your five-year retention rates aren’t extraordinary, and you experienced substantial increases in suppression in the last five years.Lines 227-236: Great job with your viral suppression initiative! Seems like a huge success. Why did you hold this key information until the Discussion, and bury it in the third paragraph? And have you published anything else about it that you can cite, too? Again, this is a big part of your story. Let the reader know in the abstract and the intro, methods, and discussion sections.Line 236: I see that this was a data-driven initiative with multiple partners, which is terrific. Readers will also want to know what those “appropriate interventions” were and ideally a few measures of those interventions. For example, did referrals to drug treatment / mental health services / housing services / adherence counseling / peer support increase from 2013 (pre-initiative) to 2017, and can you enumerate that change? What else was done? Did other PHC characteristics change? I see that the patient load decreased from >1,200 to 1,000. Did funding or staffing change? Did the ratio of case managers to patients increase? All of this is your story. If you don’t tell it fully in this paper, I hope you’ll at least give us a little more info here, and write it up completely elsewhere, because it seems exciting.Line 280 : Certainly. Did patients and/or your CAB also inform your suppression initiative? Do you want to acknowledge that in some way here or earlier?Figure 4: Beautiful and encouraging. I’m not clear on how you’re able to calculate five-year suppression for 2014 persons – would’ve thought just 2013. Same for four-year suppression for 2015 persons, etc.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool, 13 Sep 2020Reviewer #1: Title: The authors could consider a review of the title to "Retention in care and viral suppression among HIV patients in Peter Ho Clinic"The title of the manuscript was revised as follows –Annual and durable HIV retention in care and viral suppression, Peter Ho Clinic, 2013-2017. Abstract: Line 36-37 What are the comparison group? Based on the word limit for the abstract, this sentence was deleted. Method section:The authors need to provide information on the study setting to help the readers understand the context of the clinic and its operational environment. There is need for more details about the patient’s management in the hospital and the total number of patients receiving HIV care in the hospital.The setting of the clinic was described as follows:Setting. The PHC is located on the campus of Saint Michael’s Medical Center, an urban academic institution in Newark, New Jersey. Newark is the epicenter of the epidemic in New Jersey and lies in close proximity to New York City. This is the first clinic in the state to provide medical care for PLWH and serves approximately 1,200 persons yearly. Co-located services include HIV testing, access to pre-exposure prophylaxis and linkage to care coordinators. Clinical staff include infectious diseases providers and fellows, nurse practitioners, medical and non-medical case-managers, and a phlebotomist. Specialty practices include gynecology, medication assisted therapy for opioid use and pain management services. line 89-91: How long had the newly diagnosed patients been on treatment? Were they excluded because they did not experience virologic failure or because they were not eligible for the test as at the time the analysis were conducted? Could the authors provide more information about how many patients were excluded from the analysis and for what reasons in a flow diagram?The sentence was rephrased to include the reason for exclusion: Six patients were excluded from the virologic failure analysis as their viral loads were less than 200 copies/mL at the time of diagnosis . Line 98: Remove "The definition of"Doneline 98-100: In defining the annual and durable retention, what was the starting point? The start of study or the point the patient commenced on ART? There is need to clarify on this further for ease of reproducibility. It is also important because retention rate vary with the duration on care from commencement of ART. This is same for viral suppression.I added the term – calendar year to the definitions of retention and viral suppression, for example, “Annual retention in medical care included documentation of at least two medical encounters, at least 90 days apart, at PHC in the respective calendar-year . “ Also clarified under study population as follows: Patients included in this study were at least 18 years old and alive as of December 31st of the respective year. At least one time in 2013-2017, they saw a medical provider, received a prescription for ART and had viral load results documented in the electronic medical record. They were included in the study at the time of their first medical visit or viral load to six months after the last documented viral load or medical visitline 109: How about 18 and 19 years of age?The age category was 18-29. 18 and 19-year-olds constitute a miniscule proportion of PLWH in PHCline 121: How did you handle those that did not have insurance "none"? The constituted 21% of the total respondents. I added the following definition for patients without insurance: line 129-132: Could the authors provide more details about the model development? How did they handle multiple collinearity? How were factors selected for the final model?I expanded on the data analysis section as follows: :Multiple logistic regression models, using backwards deletion, were developed to identify factors associated with retention in medical care in 2017; virologic failure, 2013-2017; and viral suppression, 2013-2017, for those experiencing virologic failure. The selected variables were based on clinical and epidemiological significance. Collinearity in the categories for risk and drug use were mitigated by adhering to the hierarchical categorization developed by the Centers for Disease Control and Prevention [27], and categorizing drug use as cocaine only, heroin only and those with a history of using both drugs. Model fit was evaluated using Hosmer and Lemeshow Goodness-of-Fit test. Results section:Line 134: Were these all PLWH? Yes – I deleted the word patients and added PLWH. Where they new enrollment within the period, all previously enrolled prior to this period or both new and old enrollments? This could have been explained in the method section for more clarity. We added the following definition under covariates, earlier in the manuscript: Patient’s status was defined as Current, New and Reengaged. Current patients were those in care in 2013. In the respective calendar-year, new patients were newly diagnosed and reengaged were PLWH who did not previously receive care in PHC.Table 2: Please check the figures, the total number of new in Table 1 is 157 and is 158 in Table 2. Also, the current was 1229 in Table 1 and 1230 in Table 2. Were there additions? If anything the numbers should be less if some died within the period. Kindly cross check the figures.Thank you for this comment. I reviewed all the tables, corrected the numbers, and included Figure 1. One would expect a footnote here explaining the merging of the cells in table 1. Done for each table.line 160: "patient" status This change was made.Table 4:The authors should consider rephrasing the title of table 4. I understand that these were the initial 935 patients that ever reported virologic failure whose latest results showed some changes probably after an adherence intervention and a follow up test. It should read factors affecting viral suppression among those that reported an earlier virologic failure at PHC 2013-2017The title of Table 4 was changed: Table 4: Factors Affecting Viral Suppression among patients with Virologic Failure, Peter Ho Clinic, 2013-2017Discussion:The authors should resist the urge of repeating the results in the discussion section. They should rather discuss the implication of their finding to practice and situated it in the body of knowledge. They can also provide unique context to help the readers understanding the findings and why they may defer from other well known findings.Line 221:The authors could do more search on longitudinal retention in care among PLWH in literature, what is described as durable retention here. Here some literature to considerhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289300/https://link.springer.com/article/10.1007/s10461-019-02450-7?shared-article-rendererhttps://academic.oup.com/cid/article/62/5/648/2462795Thank you for these references, we have reviewed and included them in the paper. The discussion section was revised extensively. Line 271: Was this a cohort study? Deleted the word “cohort”. ThanksReviewer #2: This paper reports a 14-percentage-point increase in HIV viral suppression over five years in the HIV-focused Peter Ho Clinic in urban New Jersey, without consistent increases to retention in care. These findings are inspiring, but the paper should frame them more compellingly, more clearly describe analytic decisions, and highlight and analyze their suppression initiative more.AbstractPlease see comment below about conveying your unique angle and relevance throughout the paper, including in the abstract.IntroductionLines 52-54: Please make the statistics about viral suppression comparable in both sentences, i.e., both among (or not among) persons retained in care.The sentence was changed: In comparison at the Peter Ho Clinic (PHC), of 1,229 PLWH in medical care in 2013, 84% were retained for one year, of whom 73% were suppressed.Why this set of years and why this clinic? What unique questions of broad relevance were you able to ask and answer? I highlighted the following in the paper- This time-period is relevant as it is within the evaluation period of the NHAS, longitudinal evaluations are more relevant as we progress towards ending the epidemic. Share things that will help the reader see how this analysis informs not only where this leaves PHC patients and policies but also other populations and health care systems. For example, PHC is the first and largest HIV clinic in NJ, it is set within a large medical center that also provides social services, it accepts public insurance and is supported by federal Ryan White funding and many patients are low-income, NJ and Newark are racially and ethnically diverse and have a relatively high prevalence of HIV, etc. The particular angle and relevance of your paper should shine not only in the introduction but also the abstract and discussion.We added an Introductory paragraph, in addition to expanding on the setting in the Methods section.An estimated 1.04 million persons were living with HIV (PLWH) in the United States in 2018, with a prevalence of 374.6 per 100,000 population. [1] Males accounted for (75%), of whom 35% were Black, 73% were males who had sex with males (MSM), and injection drug use (IDU) was 9%. Among females, 58% were Black, of whom 77% reported heterosexual contact and 20% IDU as their transmission risk. In comparison, the prevalence rates in New Jersey and Essex County, were 419.7 and 1,194.9 per 100,000 population, respectively. [2] In Essex County, males accounted for 61% of PLWH, of whom 69% were Black, 35% were MSM, and 16% reported IDU. Among females 81% were Black, of whom 19% reported IDU and heterosexuals were 67%. The Peter Ho Clinic (PHC) is located in the City of Newark, in the county of Essex. The distribution of PLWH in Newark is like that of Essex County. [3]Under methods – I included a description of the setting to contextualize the study. Setting. The PHC is located on the campus of Saint Michael’s Medical Center, an urban academic institution in Newark, New Jersey. Newark is the epicenter of the epidemic in New Jersey and lies in close proximity to New York City. This is the first clinic in the state to provide medical care for PLWH and serves approximately 1,200 persons yearly. Co-located services include HIV testing, access to pre-exposure prophylaxis and linkage to care coordinators. Clinical staff include infectious diseases providers and fellows, nurse practitioners, medical and non-medical case-managers, and a phlebotomist. Specialty practices include gynecology, medication assisted therapy for opioid use and pain management services. MethodsLine 110: “Gender ” needs to be changed. Please specify if this is gender identity or sex assigned at birth. If the former, the terms “man” and “woman” are more appropriate, and it would also be helpful to state whether and how non-binary and transgender persons were ascertained and classified. Restated as Sex at BirthYour analyses used multiple outcomes, denominators, inclusion criteria, and time periods. This section needs to more clearly convey what exactly the analyses were and who was in each one. Places to insert expansions on this may be around lines 88-89 ; and lines 82-83 .I expanded on both sentences as follows and added Figure 1: Population. Patients included in this retrospective observational study were at least 18 years of age and alive as of December 31st of the respective year. At least one time in 2013-2017, they saw a medical provider, received a prescription for antiretroviral therapy (ART) and had viral load results in the electronic medical record. Patients were eligible at the time of their first medical visit or viral load until six months after the last documented viral load or medical visit. Six patients were excluded from the virologic failure analysis as they did not have detectable viral loads at the time of diagnosis. This study evaluated annual and durable retention in medical care and viral suppression, among PLWH, in the PHC, from 2013 to 2017. These results will be used to assess progress of this clinic towards achieving NHAS 2020 goals. In addition, factors that may contribute or serve as barriers to achieving these goals will be identified to inform future interventions. A flow chart was added to describe the clarify the denominators used in different evaluations.Lines 95-97 . A medical encounter was defined as a medical visit with a prescribing provider or an HIV viral load test…”): Guidelines have been shifting to permit once-yearly testing for persons with durable suppression. Especially since you also have a durable retention measure, did you consider looking at retention as being at least once in the year? Or did clinic policy, prescribing practices, or the HIV/AIDS Bureau guidelines sway you to only look at twice-annual?Current practice required by funders is that we have 2 medical visits and 2 viral loads each year. .I used the HIV/AIDS Bureau guidelines to arrive at the definitions of retention and durable retention as I think that this is more in line with reality which was described as 2 medical encounters – a medical visit or viral load. These are both considered as medical encounters – different than twice annual recommendations. Lines 98-100 : The durable retention definition seems unclear. How is the length of the period determined? Might be more standard to just pick one and justify it based on the literature, federal guidance, or the interest and practices of your clinic. Later when I go to the figure, I sort of understand what you’ve done – you calculated as many of the durable measures as you could for each person according to their amount of… enrollment or follow-up time? – and it would be helpful to describe that in the methods.I added the term calendar-year which I think would lend clarity- also the inclusion criteria as follows:Durable retention in care was defined as having at least two medical encounters and ART in each calendar-year, over a two, three, four, or five-year period, from 2013 to 2017.Patients were eligible from the time of their first medical visit or viral load until six months after the last documented viral load or medical visit.Line 84 : Yes, every HIV clinic should be doing this internally. But again, what about your clinic, analysis, or findings makes this publishable because it’s of interest to a broader audience? Expand on this to tell the reader how the findings will illuminate broader truths about HIV care and suppression among attendees of an urban US HIV clinic.The results of this study will be used to assess progress of this clinic towards achieving The National HIV/AIDS Strategy 2020 goals. In addition, factors that may facilitate or serve as barriers to achieving these goals, will be identified to inform future interventions and provide valuable lessons to other clinics, serving an urban population with similar challenges.I also highlight the importance of longitudinal measures of retention and viral suppression. ResultsTables 1 and 2: How come the patient status (current / new / reengaged) breakdown of the 1,000 persons retained in care in Table 2 seems inconsistent with that for the 1,000 2017 persons in Table 1? Are 705 persons current, or 908?Thank you for this comment. I reviewed the numbers. Lines 183-184 , 2014 (76%), 2015 (80%), 2016 (81%) and 2017 (87%).”): What a substantial and exciting increase. Congratulations! You are almost at 90%. What changed to make this happen? Was it clinic practice, medication changes, the slight shift in patient load toward persons with fewer financial barriers to adherence? This could be the angle for your entire paper. With a patient population with as many challenges as yours re substance use, mental illness, and poverty, many would want to know how you worked with your patients to achieve an increase to 87% suppression.We added the viral suppression intervention under Methods. Table 4: Are there any other characteristics about the care itself or contact with PHC or the suppression initiative that you’d want to include in a model? Or do you take the retention measure generally as a proxy for contact with the initiative? Could potentially break out retention differently to be more explicit about the nature of the care, e.g., instead of not retained vs. retained, could instead do something like not retained vs. retained but no case manager / nurse contact vs. retained and had a session with case manager / nurse.Added the clinic-wide suppression intervention to the methods section and discussed the impact on increasing the viral suppression rate. DiscussionLines 207-208 : Are these statistics comparable? Seems like the 71% nationally may be among all PLWH, whereas PHC patients are inherently connected with a provider and were in care during at least one point in the last five years.Deleted this commentLines 211-220: Given your attention to findings about suppression among persons not meeting the HAB criteria for retention in care , why not also look at this, potentially with a single-visit measure of retention? As it is, this first paragraph feels a bit like it goes off on a tangent here. Maybe you could explore suppression among persons not retained, at this length, in later paragraphs and, in the first paragraph, highlight several of your most important findings, such as that you’re hitting 90-90-90 targets for retention and suppression, your five-year retention rates aren’t extraordinary, and you experienced substantial increases in suppression in the last five years.Done in the discussion section Lines 227-236: Great job with your viral suppression initiative! Seems like a huge success. Why did you hold this key information until the Discussion, and bury it in the third paragraph? And have you published anything else about it that you can cite, too? Again, this is a big part of your story. Let the reader know in the abstract and the intro, methods, and discussion sections. This was moved to the Methods sectionViral Suppression Intervention. A clinic-wide viral suppression effort was implemented in 2014, involving all staff and targeting PLWH with viral loads of at least 200 copies/ml. Three teams were established, each composed of a clinician (either a nurse practitioner or doctor), a case manager, nurse, and operational staff. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2017. Every two months, each team was provided with an updated list of patients with a virologic failure. A nurse practitioner reviewed genotype results and the electronic medical record to ensure that patients were on appropriate ART. Case managers and nurses assessed barriers to adherence and medical care and implemented appropriate interventions. Line 236: I see that this was a data-driven initiative with multiple partners, which is terrific. Readers will also want to know what those “appropriate interventions” were and ideally a few measures of those interventions. For example, did referrals to drug treatment / mental health services / housing services / adherence counseling / peer support increase from 2013 (pre-initiative) to 2017, and can you enumerate that change?This would be difficult to enumerate as there were no data collected. Added the following to the Methods sectionPatients with adherence issues came in weekly for prefilled medication boxes and were transitioned to prefilled pharmacy packages when they became suppressed. The registration staff were key in scheduling and doing phone reminders for appointments. Referrals for substance use and mental health were done for on and off-site locations. Patients with unstable housing were referred to the New Jersey Housing Collaborative for assistance.  What else was done? Did other PHC characteristics change? I see that the patient load decreased from >1,200 to 1,000. Did funding or staffing change? Did the ratio of case managers to patients increase? All of this is your story. If you don’t tell it fully in this paper, I hope you’ll at least give us a little more info here, and write it up completely elsewhere, because it seems exciting.None of this happened. I think just the constant follow up by the staff made it happen. No measurable changes or significant funding increases occurred. By virtue of fluctuating number of patients there may have been subtle, transient, changes in case managers workloads, however no data was collected in this regard. I believe the consistency and diligence of follow up by the staff contributed significantly.Line 280 : Certainly. Did patients and/or your CAB also inform your suppression initiative? Do you want to acknowledge that in some way here or earlier?The CAB was not involved in developing the viral suppression initiative.I added acknowledgements to both patients and staff in PHC Figure 4: Beautiful and encouraging. I’m not clear on how you’re able to calculate five-year suppression for 2014 persons – would’ve thought just 2013. Same for four-year suppression for 2015 persons, etc.Used data up to December 2019 – added to Methods section 16 Oct 2020PONE-D-20-02167R1Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017PLOS ONEDear Dr. Mohammed,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.==============================Thank you for your substantial revisions to the paper. This looks much better. The descriptions of the clinic, its epidemiology vs the US HIV epidemic, and its initiative for unsuppressed PLWH are more thorough. I have a few additional suggestions, with line numbers from the manuscript version with changes tracked.Line 180-181, "From 2009-2016, durable viral suppression was 37% in New York City, for the two and three-year period": Please provide two percentages here if reporting suppression over two and three years.Line 216-218, "They were included in the study at the time of their first medical visit or viral load to six months after the last documented viral load or medical visit": It's the first visit/VL in the calendar years you looked at, rather than the first for the patient after diagnosis or coming to the clinic, right? Would be clearer to say, for example, "... of their first medical visit or viral load in 2013-2017."Line 224 and throughout: The term "intervention" can suggest a set of actions that are limited in time or scope. Did you basically permanently restructure clinic services for all unsuppressed PLWH, with no comparison group? May want to use a term other than "intervention" or clarify that this intervention basically became the new way you're delivering services.Line 300, "...categories of the following covariates were collapsed... insurance ": Please specify which group included the many uninsured patients.Line 337, "Patients’ status included current patients 1229 (70%), 157 (9%) newly diagnosed and 373 (21%) who reengaged in medical care": Please revise so wording is less awkward, e.g., could say "By patient status, this included 1229 current patients (70%), 157 (9%) newly diagnosed patients, and 373 (21%) patients who reengaged in medical care."Line 501-503, "This increase is attributed to the implementation of a clinic-wide viral suppression effort, involving all staff starting in 2014": Without a comparison to other PLWH in your clinic, Newark/Essex County, or the US, where VS may have also increased over these years, it would be more appropriate to swap "is attributed to" for "coincides with" to avoid suggesting causality.Line 586-612, "In this study, PLWH in public housing were...": The consideration of housing and insurance is important. Please tie the literature back to your findings more. For example, how do you resolve the findings that PHC's public housing residents did worse but housing in general is known to be helpful? And the connection between insurance challenges and retention is very plausible but would be even stronger if you could provide evidence that PLWH at PHC had challenges reenrolling in Medicaid that affected their retention in care, and if you could square that with the fact that PHC also (according to your tables) sees uninsured persons.Hopefully all of these can be addressed before publication, butrewording "intervention" is optional.==============================plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.Please submit your revised manuscript by Nov 30 2020 11:59PM. 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Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, 28 Nov 2020Dear Editor and Reviewers, Thank you for your comments. Please find the revisions outlined below Line 180-181, "From 2009-2016, durable viral suppression was 37% in New York City, for the two and three-year period": Please provide two percentages here if reporting suppression over two and three years. This sentence was clarified as follows: In a study evaluating the impact of a care coordination program, from 2009-2016, durable viral suppression was 37% in New York City, in months 13-36 of follow-up. Line 216-218, "They were included in the study at the time of their first medical visit or viral load to six months after the last documented viral load or medical visit": It's the first visit/VL in the calendar years you looked at, rather than the first for the patient after diagnosis or coming to the clinic, right? Would be clearer to say, for example, "... of their first medical visit or viral load in 2013-2017." This sentence was clarified as follows: They were included in the study at the time of their first medical visit or viral load in 2013-2017 to six months after the last documented viral load or medical visit. Line 224 and throughout: The term "intervention" can suggest a set of actions that are limited in time or scope. Did you basically permanently restructure clinic services for all unsuppressed PLWH, with no comparison group? May want to use a term other than "intervention" or clarify that this intervention basically became the new way you're delivering services. This sentence was changed as follows: Beginning in 2014, services were restructured for patients with viral loads of at least 200 copies/mL. Line 300, "...categories of the following covariates were collapsed... insurance ": Please specify which group included the many uninsured patients. The definitions were included as follows: insurance  Further: In the regression analyses, categories of the following covariates were collapsed where the outcomes were similar: age , race , insurance  and drug use, . Line 337, "Patients’ status included current patients 1229 (70%), 157 (9%) newly diagnosed and 373 (21%) who reengaged in medical care": Please revise so wording is less awkward, e.g., could say "By patient status, this included 1229 current patients (70%), 157 (9%) newly diagnosed patients, and 373 (21%) patients who reengaged in medical care." This sentence was revised as suggested. Line 501-503, "This increase is attributed to the implementation of a clinic-wide viral suppression effort, involving all staff starting in 2014": Without a comparison to other PLWH in your clinic, Newark/Essex County, or the US, where VS may have also increased over these years, it would be more appropriate to swap "is attributed to" for "coincides with" to avoid suggesting causality. This sentence was modified as follows: This increase coincides with the restructuring of clinic services for patients with a viral load at least 200 copies/ml, involving all staff starting in 2014. Line 586-612, "In this study, PLWH in public housing were...": The consideration of housing and insurance is important. Please tie the literature back to your findings more. For example, how do you resolve the findings that PHC's public housing residents did worse but housing in general is known to be helpful? This paragraph was clarified as follows: In this study, patients who lived in public compared to private housing were less likely to achieve viral suppression. They included those who were unstably housed. Among patients accessing care in Ryan White funded sites in 2018, those who lived in unstable housing had lower rates of viral suppression compared to those who lived in stable housing (72.4% versus 88.4%), respectively. [37] Previous reports indicate that public housing mitigate barriers related to viral suppression. A recent retrospective matched cohort study in New York City reported that low income PLWH who received housing services for more than one year, were more likely to be engaged in care and virally suppressed than similar populations who did not receive these services [38]. In another New York City study, PLWH in continuous, stable housing in 2015, were reported to have continuous, stable viral suppression. [38]. Conversely, time spent in emergency housing was a predictor of a lack of viral suppression. Identifying patients in unstable housing and transitioning them to a stable environment will improve viral suppression rates in this subset of patients. I also identified another limitation Fifth, in this study we evaluated public and private housing only. In future evaluations, also classifying housing as stable or unstable may improve the granularity of the results. And the connection between insurance challenges and retention is very plausible but would be even stronger if you could provide evidence that PLWH at PHC had challenges reenrolling in Medicaid that affected their retention in care, and if you could square that with the fact that PHC also (according to your tables) sees uninsured persons. Changes were made to the discussion paragraph re insurance Insurance status was another structural barrier identified in this study. New Jersey expanded Medicaid and increased access to care for low-income residents, by implementinged in accordance with many reforms recommended by the Affordable Care Act starting in 2014  [4038]. Despite the availability of public insurance, before being seen in PHC, there were many processes patients had to navigate to make this a reality., These includeding qualifying for hospital charity care if they did not have insurance [41], enrollment and reenrollment, havingand  requiring a primary care provider to issue and referrals if they had a managed care plan,  before being seen in PHC. This may have contributed to patients not being retained in medical care or achieving viral suppression. Patients who are lost to care, more symptomatic, and/or racial/ethnic minorities may be less likely to overcome these barriers [4239]. At least 70% of PLWH at PHC, qualified for federally funded services, based on an income less than the FPL, for one person, in 2017, or had either Medicaid or no insurance (Charity Care/Ryan White funding), and were primarily racial and ethnic minorities (>90%). Numerous studies have documented the importance of Ryan White federal funding in maintaining PLWH in care and improved outcomes . Urban clinics will need to maximize the use of this resource to ensure that patients overcome structural barriers and achieve the goals of the NHAS. 9 Dec 2020Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017PONE-D-20-02167R2Dear Dr. Mohammed,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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For more information, please contact Kind regards,Ellen WiewelGuest EditorPLOS ONEAdditional Editor Comments :Thank you for your revisions. Congratulations.Reviewers' comments: 14 Dec 2020PONE-D-20-02167R2 Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017 Dear Dr. Mohammed:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. 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Since adoption of this policy by Zimbabwe in 2016, the extent of implementation is unclear. Therefore we set out to determine among PLHIV ever enrolled on ART from 2004–2017 and in ART care for ≥12 months at health facilities providing ART in Zimbabwe: numbers (proportions) with VL testing uptake, VL suppression and subsequently switched to 2We used retrospective data from the electronic Patient Monitoring System (ePMS) in which PLHIV on ART are registered at 525 public and 4 private health facilities.nd-line ART. Lower age particularly adolescents (10–19 years) were more likely  to have virologic failure.Among the 392,832 PLHIV in ART care for ≥12 months, 99,721 (25.4%) had an initial VL test done and results available of whom 81,932 (82%) were virally suppressed. Among those with a VL>1000 copies/mL; 6,689 (37.2%) had a follow-up VL test and 4,086 (61%) had unsuppressed VLs of whom only 1,749 (42.8%) were switched to 2The study findings provide insights to implementation gaps including limitations in VL testing; low identification of high- risk PLHIV in care and lack of prompt utilization of test results. The use of electronic patient-level data has demonstrated its usefulness in assessing the performance of the national VL testing program. By end of 2017 implementation of VL testing was sub-optimal, and virological failure was relatively common, particularly among adolescents. Of concern is evidence of failure to act on VL test results that were received. A quality improvement initiative has been planned in response to these findings and its effect on patient management will be monitored. Over the last decade significant progress has been made in scaling up human immunodeficiency virus (HIV) treatment programs in low to middle-income countries (LMICs), with over 21 million people globally receiving antiretroviral therapy (ART) by 2017 [Viral load (VL) is a direct measure of HIV treatment response. Studies have shown that when an ART regimen is fully effective (i.e. no drug resistance) and adherence is optimized, most PLHIV become virally suppressed with undetectable VLs (<50–1000 copies/ mL) within six months of ART initiation , 3.The World Health Organization recommends VL testing for monitoring adherence to, and effectiveness of, ART among persons with HIV (PLHIV) to enable earlier detection of poor adherence and management of treatment failure. Viral suppression allows immune recovery and renders HIV- infected individuals non-infectious . VirologBy the end of 2017, Zimbabwe had a population of 13 million people and an estimated 1.3 million adults and children living with HIV of whom approximately 1.1 million patients were receiving ART . The Zimnd line ART among those with confirmed virological failure iv) and their associated demographic and clinical factors.Our specific study objectives were to determine among PLHIV initiated on ART in Zimbabwe between 01 August 2004 and 01 January 2017: i) the number (proportion) who received VL testing, and were virally suppressed ii) among those with an initial unsuppressed VL, the number (proportion) with a subsequent VL test following EAC sessions, iii) the number (proportion) switched to 2This was a retrospective cohort study design using routinely collected programme data.Zimbabwe offers HIV treatment and care services free of charge in public health facilities and selected not-for-profit private health facilities, and these are integrated with provision of general health services. There are 1,620 public health facilities offering HIV treatment and care services in Zimbabwe across 10 provinces (including Harare and Bulawayo metropolitan provinces). These health facilities are stratified into a four-tiers consisting of rural/urban primary health care (PHC) facilities at the lowest level, district hospitals and selected faith-based hospitals at the secondary referral level, 8 provincial hospitals at the third referral level and 5 central hospitals at the fourth referral level. Health services are provided by nurses at the PHCs with doctors only found from secondary referral level and above were theatre and laboratory facilities are available.Our study focused on data from 529 health facilities  providing HIV treatment and care services and using the national Electronic Patient Monitoring System (ePMS). The ePMS is an electronic-last system for capturing patient-level demographic, clinical, and laboratory information at enrolment and for follow-up review visits among PLHIV registered in HIV care. The system is in use at 529 high volume health facilities (with ≥500 PLHIV on ART by December 2012) out of 1,620 health facilities providing ART services in Zimbabwe. Despite the ePMS coming into use from 2012 onwards, historical patient-visit data were entered for patients who were alive in ART care and had been enrolled into care dating back to 2004 when ART was first offered in the public sector. To ensure that analysis was restricted to those who were eligible for VL testing, we included in our study only PLHIV enrolled into ART care between 01 August 2004 and 01 January 2017 (regardless of age) who were still alive in ART care for at least 12 months beyond 30 June 2017 at health facilities with the ePMS.Most PLHIV are HIV diagnosed at health facilities through provider-initiated or voluntary HIV testing. Alternatively, HIV testing is conducted in the community through outreach programmes and index testing. The HIV testing algorithm is based on the WHO 2015 HIV testing algorithm where an initial test is done using an Alere Determine HIV-1/2 Ag/Ab Combo rapid HIV test or Standard Q rapid HIV test followed by a confirmatory rapid HIV test using a First Response HIV 1-2-0 Card test or Chembio if the initial test is HIV-positive. If these tests are discordant they are repeated in parallel, with a final result concluded by concordant results. If still discordant, a third test (INSTI) is performed. Once diagnosed positive for HIV, a patient is retested for verification before enrolment into HIV care where they are prepared and counselled for ART .rd line ART consist of Dolutegravir (DTG) 50mg and Darunavir (600mg)/Ritonavir (100mg) twice daily. Raltegravir (400mg) twice daily could be used when DTG was not available [By end of 2018, the preferred first-line ART regimen among adolescents (10–19 years) and adults (20+ years) was a once-daily fixed-dose combination of Tenofovir (TDF) 300mg plus Lamivudine (3TC) 300mg plus Efavirenz (EFV) 400mg. The alternative first-line regimen was a combination of TDF (300mg)+3TC (300mg) and Nevirapine (NVP) 200mg. However, use of Nevirapine for HIV treatment has since been phased out. Zidovudine could be used as a substitute for Tenofovir. For those with confirmed virologic failure, the preferred second-line ART regimen consisted of Zidovudine (AZT) + 3TC + Atazanavir (ATV/r) or Lopinavir (LPV/r) if TDF was used in the first-line regimen. Alternatively, TDF could be used if AZT was used in the first-line ART regimen. Those failing second-line ART were referred for specialist assessment which included a viral load test and genotype testing prior to commencing third line ART. Medicines used as 3arunavir 00mg/RitoFig 1 shows health facilities with the ePMS versus those with VL machines onsite.In Zimbabwe, VL testing is offered free of charge at public health facilities and has been decentralized to six provinces with 18 high through-put platforms situated in laboratories at selected third- and fourth- level referral health facilities. VL samples are collected from health facilities using either Dried Blood Spot (DBS) samples for testing using Biomérieux NucliSENS and Abbott m2000 platforms or whole blood samples for testing using the Roche Taqman as well as the Abbott m2000 platforms. These samples are then transported to collection points (hubs) prior to being couriered to the laboratory. There are also 25 second-level health facilities with SAMBA Semi-Q point-of-care VL machines although they have very low testing capacity. CD4 testing still remains important for assessing patients with CD4<100 cells/mL requiring routine screening for crypotococcal meningitis using an antigen test and TB screening using the urine lipoaribomannan assay test. The CD4 test was also important for determining ART eligibility among those with CD4 cells counts below the 200-, 350- and eventually 500- thresholds overtime, prior to adoption of the “HIV treat-all” approach in mid-2016 where all HIV-diagnosed PLHIV were eligible for ART initiation, regardless of CD4 count.nd-line ART. Current pregnancy status referred to the last visit when data was collected from 30 June 2017 onwards among the women living with HIV (WLHIV) who were included in this study. This definition was chosen since women are eligible for VL testing during pregnancy in order to assess whether they are at high risk or low risk of mother-to-child transmission of HIV. Anemia was defined as having hemoglobin levels <13.5g/dL among men or <12g/dL among women.The primary source document for data variables included in this study was the individual ART care booklet which is entered in the ePMS. Data variables abstracted from the EPMS for purposes of this study include sex, date of birth, date of ART initiation, WHO clinical staging, CD4 cell count, current pregnancy status, anemia status at enrolment, dates of VL sample collection and VL test results and date of switching to 2The ePMS is an offline system with a MySQL database format  with a Microsoft Access front-end. Upon receipt of routine quarterly submissions of health facility-level data back-up files for the October-December 4 2018 period, selected variables were imported using Stata version 15  through the “OBDC data source” command into separate datasets for demographics, clinical data, laboratory tests and patient follow-up visit data. These were separate datasets which were merged into health facility-specific datasets and then appended into one large dataset.The ART number (which is a unique identifier assigned to a patient upon enrolment into life-long HIV care) was used to de-duplicate data for patients who transferred from one health facility to another with the ePMS installed and also to account for their current ART outcomes, especially for patients who were self-transfers and might have been misclassified as lost-to-follow up. However, this was not possible for a patient who might have self-transferred to another health facility and presented as a new patient and therefore assigned a new ART number. We also could not determine the true ART outcomes among self-transfers who might have relocated to other health facilities without the ePMS, given that this is available in approximately 40%  of all health facilities.Categorical variables were summarized by frequencies and proportions whilst continuous skewed variables were summarized as medians and interquartile ranges.nd-line ART following confirmed virologic failure. An unsuppressed viral load is any VL measurement that is ≥1,000 copies/ml whilst a confirmed virologic failure is defined as a VL ≥1,000 copies/ml based on two consecutive VL measurements within a 3-month interval following enhanced adherence counselling and after being on ART for at least 6 months according to WHO [The outcomes of interest were the proportion of those on ART who i) had ever had a VL test ii) had an initial unsuppressed VL iii) had a repeat VL test , iv) had confirmed virologic failure and v) had switched to 2However in this study, a confirmed virologic failure was defined as a documented follow-up unsuppressed VL received within 9 months after date of the initial VL result and after being on ART for at least 6 months. This was assuming that 3 months after the initial unsuppressed VL there would be EAC sessions whilst the 3 to 6 months after EAC was to account for date of receipt of the VL result. The censoring date for this study was therefore set at 31 December 2018 to account for those initiated on ART by 01 January 2017.Bivariate analyses using the Chi square test were done to determine associations between various demographic and clinical characteristics and ever having a VL test done and to compare proportions with VL suppression by gender between the different age groups. We also calculated unadjusted and multivariable-adjusted relative risks and their 95% confidence intervals in order to determine factors associated with having a follow-up unsuppressed VL using a generalized linear model with a log link and poisson distribution with a robust error variance. All variables with a p value<0.25 in the Chi Square test for associations with having an unsuppressed follow-up VL result were included in the multivariate adjusted regression model. Variables adjusted for were province, sex, age group, current pregnancy status, WHO clinical staging, baseline CD4 cell count, ART regimen prior to a first VL test, time to the first VL test since ART initiation and level of health care facility. All p-values less than 0.05 were statistically significant.This study was approved by the Medical Research Council of Zimbabwe  and the Joint Research Ethics Committee (JREC) for University of Zimbabwe College of Health Sciences and Parirenyatwa Group Hospitals . The ethics committee waived the requirement for informed consent by participants as VL testing is part of ministry of health routine standard of care for monitoring HIV treatment response. Data were also fully anonymized as patient names were excluded in the abstraction of data. Instead patient ART numbers (which are unique identifiers assigned to patients upon enrolment in HIV care) were abstracted and later replaced in the electronic database with a sequential number to ensure patients cannot be traced back to the facility.Fig 2 shows the cumulative number of PLHIV initiated on ART by year versus the proportion with at least one VL test done, care for at least 12 months and entered in the ePMS. There was an exponential increase in VL coverage from <1% in 2004 when the public sector ART programme started to 25.4% by 2018 as the cumulative number increased from 2,723 to 392,832 over the same periods.Overall, there were 392,832 study participants included in our study who had been initiated on ART and entered in the ePMS across 529 health facilities in Zimbabwe and had been on ART for at least 12 months. Table 1 shows variations in the proportions of active patients on ART who had ever had a VL test by province, ranging from 43% in Manicaland to only 10% in Mashonaland Central. There were no gender differences observed . Higher proportions of adolescents (10–19 years) and patients aged above 50 years (29.05% and 29.28% respectively) had had a VL test compared with other age groups. Women who were not pregnant were more likely to have accessed at least one VL test compared to pregnant women (26.2% vs 17.5%). Those initiated on ART within the primary care level (22%) were less likely to have had a VL test than those at higher level facilities. Patients who had presented at ART enrollment with advanced HIV disease or with low CD4 of <200 cells per ml were more likely to have had at least one VL test done. Patients receiving 2nd line ART were twice as likely to have had a VL test done (47.8%) compared to those on 1st line ART (24.6%).Fig 3).The proportion of PLHIV with viral suppression improved from 72.9% : 70.4–75.2) in 2013 to 83.5% (95% CI: 83.2–83.8) in 2017Fig 5 shows a flow chart portraying uptake of an initial VL, proportion with unsuppressed VLs, subsequent access to follow-up VL test, confirmed virologic failure and proportions switched to second-line ARVs among PLHIV in ART care for at least 12 months and active in care beyond 31 March 2017. Of 392,832 PLHIV, 99,902 (25.4%) had ever had a VL test done. Median time to first VL test from start of ART was 63 months  based on available data for 99,721 (99.8%) patients. Among the 99,721 active patients for whom VL data was available; 82%  were virally suppressed based on the initial VL test while the remainder 18%  had a VL of >1,000 copies/ml. Of the 17,970 with unsuppressed 1st VLs, 37.2%  had a follow-up VL test. Data on dates for both 1st and 2nd VL tests was available for 6,314 /6,689 (94.4%) patients with 1st VL test that was unsuppressed. Of these 6,314 patients, the time from the 1st unsuppressed VL test to the 2nd VL test was a median of 187 days, .nd unsuppressed VL test were switched to 2nd line ART , of whom—1,528/1,749 (87.4%) switched from 1st- to 2nd-line ART whilst 157/1749 (9%) previously on 2nd-line ART and 64/1,749 (3.7%) had their ART regimen prior to the initial ART regimen unspecified. Of the 749 with complete data, time to switch to 2nd line ART after the 2nd VL test was a median of 89 days .Following an initial unsuppressed VL test result, among those who had a follow up VL test (n = 6689), 38.9% had a suppressed VL test at follow up. Fewer than half of the patients with a 2Fig 5 and Table 2). Provinces with the highest proportions of patients with unsuppressed VL were Harare (21.1%), Mashonaland Central (21.2%) and Bulawayo (23%). Males compared to females had a higher proportion of patients with unsuppressed VL (21% vs 16.4%).A total of 17,970 active patients had an unsuppressed initial VL result  and pediatrics  being more likely to have virologic failure. Patients on second line ART were 30% less likely to have virologic failure on a repeat VL test compared to those receiving first line ART . Time taken to initial VL test was an important predictor of virologic failure in repeat testing. Patients who had been on ART for >5 years before having their first VL test were 46% more likely to have virologic failure  compared to those who had the initial VL ≤6 months post ART initiation.This is the first study to assess provision of public sector VL testing services in Zimbabwe using the ePMS system, demonstrating its ability to track patients in general and VL testing scale up overtime. The study results revealed that only a quarter (25.4%) of the active ART patients had ever had a VL test done, and among those with a first high VL, 37.2% had a repeat VL test done. As shown in population based and clinical studies; high-risk populations included adolescents and males who were least likely to have an initial suppressed VL , 12. ProThis study used secondary analysis of data collected via Zimbabwe’s ePMS deployed at most high-volume health facilities providing ART services in Zimbabwe, across all the four tiers of the health care delivery system and includes 840,971 PLHIV. Of note 75% of all ART patients in Zimbabwe are captured within ePMS .Importantly only a quarter of the active ART patients had accessed an initial VL test by end 2017 which is in contrast to higher VL testing coverage of over 75% of individuals on ART each year reported in recent years in some African countries including South Africa, Namibia, Kenya, and Uganda . Other cPossible reasons for the low VL coverage include limited VL testing capacity; inadequate and centralized VL platforms with limited Point of Care VL devices, limited transportation systems of specimens from peripheral health facilities to central laboratories, stock-outs of reagents; and few laboratory scientists to perform the tests. A survey conducted by WHO in low to middle-income countries (LMICs) in 2014 cited several reasons for slow implementation of VL testing including financial constraints, insufficient and overburdened healthcare professionals, poor training and lack of knowledge, and weak transport and laboratory systems . The natst VL test was over 5 years, because scale up of routine VL testing only started in 2016. We would anticipate that time to first VL will reduce as roll out continues. Health care worker training will be critical to ensure timely testing and that results are acted on appropriately.The median time from ART enrolment to 1As shown, management of patients with an unsuppressed initial VL test was sub-optimal. Around a third (37%) had a repeat VL test done within 9 month of the first test, despite guidelines for 100% retesting by 3 months. Wide variations in the uptake of a repeat VL test following an unsuppressed VL exists in literature. A study in Mozambique during 2014–2015 at MSF facilities showed comparable low proportions of patients with follow-up VL tests done among those with a high first VL result (35%)  with 88.nd line ART after the 2nd VL test  which contrasts other studies in rural Rwanda (median of 17 days IQR: 8–42)) [nd line ART.Of concern were delays in switching patients to 2: 8–42)) . Lengthy: 8–42)) , 21. Thend unsuppressed VL test were switched to a 2nd line ART regimen, suggesting that dissemination and training of clinicians in the revised ARV Guidelines and the management of treatment failure has not been effective. A systematic review from 16 sub-Saharan countries showed that 58% of patients with confirmed virologic failure were switched to second line ART [Fewer than half of active patients (42.8%) with a 2line ART . ClearlyThe levels of viral suppression among patients enrolled into the national ART program falls below the UNAIDS 90-90-90 fast track targets. No gender differences were observed in accessing VL testing although in other studies  more womIn 2019 Zimbabwe introduced dolutegravir, a potent integrase inhibitor as part of its first line therapy. It has a higher barrier to resistance than efavirenz and fewer side effects. It is hoped that this change in regimen will support a higher proportion of patients achieving viral suppression.Children and adolescent groups were the least likely to be virally suppressed , consistent with the ZIMPHIA survey findings and studies conducted in Uganda, Swaziland, Kenya and Mozambique , 26, 27.nd line Protease Inhibitor medicines. We also found in our study that children and adolescents were more likely to have virologic failure and this has been observed elsewhere, including people with low recent CD4 below 350 [Lastly, factors associated with virologic failure included patients receiving 1st line ART and patients with longer duration on ART. A recent study  conducteelow 350 . This isThis study has several strengths including: use of a huge data set with 75% of all ART patients in Zimbabwe assessed over 13 years of follow up; the assessment of recent (2017) VL scale up implementation and providing opportunities for quality improvement projects.Study limitations included the exclusion of health facilities that had not started using the ePMS. These are typically primary care facilities with low client volumes in rural settings. Another limitation was that we exclusively used and analyzed programme data and so were restricted to analysis of pre-determined data variables with some incomplete and inaccurate data entries. Critically we were unable to assess whether patients received EAC sessions following an initial unsuppressed VL test result or the socio-economic and educational status of patients. We were also unable to ascertain whether a VL test was conducted based on clinical need (ie ‘targeted’ testing) or as part of ‘routine’ scale up. Finally, we might have under-estimated the uptake of VL testing services where documentation of medical records is poor, as our study relied on a documented VL test result.In conclusion, proportions of PLHIV with VL suppression improved from 72.9% in 2013 to over 83.5% in 2018. The government’s policy of using VL testing as a routine practice for monitoring adherence and treatment response provided opportunities to improve patient monitoring and treatment outcomes however, due to its implementation gaps, treatment was not fully optimized. Strengthening the capacity for VL testing, the identification of high- risk patients with viral failure and prompt utilization of the test results is paramount for treatment optimization. A quality improvement (QI) intervention has been planned in Zimbabwe to respond to these suboptimal results. The ePMS has demonstrated its usefulness in assessing the performance of the national VL testing program albeit some limitations, in order to help policy- makers to address identified bottlenecks that impede progress.