Entry into the HIV treatment cascade begins with diagnosis. Current CDC guidelines recommend that healthcare professionals offer every patient between the ages of 13 and 64 an HIV test at least once, as an initiative to make HIV screening a routine rather than risk-based practice in healthcare settings [
12]. HIV testing has never been more efficient or patient-friendly, as rapid test results can be available in under half an hour [
13]; thus, integrating testing into routine health care visits is not a difficult task. Moreover, home testing is now available, providing individuals with enhanced access and control in learning their HIV serostatus. The US Preventative Services Task Force (USPSTF) has guidelines similar to the CDC’s for routine HIV testing [
14], which has important implications for insurance coverage and payment for this screening test. However, it is estimated that approximately one in eight individuals who are HIV-positive are not aware of their serostatus, leaving ample room for improvements in domestic HIV testing and diagnosis [
11]. This is not only a public health risk as it increases the probability that PLWH will unknowingly transmit HIV to others, but it is also detrimental to individual medical outcomes, as late diagnosis is associated with increased morbidity and mortality [
15]. Further, Skarbinski and colleagues estimate that 91.5% of all new HIV infections are attributable to PLWH who are either undiagnosed or who are diagnosed but not retained in care [
16]. In order to address these weaknesses in the continuum, one of the key goals set forth by the 2020 NHAS is to increase the number of PLWH who are aware of their status to 90% [
6]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently set international goals for 2020 termed the “90–90–90 target,” which aim to increase the number of PLWH who know their serostatus to 90%, and, among those who are diagnosed, to increase the percentage who are prescribed ART to 90% [
17]. Likewise, among PLWH who are both diagnosed and on ART, the 90–90–90 target aims for 90% of PLWH to achieve and maintain viral suppression [
17]. In response to the 90–90–90 target initiative, five cities shared their continuum of care data at the 21st International AIDS Conference, held in Durban, South Africa on July 18–22, 2016. [
18]. These cities included San Francisco, California; Denver, Colorado; Amsterdam, Netherlands; Paris, France, and Kyiv, Ukraine, all of which have joined the global Fast-Track Cities Initiative that seeks to fulfill UNAIDS targets in urban areas with high HIV burdens [
18]. In these fast-track cities, the percentage of PLWH who know their serostatus ranges from 51% in Kyiv to 93% in Amsterdam and San Francisco [
18]. At the country and province levels, the US falls somewhere in the middle range, above British Columbia but below Denmark and Australia [
19]. These numbers underscore the variability that exists even at the entry point of the continuum.
For low-income individuals in the US, Medicaid is their most common source of health coverage. As originally written, the ACA would have made routine HIV testing a universally-covered preventative screening measure; however, unequal Medicaid expansion has led to state-level variation in reimbursable routine HIV testing [
20]. Currently, just 34 states cover routine HIV testing, while 16 cover only “medically necessary” HIV testing, which is defined by the state [
20]. Notably, the states that do not offer reimbursable routine HIV testing are predominantly the ones with the highest HIV infection rates, and they are overwhelmingly found in the South [
6,
20,
21]. This coverage disparity may bar individuals from getting tested, and it ultimately prevents PLWH who are unaware of their serostatus from receiving treatment.