Multidimensional Depressive Symptom Exposure and Incident Cognitive Decline: A Prospective Cohort Study.

Despite the Ending the HIV Epidemic (EHE) goal to have increased viral suppression among people with Human Immunodeficiency Virus (HIV-1, PWH) to 95% by 2025, national retention and viral suppression estimates remain well below this target [, ]. Moreover, traditional cross-sectional analyses, which are commonly used to report these metrics, provide a limited snapshot of the true HIV care continuum journey, failing to comprehensively quantify when and how PWH transition into and out of care over time []. Thus, the dynamic state of the care continuum is poorly understood, creating a critical barrier to strengthening retention and reengagement services. This is particularly true of EHE priority states such as Missouri, which ranks the lowest in the nation in terms of public health spending per capita []. Nuanced data regarding the care continuum in these settings are urgently needed to inform a more robust but cost-effective HIV response to end the epidemic. Multistate methods are a novel longitudinal analytic approach that are being increasingly used to reveal more detailed and dynamic care trajectories for PWH, thus providing stronger evidence to improve service delivery. This method facilitates descriptions of how individuals transition into and out of distinct clinical care states over time and identifies specific gaps in—and opportunities to improve—HIV care engagement along the care continuum [, ]. For example, multistate models can quantify the frequency, prevalence, and duration of retention, reengagement, and disengagement, including their relation to other care outcomes (eg, viral suppression) and across subpopulations (eg, age categories) [, , ]. Therefore, multistate techniques can guide resource allocation through identifying gaps in the care continuum and the subpopulations at risk during these time points. Despite the promise of multistate methods, these approaches have not been applied to explore care continuum outcomes in EHE priority states, perpetuating a significant challenge in mounting a robust data-driven response to ending the epidemic in these settings [, ]. Missouri, an EHE state with urban and rural epidemics, is home to an estimated 13 271 PWH, of whom 47% reside in St Louis [, ]. In 2022, 65.1% of PWH linked to care were virally suppressed, and 67.7% of Ryan White HIV/AIDS Program clients in the state were retained, estimates well below EHE goals [, ]. While these data, derived from cross-sectional analyses, provide a basic picture of the current state of HIV care in Missouri, they do not facilitate the necessary planning to develop effective interventions to improve outcomes. Such a response requires an understanding of the magnitude, frequency, and duration of disengagement and reengagement over time, as well as how these outcomes differ across distinct subpopulations. (1) To address these gaps in understanding care continuum outcomes in the state, (2) to strengthen local retention and reengagement services, and (3) to improve HIV care outcomes across the continuum, we conducted a multistate analysis to characterize transitions into and out of distinct HIV care states over time among PWH in St Louis, the region with the highest incidence of HIV in Missouri [, ]. Through this analysis, we depict more nuanced patient care journeys and highlight potential gaps that clinics, programs, and policies should target to improve service delivery and outcomes.