Review Article

Breakdowns in the HIV Care Cascade: Implications for National HIV Control Programs

Abstract

Background: The HIV care cascade is widely used to monitor national HIV responses, yet persistent losses across cascade stages continue to undermine epidemic control. Methods: We conducted a structured narrative review of peer-reviewed studies and programmatic reports published from 2010 onward, synthesizing evidence on breakdowns across the HIV care cascade using a systems-oriented analytical framework. Results: Evidence consistently identified linkage to care and long-term retention on antiretroviral therapy as the most vulnerable cascade transitions. Attrition was driven by interacting individual, health system, and structural factors, including stigma, fragmented service delivery, weak health information systems, and restrictive policy environments. Aggregate cascade indicators frequently masked subnational disparities and systemic weaknesses. Conclusion: Cascade breakdowns reflect system-level failures that directly compromise national HIV program performance. Strengthening continuity of care and integrating equity-oriented, system-resilient strategies are essential for achieving sustainable epidemic control.