Pre-existing connection with primary health
care is associated with more prompt diagnosis of HIV infection and an increased
likelihood of virological suppression one year after diagnosis among gay men,
investigators from the United States report in AIDS Patient Care and STDs.
The findings of the study could have
implications for 'test and treat' strategies currently being proposed as a way
of controlling the ongoing HIV epidemic among gay and other men who have sex
with men (MSM) in the United States and other countries.
“Identifying acutely infected patients with
high levels of viremia has considerable benefits at the individual and
community level, and underscores the importance of educating care providers in
the recognition of ARS [acute retroviral syndrome],” comment the authors.
The study was conducted by investigators
from Fenway Health, Boston, a medical facility that provides care to approximately
20,000 patients, over a quarter of whom are men who have sex with men.
Investigators at Fenway were concerned that
only 50% of people with HIV are fully engaged in care. They wanted to see if
utilisation of healthcare facilities in the period before diagnosis with the
virus was associated with the early detection of infections and suppression of
viral load within the first year of follow-up.
People were defined as engaged with care
if they had a negative HIV test or physical examination in the 24 months before
their diagnosis. All other patients were defined as new presentations.
A review of medical records held between 2000
and 2010 identified 754 new HIV diagnoses among men who have sex with men. Some
291 of these infections involved people who had already received care at
There were significant demographic
differences between people who were already known at Fenway and those seen
for the first time at the point of their HIV diagnosis. People who were
previously engaged with care were more likely to be white (p < 0.001) and
have private insurance (p < 0.001) than new patients.
In terms of HIV diagnosis, existing patients
were more often diagnosed with acute infection (20 vs 8%, p < 0.001) or as
a consequence of routine screening (25 vs 11%, p < 0.001) than new
Linkage to specialist HIV care was more
rapid for previously engaged patients, a median of just four days compared to
64 days for men being seen for the first time. One year after diagnosis, 86% of
existing patients were still receiving follow-up compared to 79% of new
patients, a significant difference (p = 0.012).
Focusing on the 12% of patients with acute
retroviral syndrome, the investigators found that 63% of these individuals were
already known to Fenway Health. Individuals diagnosed with acute retroviral syndrome were
more likely to have been tested after a risky sexual encounter (AOR = 17.32;
95% CI, 1.81-165.67) or to present with symptoms (AOR = 191; 95% CI,
26.16-1406.4) than people who had routine testing.
Almost a fifth of men (19%) met the
criteria for an AIDS diagnosis at the time their HIV was detected. Prevalence
of AIDS at the time of diagnosis was similar among engaged (17%) and new
patients (21%). Routine screening for HIV was associated with a lower risk of
AIDS at diagnosis (AOR = 0.47; 95% CI, 0.23-0.98).
Turning to longer-term outcomes, the
investigators found that 47% of the 595 patients who were still engaged with
care after one year had an undetectable viral load at this point. This included
almost all (99%) the people who had initiated antiretroviral therapy.
Black race was associated with lower odds
of virological suppression, a finding “corroborating other concerning
observations of the continued prevalence of racial disparities with regard to
HIV prevalence, diagnostic timing and engagement in care”. The authors suggest
their study confirms “the need for further research in this area and culturally-tailored
programs to engage Black MSM in their care environments”.
The investigators conclude their research
“confirms the positive influence of engagement in primary care prior to
seroconversion on important HIV outcomes at diagnosis and within one year”.
They call for further studies and public health initiatives to “focus on more
accurately defining engagement and retention, especially as it pertains to
healthcare provisions for MSM, and on the development of HIV prevention methods
specific to MSM to reduce the high incidence of AIDS when first diagnosed with