Engagement with health care leads to more prompt HIV diagnosis and higher rates of virological suppression among gay men

Implications for 'test and treat'

Michael Carter
Published: 16 May 2013

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 Fenway Health.

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 patients.

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 HIV.”

Reference

Axelrad JE et al. Trends in the spectrum of engagement in HIV care and subsequent clinical outcomes among men who have sex with men (MSM) at a Boston community health center. AIDS Patient Care and STDs, 27: 287-96, 2013 (DOI: 10.1089/apc.2012.0471).