Only 45% of
HIV-positive patients in the US are receiving regular medical monitoring,
research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes suggests.
The study also showed
that a third of patients were not being linked with specialist HIV care within
the first year of their diagnosis with the infection.
Individuals of black
or Hispanic race were less likely to be retained in care than white patients.
Especially low engagement in ongoing care was observed in injecting drug users.
“We found a large
proportion of people with HIV are not in continuous care and such care is lower
among black/African-Americans and specific risk groups,” comment the authors.
“Implementation of effective linkage and care retention initiatives is needed
to raise the percentage of PLWH [people living with HIV] in continuous HIV
With the right
treatment and care, the prognosis of many HIV-positive patients is now
recommend that all patients with HIV should have regular clinic appointments involving
measurement of CD4 cell count and viral load. The interval between these visits
varies between patients. Appointments every three to four months are
recommended for patients with a detectable viral load. Individuals taking HIV
therapy with viral suppression (defined as below 400 copies/ml for the purpose
of this study) should be monitored at intervals of no more than six months.
Therefore, patients should have follow-up appointments at their clinic on at
least two occasions in any twelve-month period.
suggests that only 54% of HIV-positive patients in the US engage with regular
Investigators from the
Centers for Disease Control and Prevention wished to establish a more accurate
understanding of this important factor in patient outcomes.
They therefore studied
data collected from 13 US states and territories from 2008 and 2009. The
investigators defined engagement in care as two or more CD4 or viral load
measurements at least three months apart in a twelve-month period. Data were
further examined to see if retention in care differed according to demographic
characteristics of HIV risk group.
A total of 100,375
individuals were included in the study. Only 45% had two or more care visits at
least three months apart. Moreover, 41% of patients had no follow-up tests at
The proportion of
patients retained in care differed by race. Whereas 50% of white patients
received the minimum recommended standard of care, this fell to 41% for black
patients and 40% for Hispanic patients.
Levels of care also
differed according to HIV risk group. Heterosexual women (50%) were the group
most likely to receive regular follow-up, followed by gay and other men who
have sex with men (48%), heterosexual men (45%), and female and male injecting
drug users (43 and 37% respectively).
Analysis of the
patients retained in care showed that 89% had at least one viral load test per
year. Results of these tests indicated that 77% of these individuals had a
viral load below 400 copies/ml. However, only 53% of patients with regular
follow-up sustained viral suppression over a two-year period.
Among the patients
with a CD4 cell result, 63% had a count above 350 cells/mm3, but
only 40% sustained a CD4 cell count above this level for two years.
Worryingly, 40% of patients
with an AIDS diagnosis did not have any follow-up visits.
The investigators also
established that a large proportion of patients newly diagnosed with HIV were
not being successfully linked to care. Only 64% of patients who were diagnosed
with the infection in 2008 had at least two follow-up appointments at intervals
of three months. Once again, there were significant differences according to
race, and the proportion was higher for white patients compared to those of
Hispanic or black race (75 vs 69 vs 54%, p < 0.05).
A number of possible
reasons for the poor rates of retention and engagement in care are provided by the investigators. These include a high prevalence of mental
health problems in HIV-positive patients, as well as “stigma and some social
determinants of health such as lack of health insurance, lower education,
poverty, unemployment, homelessness and lack of transport”.
suppressive HIV therapy significantly reduces the risk of onward transmission
of the virus. But the investigators believe their findings have potentially
serious implications for 'treatment-as-prevention' strategies.
“The potential impact
of treatment and viral load suppression on local HIV transmission is not fully
realized with more than 40% of persons not in care, and presumably unsuppressed
viremia. In addition, an estimated 20% of persons with HIV have not been
diagnosed…accounting for high transmission potential due to their presumed
unsuppressed viremia and higher risk behaviour compared to those aware of their