Only a small minority of HIV-positive patients in the United States are
gaining the full benefit of antiretroviral therapy, a study published in the
November 29th edition of Morbidity
and Mortality Weekly Report shows.
Investigators calculated that only a half of all patients are retained
in care and that only 28% of people infected with HIV in the US have an undetectable viral load.
“More effort is needed to ensure that…patients remain in
care and to eliminate disparities between subgroups who are prescribed ART
[antiretroviral therapy] and subsequently achieve viral suppression,” comment
They warn that the goals of the 2010 US National HIV/AIDS
Strategy to increases access to care, improve outcomes and reduce health
inequalities can only be met by “achieving high levels of engagement at every
stage in the continuum of care.”
The current low proportion of patients with viral
suppression would also suggest that the use of HIV treatment as prevention will have only a
minimal impact on the continuing epidemic in the US until these issues can be addressed.
An estimated 1.2 million individuals were living with HIV in
the US at the end of 2008. With appropriate treatment and care the prognosis of
HIV-infected patients can be excellent. Moreover, therapy that suppresses viral
load to below the limit of detection significantly reduces the risk of onward
transmission of the virus.
To take advantages of the benefits offered by modern HIV
medicine it is essential that infected patients are diagnosed, linked and
retained in care, prescribed antiretroviral therapy when appropriate, and that
this treatment achieves virological suppression.
Using recent surveillance data, the investigators calculated
the proportion of patients in the US receiving services at various points in
this care continuum.
They calculated that a fifth of HIV infections in the
country were undiagnosed. An analysis of published studies suggested that 77%
of diagnosed patients were initially linked with care. However, retention rates
were poor and only 51% of individuals continued to regularly access care.
Use of antiretroviral therapy among the patients remaining
in care was high, with 89% of individuals taking this treatment. Moreover, 77%
of these patients achieved an suppression of the virus (defined as a viral load
below 200 copies/ml).
Overall, the high rate of undiagnosed infections and the
large proportion of patients dropping out of care meant that only 28% of all
HIV-positive patients in the US had an undetectable viral load.
Racial disparities were apparent in the use of HIV therapy
and in treatment outcomes.
Of the 92% of whites who were treated with anti-HIV drugs,
84% achieved virological suppression. Use of treatment was less prevalent among
Hispanic patients (89%), and the proportion with suppression of the virus was
somewhat poorer than those seen in whites (79%). Lower still were rates of treatment
utilisation in black patients (86%) and only 70% of these patients experienced
a fall in their viral load to below 200 copies/ml.
The study also suggested that HIV prevention efforts needed
to be intensified. Only 45% of patients in care had received HIV prevention
counselling. There were disparities according to age, with 73% of patients aged
18 to 24 receiving such counselling, compared to 36% of those aged over 55.
Over half of black (54%) and Hispanic (52%) of patients were provided with
prevention counselling compared to only 29% of whites. The proportion of
patients receiving counselling also differed by HIV risk group, and was higher
for gay men and other men who have sex with men (MSM) compared to men reporting
sex with a woman (50% vs. 39%).
“These low percentages, especially among MSM, who account
for most new HIV infections in the United States, indicate a need for
health-care providers to deliver HIV prevention more consistently,” suggest the
“Only an estimated 28% of all HIV-infected persons in the
United States are virally suppressed, largely because even among those with
diagnosed infections, only 51% are receiving regular HIV care,” emphasise the
They warn: “Without substantial improvement in these
percentages, 1.2 million new HIV infections would be expected to occur over the
next 20 years.” This could result in $450 billion in health-related
expenditure. “Only with success at each step of the continuum of HIV care…can
the ultimate goals of improving health, extending lives, and preventing further
HIV transmission be achieved.”