The proportion of people living with HIV receiving care in the United States who accessed antiretroviral therapy (ART) and achieved viral suppression increased substantially between 2009 and 2013, according to research published in the online edition of AIDS.
There was a 6% overall increase in the proportion of people prescribed antiretrovirals, whereas the proportion of individuals with viral suppression and sustained viral suppression increased by 11% and 17%, respectively. The increases were most pronounced in young people aged 18-29 and black people.
“This analysis demonstrates consistent increases in ART prescription and viral suppression among persons in HIV clinical care in the United States, overall and in nearly every demographic sub-group examined,” comment the investigators. “However, there is still a significant gap between the percentage of patients who are prescribed ART and who have sustained viral suppression.”
In 2012, the United States Department of Health and Human Services issued updated guidelines recommending that all people with HIV should receive ART. One of the key goals of the US National HIV/AIDS Strategy (NHAS) is to increase access to care and improve outcomes for people with HIV. An undetectable viral load is a key marker for HIV outcomes as it is associated with a low risk of disease progression and transmission to sexual partners.
A team of researchers from the Centers for Disease Control and Prevention analysed data collected between 2009 and 2013 to estimate trends in ART prescription and viral suppression among people in HIV care.
Data were obtained from the Medical Monitoring Project, a nationally representative sample of HIV-positive adults receiving medical care.
The authors calculated the percentage of people prescribed ART (new and continuing prescriptions), with viral suppression (viral load below 200 copies/ml at last monitoring) and with sustained viral suppression (viral load below 200 copies/ml in all tests conducted in a twelve-month period).
Results were encouraging for all three outcomes.
In 2013, 94% of people in HIV care were receiving ART, compared to 88.7% in 2009. This 6% increase was significant (p < 0.01). Increases were seen in almost all sub-groups. A larger increase was observed for women compared to men (10% vs. 5%, respectively). Use of ART increased by 24% among people aged between 18 and 29 years, from 72% in 2009 to 89% in 2013. ART prescription increased by 8% among black people, 7% among Hispanic people and by 3% among white people. However, in 2013, white people were still significantly more likely to be receiving ART compared to black people (95% vs. 93%, p = 0.01).
Between 2009 and 2013, the proportion of people with viral suppression increased from 72% to 80%, an 11% increase (trend, p < 0.01). Increases were observed in every sub-group. The magnitude of the increase was higher among women compared to men (16% vs. 10%, respectively), but there was a disparity in outcomes according to sex. In 2013, 81% of men and 77% of women had viral suppression (p < 0.01). The proportion of younger people with viral suppression increased by a fifth. There was an 18% increase for black people, twice that observed in white people (8%) and Hispanic people (9%). However, a disparity still persisted according to race, with 86% of white people having viral suppression in 2013 compared to 75% of black people.
The investigators calculated that increased use of ART accounted for 30% of the increase in the proportion of people with viral suppression.
In 2009, 58% of people had sustained viral suppression. This had increased to 68% in 2013, a 17% increase over time (trend, p < 0.01). Individuals had a mean of 2.8 viral load tests each year.
Sustained viral suppression increased in every sub-group. A 21% increase was observed in women compared to a 16% increase in men. However in 2013 a higher proportion of men than women had sustained viral suppression (70% vs. 64%, p < 0.01). A big increase (60%) was observed in the proportion of people aged under 29 with sustained viral suppression. Despite this, just 51% of this age group had sustained viral suppression in 2013, compared to 74% of people aged 50 and over. The proportion of black people with sustained viral suppression increased by almost a quarter. This compared to a 17% increase in Hispanic people and a 14% increase in white people. Nevertheless, in 2013 white people were still significantly more likely to have sustained viral suppression compared to black people (76% vs. 61%, p < 0.01).
The authors estimated that 19% of the increase in the proportion of people with sustained viral suppression could be attributed to the increased use of ART.
“These findings illustrate progress towards NHAS goals of improving health outcomes for persons living with HIV,” write the researchers.
They believe that several factors contributed to this progress.
- Earlier initiation of ART
- Improvements in HIV therapy that facilitated better adherence, such as lower pill burden, reduced dosing frequency and safer, less toxic therapies.
- Elimination of AIDS Drug Assistance Program (ADAP) waiting lists
- Better case management and engagement in care.
“During a five-year period, viral suppression increased significantly among persons receiving HIV clinical care,” conclude the investigators. However, they were concerned at the large and continuing gap between the proportion of people prescribed ART and the percentage with sustained viral suppression. “Helping patients to sustain viral suppression may require enhanced efforts from clinical care providers and support service organizations to address the underlying social and behavioral factors that affect access to care, long-term medication adherence, and overall health.”
Bradley H et al. Increased ART prescription and HIV viral suppression among persons receiving clinical care for HIV infection. AIDS, online edition. DOI: 10.1097/QAD.0000000000001164 (2016).