SEATTLE – Greater efforts are needed to get people with HIV infection into medical care, a necessary prerequisite to therapy and viral suppression, suggests a cross-sectional survey of 4,217 HIV-positive adults conducted by the Centers for Disease Control and Prevention.
Survey results, reported at the Conference on Retroviruses and Opportunistic Infections, also showed that only an estimated 36% of adults living with HIV in 2009 had at least one medical care visit between January and April of that year.
© Dr. A. Harrison; Dr. P. Feorino / CDC
A new survey shows that most adults with HIV (pictured above) do not receive regular medical care.
But within this group, measures of therapy were good: 89% had received at least one prescription for antiretroviral therapy (ART) in the past year, and 72% had achieved a suppressed HIV viral load, defined as having 200 copies/mL or less of the virus at the most recent measurement in the past year.
"Increasing the size of the in-care population is critical to increase the overall proportion of HIV-infected persons who are on ART and suppressed," said Dr. Jacek Skarbinski, an investigator in the Division of HIV/AIDS Prevention at the CDC. "We find that most HIV-infected adults in care are already on ART."
Analyses have suggested that expanding guidelines regarding when to initiate ART – from the current recommendation (presence of AIDS or a nadir CD4 cell count of 500 cells/mL or lower) to a new one covering all HIV-infected people (regardless of CD4 cell count) – would have only a small impact. Such expansion would increase the percentage of people in care who are on ART by just 3%.
In additional study findings, certain groups of people in care – young adults, blacks, and those living in poverty, among others – were significantly less likely to be prescribed ART, to achieve viral suppression, or both. Thus, "we need to address disparities in HIV care and treatment, especially by age, race, and income," Dr. Skarbinski maintained.
"The study is interesting as it highlights what can be achieved through use of basic epidemiological tools to provide estimates of the numbers receiving treatment across the country as a whole and within subgroups," Kholoud Porter, Ph.D., session comoderator and senior epidemiologist with the MRC Clinical Trials Unit in London, said in an interview. "This is important information for health care planning."
"The continuum of engagement in HIV care includes HIV diagnosis, linkage to and retention in care, prescription of ART, and viral suppression," Dr. Skarbinski said.
To obtain national estimates of these outcomes, he and colleagues analyzed data from the Medical Monitoring Project, a supplemental surveillance system that captures information on nationally representative samples of HIV-infected people in care.
In 2009, it collected data from 17 states and territories, 461 facilities within those states and territories, and 4,217 HIV-infected patients receiving care in those facilities. Patients were interviewed and their medical records were abstracted to ascertain prescription of ART and achievement of viral suppression.
The patients represented an estimated 421,186 adults in care at the population level, or just 36% of all 1.2 million people living with HIV nationally on the basis of a recent estimate (MMWR Morb. Mortal. Wkly. Rep. 2011;60:689-93). The value was higher, but still only 41%, when analyses were annualized to reflect receipt of care during the whole year and not just the first 4 months.
Patients in care were predominantly 40 years of age or older (75%), male (71%), non-Hispanic black (41%) or white (34%), and men who had sex with men (47%). The majority had more than a high school education (51%) but also lived below the poverty line (54%) and had public health insurance (62%). Half were at least 10 years out from diagnosis, and two-thirds had AIDS.
Multivariate analyses showed that individuals in care were significantly less likely to be prescribed ART if they were aged 18-29, non-Hispanic black, female, in the first 4 years after diagnosis, and did not have AIDS (regardless of nadir CD4 cell count).
Similarly, individuals in care were significantly less likely to be prescribed antiretroviral therapy if they were aged 18-49, non-Hispanic black or of "other" race/ethnicity, were living at or below the poverty level, and did not have AIDS and had a nadir CD4 cell count of greater than 500.
The study data suggested that nationally, 45,133 HIV-infected adults in care were not prescribed ART, of whom 74% were eligible under current treatment guidelines.
Dr. Skarbinski disclosed that he had no relevant conflicts of interest.