Abstract and Introduction
Abstract
Objectives: The National HIV/AIDS Strategy emphasizes virologic suppression (VS) to reduce HIV incidence in the United States. We assessed temporal trends of and disparities in time to combination antiretroviral therapy (cART) initiation and HIV VS in a large demographically diverse cohort of HIV-infected patients.
Design: We included antiretroviral-naive HIV Outpatient Study participants from 2000 to 2013 enrolled within 6 months of their HIV diagnosis who attended ≥2 HIV care–related visits.
Methods: We evaluated time from HIV diagnosis to first use of cART, time from HIV diagnosis to VS, and time from first use of cART to VS. Kaplan–Meier time-to-event curves and Cox proportional hazards models were used to assess temporal trends and correlates of initiating cART and achieving HIV VS (<500 copies per milliliter).
Results: Among 1156 HIV Outpatient Study patients [median age, 37 years; 43.2% non-Hispanic/Latino black (NHB), 14.1% Hispanic/Latino], estimated median times from HIV diagnosis to cART initiation and from HIV diagnosis to VS both shortened by >40% during the 13.5-year study period, reaching, respectively, 2.5 and 5.4 months. In multivariable analyses, NHB patients (as compared with non-Hispanic/Latino white) and those who had injected drugs (as compared with those who did not) initiated cART in a less timely fashion. After adjusting for CD4 cell count and viral load at cART initiation, NHB patients and those aged <30 years (compared with ≥40 years) had lower rates of VS.
Conclusions: Despite improvements in HIV treatment over time, patients who were NHB, younger, or used injection drugs had less favorable outcomes.
Introduction
The National HIV/AIDS Strategy in the United States emphasizes the importance of virologic suppression (VS) to improve the health of HIV-infected individuals and to reduce population-level transmission of HIV infection. Modern combination antiretroviral therapy (cART) regimens are better tolerated and less complex than older regimens, increasing the likelihood of achieving VS. The success of HPTN 052, the HIV Prevention Trials Network randomized trial which demonstrated 96% reduction in HIV transmission with use of cART in HIV serodiscordant couples, lent support to the recommendation for universal treatment of persons with HIV infection in the United States, regardless of their CD4 cell count. Owing to improvements in the potency and tolerability of cART and changes in US guidelines to offer treatment to all patients, HIV-infected persons in the United States have been increasingly prescribed cART and achieving VS sooner after entry into HIV care. Unfortunately, disparities in the continuum of HIV care in the United States persist and access to HIV treatment and subsequent clinical responses are not equitably distributed. For example, despite the disproportionately higher diagnosis rates of HIV infection among non-Hispanic/Latino blacks (NHBs) compared with non-Hispanic/Latino whites, individuals in the former group have had less access to and uptake of cART and higher rates of virologic nonsuppression. We sought to evaluate temporal trends in cART initiation and VS in a large and demographically diverse cohort of HIV-infected patients to investigate potential risk factors and sociodemographic disparities. Understanding sociodemographic disparities is a first step toward identifying modifiable factors for interventions to improve the continuum of care for all HIV-infected persons in the United States.