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Timely ART Start Rates Climbing Steadily Across US and Canada
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XIX International AIDS Conference, July 22-27, 2012, Washington, DC
Mark Mascolini
Whereas only half of US and Canadian residents eligible for antiretroviral therapy (ART) started within 6 months of eligibility in 2001, almost three quarters started within 6 months in 2009, according to a 10,577-person analysis by the NA-ACCORD group [1]. Cumulative incidence of virologic suppression 1 year after ART eligibility jumped from 55% in 2001 to 81% in 2009.
Over the past decade, antiretroviral treatment guidelines in the United States have become more aggressive. In 2012, both the Department of Health and Human Services and IAS-USA guidelines recommended ART for everyone with HIV infection, regardless of CD4 count.
To determine how often HIV-positive people in the US and Canada start ART when eligible, and how often eligible people reach an undetectable viral load, NA-ACCORD investigators planned this study of 10,577 people in 17 cohorts. All these people became newly eligible to start ART from 2001 through 2009 because of a CD4 count below 350 (the start signal in those years) or an AIDS diagnosis. No study participants had taken ART earlier, and all had at least two CD4 counts in the study period.
NA-ACCORD researchers also evaluated 9078 people for virologic suppression 1 year after becoming eligible for ART. These cohort members had a viral load above 500 copies at ART eligibility and at least one viral load recorded within 1 year. Finally, the investigators assessed virologic suppression rates 1 year after 5328 people began ART.
To determine trends in starting ART and viral suppression, the NA-ACCORD team used Cox regression models that adjusted for age, gender, HIV transmission risk, race or ethnicity, CD4 count, viral load, cohort type, state or province of residence, and documented psychosocial behaviors, including mental illness and drug and alcohol abuse.
Adjusted cumulative incidence of ART initiation within 6 months of eligibility jumped from 52% (95% confidence interval [CI] 49 to 55) in 2001 to 73% (95% CI 70 to 75) in 2009. Adjusted cumulative incidence of virologic suppression 1 year after eligibility (in people who did or did not start ART) climbed from 55% (95% CI 51 to 58) in 2001 to 81% (95% CI 78 to 84) in 2009. Among people who did begin treatment, the virologic suppression rate rose from 83% (95% CI 79 to 87) in 2001 to 92% (95% CI 89 to 94) in 2009.
Chances that eligible people would start ART rose 5% in every study year (hazard ratio [HR] 1.05 per year, 95% CI 1.04 to 1.06). Chances of virologic suppression climbed 7% per year (HR 1.07 per year, 95% CI 1.06 to 1.09). These trends became stronger from 2006 through 2009 than in earlier years.
"In the last decade," the researchers concluded, "timely ART initiation and resulting virologic suppression have greatly improved in North America concurrent with the introduction of better regimens."
Despite these improvements in antiretroviral initiation and virologic suppression, HIV incidence (the new diagnosis rate) stayed stuck at about 50,000 per year in the United States in the last years of this analysis, 2006 through 2009 [2].
References
1. Hanna DB, Buchacz K, Gebo KA, et al. Trends in antiretroviral therapy initiation and virologic suppression among newly clinically-eligible HIV-infected individuals in North America, 2001 to 2009. XIX International AIDS Conference. July 22-27, 2012, Washington, DC. Abstract LBPE29.
2. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One. 2001;6(8):e17502. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0017502.
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