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Time to ART Improves for Blacks, Southerners
in US, But Still Lags for Drug Users
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CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021
Mark Mascolini
Chances of getting an antiretroviral therapy (ART) prescription within 30 days of entering HIV care improved across the United States from 2012 through 2018, notably in two groups with initially worse chances of timely ART-blacks and people living in the South [1]. But this 11,853-person CDC/NA-ACCORD analysis found a persisting risk of delayed ART among people with a history of drug dependence or abuse (DDA).
Since 2012 US antiretroviral treatment guidelines have called for starting ART as soon as possible after HIV diagnosis, regardless of CD4 count. To chart challenges and progress toward that goal, researchers from the Centers for Disease Control and Prevention (CDC) and the NA-ACCORD cohort collaboration scrutinized cohort data for the years 2012 through 2018. They aimed specifically (1) to describe trends in "timely ART," defined as having an ART prescription within 30 days of entering HIV care among antiretroviral-naive people and (2) to spot disparities in timely ART by race/ethnicity, geographic region, or DDA history.
The study population consisted of people 18 or older entering their first HIV care in a US NA-ACCORD cohort from January 2012 through December 2018 and making at least 2 clinic visits in 12 months. Using Kaplan-Meier survival analysis, the researchers calculated cumulative incidence of timely ART by (1) CD4 strata for 2012-2018, (2) race/ethnicity for 2012-2015 versus 2016-2018, and (3) geographic region for 2012-2015 versus 2016-2018. They estimated unadjusted and adjusted hazard ratios to identify associations of numerous sociodemographic and clinical variables and timely ART for 2012-2018 and for 2012-2015 versus 2016-2018.
Among the 11,853 eligible participants, 77% were younger than 50, 48% men who have sex with men (MSM), 45% black, 15% Hispanic, 51% living in the South, and 28% living in the West. Overall, 6688 people (56%) achieved timely ART. A median of 9 days passed between entering care and getting an antiretroviral prescription (interquartile range 1 to 20).
Cumulative incidence of timely ART soared from 42% in 2012 to 82% in 2018. Timely ART incidence improved significantly in every CD4 bracket assessed: 0-199, 200-349, 350-500, and 500+ (P < 0.001 for all improvements).
For the entire 2012-2018 study period, blacks had a significantly lower chance to timely ART than whites (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.83 to 0.94). But Hispanics did not differ from whites in chances of early ART. Compared with people living in the West, those in the South had about a 20% lower chance of timely ART (aHR 0.78, 95% CI 0.69 to 0.88). People with a DDA history also had about a 20% lower chance of timely ART (aHR 0.81, 95% CI 0.74 to 0.90). Compared with MSM, male injection drug users had a 15% lower chance of achieving timely ART (aHR 0.85, 95% CI 0.76 to 0.95). CD4 counts below 500 and viral loads above 10,000 copies significantly improved chances of timely ART.
When the researchers split the analysis by year of entering HIV care-8494 people in 2012-2015 and 3359 people in 2016-2018-they found that the black disadvantage to starting timely ART remained evident in 2012-2015 (aHR 0.87, 95% CI 0.81 to 0.94) but disappeared in 2016-2018 (aHR 0.92, 95% CI 0.83 to 1.02).
In 2016-2018, the South no longer lagged the West in timely ART (aHR 0.97, 95% CI 0.75 to 1.26). But now the Northeast outpaced the West in timely ART in an association verging on significance (aHR 1.37, 95% CI 0.99 to 1.90).
In the 2016-2018 analysis, people with a DDA history still significantly trailed those without such a history in achieving timely ART (aHR 0.72, 95% CI 0.61 to 0.85). But in 2016-2018 male injection drug users no longer lagged MSM in chances of timely ART (aHR 0.93, 95% CI 0.78 to 1.11).
Interpreting the findings with blacks, people with drug dependence or abuse (DDA), and male injection drug users is tricky because this kind of analysis says nothing about whether delayed ART reflects a provider’s clinical decision (or bias) or the patient’s choice. Whatever the reasons, it is encouraging that chances of timely ART improved during the study period for blacks and male drug injectors so that they no longer lagged comparison groups in 2016-2018. But people with a DDA history still suffered a disadvantage in starting antiretroviral quickly in 2016-2018, regardless of whether that delay was self-induced or determined by their provider. The researchers suggested that additional support services (or maybe more focused or effective services) could remedy this persisting challenge with the DDA group.
References
1. Li J, Humes E, Hanna DB, et al. Disparities in timely receipt of ART prescription in HIV care in the US, 2012-2018. CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021. Abstract 104.
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