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Faster Time to Viral Suppression in US South, But Suppression Rates Still Modest
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CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021
Mark Mascolini
Time to HIV suppression after starting antiretroviral therapy (ART) improved substantially from 2012-2015 to 2016-2019 in three southern US states-Alabama, Louisiana, and Mississippi [1]. But this population-based study of 16,818 people charted viral suppression rates only around 50% to 60% after 6 months of treatment in 2016-2019. Younger age, nonwhite race, and male sex independently predicted longer time to viral suppression.
Researchers from the University of Alabama and collaborators at other centers reminded colleagues that the South continues to be a focal point of the US HIV epidemic. States in the southeastern part of the country maintain the highest regional rates of new HIV diagnoses in the United States, the highest percenter of people with HIV, and the lowest viral suppression rates.
The research team argued that time to viral suppression reflects several critical variables in HIV control, including success of testing, clinical care, ART, and supportive services. To get a better understanding of patterns in time to viral suppression in the US deep South, the investigators conducted a retrospective, population-based cohort study of everyone at least 13 years old newly diagnosed with HIV from 2012 through 2019 in Alabama, Louisiana, and Mississippi. They used the Kaplan-Meier method to estimate time to viral suppression (defined as a viral load below 200 copies) by year of diagnosis in each state: 2012-2015 and 2016-2019. Cox proportional hazards models explored associations between time to viral suppression and age, race/ethnicity, sex at birth, HIV transmission mode, AIDS stage at diagnosis, and year of diagnosis.
The analysis included 4996 people in Alabama, 8199 in Louisiana, and 3623 in Mississippi. Across the three states, about 75% of participants were men, about half men who have sex with men (MSM), almost three quarters black, and about one quarter with stage 3 AIDS.
From 2012-2015 to 2016-2019, median time to viral suppression dropped dramatically from 211 to 135 days in Alabama, from 241 to 118 days in Louisiana, and from 331 to 168 days in Mississippi. In 2012-2015 only two regions in the three states-southeastern and northeastern Alabama-had a median time to viral suppression of 91 to 180 days. In 2016-2019 all of Alabama and most of Louisiana and Mississippi had a median time to viral suppression of 91 to 180 days. In 2016-2019 the most southeastern region of Louisiana reached a median time to viral suppression of 0 to 90 days.
But proportions of people reaching viral suppression within 6 months of starting ART remained low in all three states in 2016-2019: about 50% in Mississippi and about 60% in Alabama and Louisiana.
A Cox proportional hazards model adjusted for age group, sex at birth, race/ethnicity, HIV transmission method, and AIDS stage identified several independent predictors of longer time to viral suppression in 2016-2019:
Younger age: 25-44 (hazard ratio [HR] 0.917) and 13-24 (HR 0.871) vs 44+
Sex at birth: Male (HR 0.811) vs female
Race/ethnicity: Black (HR 0.819) and Hispanic (HR 0.859) vs white
Method of transmission: Heterosexual contact (HR 0.925) and injection drug use only (HR 0.638) vs MSM or MSM and injection drug use
AIDS stage: Stage 3 (HR 1.370, 95% CI 1.315 to 1.428) vs not stage 3
(Upper bound of all 95% confidence intervals for first 4 comparisons below 1.0.)
The researchers speculated that improving time to viral suppression in Alabama, Louisiana, and Mississippi may reflect adoption of universal testing and treating as well as development of better-tolerated antiretroviral regimens. In Louisiana Medicaid expansion in 2016 may have helped quicken time to suppression. The researchers plan to use geospatial analytic tools "to assess the impact and interplay of individual, structural, and community-level sociocontextual variables on time to viral suppression in these areas of the Deep South."
Reference
1. Rana A, Batey DS, Bassler J, et al. Geographic differences in time to viral suppression in the deep South, 2012-2019. CROI 2021, Conference on Retroviruses and Opportunistic Infections, March 6-10, 2021. Abstract 105.
In our analyses of variables available in the surveillance data, our findings confirm previously reported predictors of outcomes across the care continuum in the South. Namely, younger age, male sex at birth, non-white race, and non-MSM transmission were associated with longer time to VS; while presenting with advanced and likely symptomatic dz at at diagnosis, was associated shorter time to VS in both time periods.
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