July 25, 2012
Despite all the talk about the "HIV treatment cascade" in the last year, there is still much to understand about it. "Cascade" refers to the graphic representation of how many people living with HIV/AIDS in the U.S. get tested, get linked to care, stay in care, get on antiretroviral treatment, and ultimately get to a suppressed viral load. It provides a critical picture of how close we are -- or are not -- in the U.S. to achieving the "end of AIDS" that some people, including political and government leaders, claim commitment to reaching.
In an oral poster discussion on July 23, presenters focused on various aspects of the cascade. Some addressed the terms used in the cascade, including Sarah Rowan from the University of Colorado, who presented local data from 2005 through 2009 showing that the number of people who are "out of care," as referred to in the cascade, may actually be the result of patient migration to another clinic or another state -- or include people who have died. Jonathon Mermin from the U.S. Centers for Disease Control and Prevention, who was facilitating the session, noted that there would be programs in the next two years "to better define" the populations and categories used in the cascade.
Other presenters homed in on factors associated with each point in the cascade, methods to characterize each group, and ways to improve the current (rather dismal) indicators that we are nowhere near where we need to be if the intention to end AIDS is real. Nanette Benbow of the Chicago Department of Public Health, for example, compared four U.S. cities (Chicago, Los Angeles, Philadelphia and San Francisco) with respect to four points on the cascade in 2009: "linked to care," "accessed care," "got on treatment" and "attained viral suppression." While the general flow of the cascade in each city tracked the nation, the California cities had higher percentages in each category.
Sarah Willis of George Washington University presented data on the factors associated with achieving viral suppression in people newly diagnosed with HIV/AIDS in Washington, D.C., during 2006 and 2007. She found that people who are older than 50 were two times more likely to achieve viral suppression than those who were 13 to 29 years old. Among people who achieved suppression, there were no differences in initial viral load, but people who were diagnosed with AIDS were 1.7 times more likely to achieve an undetectable viral load (measured as less than 400 copies/mL) than people diagnosed with HIV infection but not AIDS.
To the surprise of no one, Willis concluded that engagement in care is directly linked to achieving viral suppression. This was demonstrated by showing that people who had two or more viral load tests in a year were 7.4 times more likely to achieve viral suppression than those who had less than two tests per year.
The most-discussed poster of the session was presented by Chi Chi Udeagu from the New York City Department of Health and Mental Hygiene. Udeagu shared results from her program's attempts, from July 2008 to December 2010, to find people who were out of care for more than nine months and re-engage them in care and treatment. Using surveillance data and a variety of outreach methods, they were able to find 86% of people (689) identified as out of care. Of those, 414 were confirmed to be out of care, but the rest were either currently in care elsewhere (33%), had moved (4%), had died (2%) or were incarcerated (less than 1%). Ultimately, 79% of people (327) who were truly out of care accepted a new HIV medical appointment and 77% of them (252) kept the appointment.
In a shout-out to the need for expanded community treatment education, Udeagu noted that the most common reason cited by people who were out of care (41%) was that they "felt well." In the discussion period, Udeagu said that a variety of reasons for being out of care were cited, among them depression and, alarmingly, disbelief that they had HIV.
By way of emphasizing the importance of finding people who are out of care and re-engaging them, Udeagu noted that, while out of care, 48% of people had a CD4 count less than 200 cells/mL and 57% had a viral load greater than 10,000 copies/mL. A separate aspect of the intervention that offered partner services in the re-engagement effort found that a total of 65 partners were named, of which 22 had an HIV-uninfected or unknown status and three were newly diagnosed with HIV infection.
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