September 6, 2012
The summer of 2012 was as eventful, HIV care-wise, as it was hot. The sweltering season saw the U.S. Food and Drug Administration's approval of antiretrovirals for use in HIV-uninfected persons to prevent acquisition of the virus, the release of a home-based rapid HIV test, the revealing of the ultra-top-secret name of the Quad (rhymes with guild), and, of course, the return of the International AIDS Conference to the U.S. These events have been covered widely and, in the case of pre-exposure prophylaxis (PrEP), to death. Below are a few other reports of potential interest to a provider of HIV care that may have been missed in the heat of these other stories.
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Baligh R. Yehia et al. JAMA 2012; 308(4):338-341. Read the abstract.
What percentage of the patients in your clinic have a viral load that is undetectable? Most of us are not sure and, even if we do know, it is not totally clear what the ideal number should be. Clinical trials of initial antiretroviral therapies yield suppression rates of 80% to 90% at a year or two, but this falls slowly with longer follow-up. However, clinical trial participants are not always representative of those being cared for in our clinics, and studies typically provide support in terms of medication and monitoring that are absent in usual care.
Researchers from the HIV Research Network, a consortium of clinical centers across the U.S., looked at their collected data to get a sense of more real world suppression rates. The records of 32,483 patients who were in care during 2001 to 2010 were examined (about 70% male, 75% non-white, 30%-40% men who have sex with men [MSM], and 30% uninsured). The proportion on antiretroviral therapy (ART) increased from 66% to 86% over the course of the decade.
Using a definition of viral suppression of plasma HIV RNA <400 copies/mL throughout the calendar year studied, rates of suppression increased from 45% in 2001 to 72% in 2010. Pretty impressive -- and this includes all patients on ART, including those on their first, second, third or beyond regimens. The bad news was that suppression rates were lower for blacks and injection drug users each year studied. In contrast, virologic success was more common in older patients (>30 years with odds of suppression increasing with age) and those with private insurance (advantage seen even when compared to those on Medicaid and Medicare).
The study is important as it uses a fairly strict definition of viral suppression across multiple clinics treating a large number of patients to provide insights into how well we are doing. While rates of treatment success have increased over time, the finding that only three quarters of the patients receiving ART were treated successfully is concerning. Uncontrolled viremia for one in four patients has ramifications for individual and, of course, public health.
The finding that blacks were less likely to achieve virologic suppression, while not a new finding, underscores thinking that more circulating virus among African Americans, especially black MSM, contributes to racial disparities in HIV prevalence and incidence. More worrisome is that the study makes plain the limits of what you and I as practitioners can do. We have great therapies and a deep understanding about how to use them, but structural factors (such as under-insurance, poverty, substance abuse and the chaos that accompanies each) create a bulwark against which our expertise and best intentions crash. How to even start to change that would take an act of Congress (literally).
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