January 24, 2014
Efforts are ongoing on national and local levels to promote HIV testing, identify those with acute infection, link and retain persons living with HIV infection in medical care, and achieve higher rates of viral suppression. Monitoring these steps throughout HIV diagnosis and treatment, known as the HIV care continuum, can be used to assess progress toward these goals and target the groups most in need.4,5 Published national statistics† from 18 states and the District of Columbia indicate 50.9% retained in care, and 43.4% virally suppressed; however, these proportions are among persons living with HIV and are not directly comparable to the Georgia proportions, which represent only those persons with newly diagnosed HIV.
Disease stage at diagnosis has not been studied as an indicator of viral suppression. In this study, prevalence of viral suppression ≤15 months after diagnosis was significantly lower among those with stage 1 and 2 disease at diagnosis, compared with stage 3. Because 1) national HIV treatment guidelines were changed to recommend ART at all disease stages after this study's analysis period, and 2) a recent survey of clinicians at HIV treatment centers in two states, conducted before guideline changes, revealed that only 14% would initiate ART regardless of CD4+ count,6 the lower prevalence of viral suppression among patients with an earlier disease stage at diagnosis likely resulted, in part, from fewer patients starting ART during early stages of disease. At the time of the study, the guidelines recommended treatment for persons with stage 2 disease, and the results indicate that recommended treatment for these persons was not fully implemented. Adherence to medication regimens might also be better among persons with more advanced disease, compared with those with subclinical disease.1,2 Similar to other recent studies, this report also found lack of viral suppression occurring more commonly among young persons and blacks.7-9 In addition to closing these gaps, an opportunity exists for improving viral suppression among those diagnosed at an early disease stage as guidelines for wider initiation of ART are implemented.
The findings in this report are subject to at least three limitations. First, data might have been incomplete as a result of underreporting, laboratory tests performed in other jurisdictions that might not be reported to DPH, incomplete report forms, patients lost to follow-up, or patients accessing HIV treatment outside Georgia. Second, the definition of "retained in care" might exclude patients who were tested outside the specified timeframe but are retained in care and patients who might receive care without laboratory tests. Finally, it was not possible to assess ART use or adherence.
Early diagnosis of HIV infection allows for timely interventions to achieve viral suppression, which benefits patients by improving their health status and the community by reducing HIV transmission.1 However, this study found that, even among persons retained in care, earlier diagnosis correlates with lower viral suppression. Not only were persons with stage 1 disease at diagnosis less likely to have viral suppression than those at stage 3 (as would be expected because ART was not recommended for stage 1 disease in 2010), but patients with stage 2 disease were less likely to have viral suppression than those with stage 3 disease, even though ART was recommended for both stages. It is now recommended that persons diagnosed with early disease are initiated on ART; as new guidelines are implemented, the prevalence of viral suppression should increase among this population from the baseline rate found by this study. These findings can be used to emphasize the importance of implementing the guidelines by expanding treatment to persons at all disease stages to close the gap in viral suppression among persons diagnosed at disease stages 1 and 2, and of assessing the impact of the new treatment guidelines; if no improvements in viral suppression among persons with stage 1 and 2 disease are observed in 2013, additional studies could determine if prescribing practices have not changed, or if there are other reasons for the poor suppression. All state or local health departments should monitor the continuum of care for persons living with HIV in their jurisdiction to determine care and treatment needs and evaluate public health interventions and implementation of treatment guidelines. Health-care providers and community-based organizations should implement the new treatment guidelines by initiating ART at all disease stages and inform patients about the benefits of earlier initiation of, and adherence to, ART for viral suppression at all disease stages.
HIV/AIDS Epidemiology Program Core HIV surveillance staff, Georgia Department of Public Health. Georgia health-care facility staff. Staff of laboratory facilities in Georgia. Irene Hall, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Eddie Weiss, MD, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, CDC.
Laura Edison, D.V.M., EIS officer, Georgia Department of Public Health. Denise Hughes, Georgia Department of Public Health. Cherie Drenzek, D.V.M., Georgia Department of Public Health. Jane Kelly, M.D., Georgia Department of Public Health, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. (Corresponding author: Laura Edison, firstname.lastname@example.org, 404-657-6452)
What is already known on this topic?
Efforts are ongoing on national and local levels to promote testing for human immunodeficiency virus (HIV) infection, identify those with acute infection, link and retain persons living with HIV in medical care, and achieve higher rates of viral suppression. Disparities in adherence and viral suppression have been examined previously; however, disease stage at diagnosis has not been assessed as an indicator of viral suppression.
What is added by this report?
In a multivariate analysis of patients with newly diagnosed HIV infection in Georgia during 2010, disease stage at diagnosis was a statistically significant indicator of viral suppression among those retained in care, with the prevalence of viral suppression decreasing with earlier disease stage at diagnosis; fewer persons with stage 1 disease (prevalence ratio = 0.8; 95% confidence interval = 0.7-0.9) and stage 2 disease (prevalence ratio = 0.9; 95% confidence interval = 0.8-1.0) achieved viral suppression, compared with persons with stage 3 disease at diagnosis.
What are the implications for public health practice?
It is now recommended that persons diagnosed with early disease are initiated on antiretroviral therapy. As new HIV treatment guidelines are implemented, the prevalence of viral suppression should increase among this population from the baseline rate found by this study. These findings can be used to emphasize the importance of implementing and assessing the impact of the new guidelines. If no improvements in viral suppression among persons with stage 1 disease are observed in 2013, additional studies could determine if prescribing practices have not changed or if there are other reasons for the poor suppression.
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