January 24, 2014
Advances in treatment have led to dramatic improvements in the health of persons infected with human immunodeficiency virus (HIV). Moreover, treatment can reduce HIV transmission because suppressed levels of circulating virus makes HIV-infected persons less infectious.1 Until recently, antiretroviral therapy (ART) was recommended only for HIV patients with advanced disease (stages 2 and 3), and was optional for patients with early disease (stage 1). In March 2012, national HIV treatment guidelines were changed to recommend ART at all disease stages.1 To establish a baseline for care and treatment outcomes among persons with HIV, the Georgia Department of Public Health (DPH) examined whether viral suppression among HIV patients in Georgia varied by disease stage at diagnosis before implementation of the new guidelines. Disease stage at diagnosis was assessed as an indicator of viral suppression several months after diagnosis, adjusting for age, sex, and race/ethnicity among patients who were reported to DPH with HIV infections newly diagnosed during 2010 and retained in care. This report describes the results of that analysis, which indicated that disease stage at diagnosis was a significant indicator of viral suppression; viral suppression was significantly less frequent among persons with earlier disease stage at diagnosis. Compared with viral suppression among 80.5% of persons with stage 3 HIV disease, only 72.3% with stage 2 disease (prevalence ratio [PR] = 0.9; 95% confidence interval [CI] = 0.8-1.0) and 64.5% with stage 1 disease (PR = 0.8; CI = 0.7-0.9) met criteria for viral suppression, likely resulting from lack of initiating treatment or inadequate adherence to treatment regimens, as suggested in previous studies.1,2 These data can serve as a baseline to determine the impact of the guideline change in the future, and can be used to emphasize the importance of implementing the guidelines by expanding treatment to persons at all disease stages to reach the goal of viral suppression for all persons with HIV, thus closing the gap in viral suppression among persons diagnosed at disease stages 1 and 2. Health-care providers and community-based organizations should inform patients of the recommendation for ART initiation at all disease stages.
Georgia state law* requires that health-care providers report cases of HIV infection and that laboratories report test results indicative of HIV infection (including positive Western blots, all viral loads, CD4+ counts, and viral nucleotide sequence results) to DPH. Prevalence of viral suppression was determined among Georgia patients aged ≥13 years who had HIV infection newly diagnosed during 2010 and who were retained in care by using the last viral load reported at 4-15 months after diagnosis. Patients were considered retained in care if they had at least two laboratory reports containing a CD4+ or viral load >3 months apart during the 4-15 months after diagnosis. Patients who were retained in care and died ≤15 months after diagnosis were included, and 16 patients with no record of their sex at birth were excluded from the analysis.
Viral suppression was defined as a viral load <200 copies/mL as measured using the last viral load reported at 4-15 months after diagnosis. Disease stage at diagnosis was determined by using the first recorded CD4+ count (or percentage of total lymphocytes if CD4+ count was unavailable) ≤3 months after diagnosis and was defined as stage 1 (≥500 cells/µL or ≥29%), stage 2 (200-499 cells/µL or 14%-28%), or stage 3 (<200 cells/µL or <14%). Transmission categories (i.e., male-to-male sexual contact, injection drug use, male-to-male sexual contact and injection drug use, heterosexual contact, and other/unknown) were assigned by reviewing each patient's HIV infection risk factors and using a hierarchy of risks previously described to determine the most likely route of HIV transmission.3 Missing transmission category data were estimated by using a multiple imputation method, as previously described.3 Because transmission category was not a significant effect modifier or confounder of the association between viral suppression and any other variable, it was excluded from the final model. PRs for viral suppression and 95% CIs were estimated by using log-binomial regression; sex, race/ethnicity, age at diagnosis, and disease stage at diagnosis were included in the model.
During 2010, a total of 2,921 new HIV infections were diagnosed among persons in Georgia aged ≥13 years, 1,340 (45.9%) patients were retained in care, and 958 (32.8%) met criteria for viral suppression. The analysis presented in this report examines the cross-section of the newly diagnosed population that is retained in care. Among those retained in care, the majority were black (53.7%), and 27.3% were aged 25-34 years; 22.9% were aged 35-44 years, and 21.6% were aged 45-54 years. Male-to-male sexual contact (61.7% of men) and heterosexual contact (67.9% of women) were the most commonly reported transmission categories among men and women, respectively (Table 1).
Among the 1,340 persons retained in care, 958 (71.5%) met criteria for viral suppression ≤15 months after diagnosis. Blacks (63.3%) and persons aged 13-24 years (56.5%) had the lowest prevalence of meeting criteria for viral suppression. A lower percentage of persons with stage 1 disease at diagnosis (64.5%) met criteria for viral suppression than those with stage 2 (72.3%), stage 3 (80.5%), or unknown disease stage (66.3%) at diagnosis. By transmission category, the lowest percentage of viral suppression was among men with infection attributed to male-to-male sexual contact and injection drug use (65.3%) and women with heterosexual contact (67.9%) (Table 1).
Race/ethnicity, age, and disease stage at diagnosis were statistically significant indicators of viral suppression ≤15 months after diagnosis: black persons (PR = 0.9; CI = 0.8-0.9), persons aged 13-24 years (PR = 0.8; CI = 0.7-0.9), and persons diagnosed at disease stage 1 (PR = 0.8; CI = 0.7-0.9) and stage 2 (PR = 0.9; CI = 0.8-1.0) had a lower prevalence of viral suppression, compared with white persons, persons aged ≥55 years, and persons diagnosed at disease stage 3, respectively (Table 2).
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