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HIV Spotlight on Center on Caring for the Newly Diagnosed Patient

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Undetectable Viral Load More Likely in People Who Receive Steady HIV Care

April 2015

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About three quarters of HIV-positive people who made two or more clinic visits at least 3 months apart in 2010 had an undetectable viral load in a 339,000-person US study.1 Only about half of HIV-positive people who made fewer clinic visits had an undetectable viral load. This difference in rates of HIV control held true regardless of age, sex (male or female), race or ethnicity, or route of HIV infection.

Someone who has a positive HIV test should promptly begin care with an HIV provider, should make regular visits scheduled by the provider, and should start antiretroviral therapy. The main goal of antiretroviral therapy is to reach an undetectable viral load and to keep the viral load undetectable through steady treatment. Reaching and maintaining an undetectable viral load are the keys to regaining health and to avoiding passing HIV to sex partners.

Research by the Centers for Disease Control and Prevention (CDC) shows that many people diagnosed with HIV infection in the United States do not make regular visits to their HIV provider. A study of 338,959 HIV-positive people found that only half made at least two clinic visits at least 3 months apart in 2010.2 Of these 338,959 people with HIV, only 43% had an undetectable viral load. Among people who had at least one CD4 count or viral load test in that year, 69% had an undetectable viral load.

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To get a better understanding of how making regular HIV clinic visits affects chances of reaching an undetectable viral load, CDC researchers conducted a new analysis of findings on these 338,959 people with HIV. This new study aimed to determine the impact of keeping clinic visits on viral load in the entire study group, in men and women, and in subgroups of different ages, races and ethnic groups, and routes of HIV infection.


How the Study Worked

CDC researchers used data on HIV-positive people collected by the National HIV Surveillance System through December 2012. These data came from 18 states and Washington, DC. All 19 areas report CD4 count and viral load results to city or state health departments.

The researchers used reports of CD4 counts and viral loads to determine how many people diagnosed with HIV were in care during the study period. All these people were 13 years old or older at the end of 2009. The CDC team considered three definitions of HIV care:

  • Engaged in care meant having at least one CD4 count or viral load test during 2010
  • Retained in continuous care meant having at least two CD4 counts or viral load tests done at least 3 months apart during 2010
  • Retained in care according to the US Health and Human Services (HHS) definition meant having at least one CD4 count or viral load test in each 6-month period of a 24-month period, with at least 60 days between tests in two 6-month periods

The main goal of the study was to see how many people in each of these three care groups had an undetectable viral load, defined as a viral load of 200 copies or less on the most recent viral load test. The CDC investigators used standard statistical methods to analyze differences in undetectable viral load rates according to the different care definitions. They also analyzed undetectable viral load rates in various subgroups according to age, sex, race or ethnicity, and route of HIV infection (sex between men, sex between men and women, and injecting drugs).


What the Study Found

The first analysis involved 338,959 people diagnosed with HIV by the end of 2009 and alive at the end of 2010. Three quarters of this group were male and one quarter female. Nearly half of the group (45%) was black, 30% were white, 21% were Hispanic, and the rest had other racial backgrounds. Most of the group (51%) got infected during sex between men, while 24% got infected during sex between men and women and 18% got infected while injecting drugs. Another 6% were gay or bisexual men who injected drugs.

Of the 338,959 HIV-positive people, 63% had any care in 2010 (at least one CD4 count or viral load test). Of these 214,734 people in care, 20% were considered engaged in care (at least one CD4 count or viral load test in 2010) and 80% were considered retained in continuous care (at least two CD4 counts or viral load tests at least 3 months apart in 2010). Proportions of people engaged in care and retained in care did not differ by sex, race or ethnicity, or HIV infection route. Compared with the overall group, a lower proportion of people 13 to 34 years old were retained in care (76%) and higher proportion of people 55 or older were retained in care (84%).

Slightly fewer than half of people engaged in care -- 48% -- had an undetectable viral load in 2010, compared with 74% of people retained in continuous care (Figure 1). This sharp difference in proportions with an undetectable viral load held true for both males and females (Figure 1), for all five age groups considered (Figure 2), for all racial and ethnic groups (Figure 3), and for each HIV risk group (Figure 4).

In both the engaged in care group and the retained in continuous care group, proportions with an undetectable viral load climbed steadily from the youngest age group through the oldest group (Figure 2). But even the best viral load results in the engaged group (53.5% and 58.0% in the two oldest groups) did not measure up to the worst viral load results in the retained group (53.4% and 65.4% in the two youngest groups) (Figure 2).

In both the engaged group and the retained group, (1) males had better viral load results than females (Figure 1), (2) whites had better results than Hispanics and Hispanics had better results than blacks (Figure 3), and (3) gay/bisexual men had better results than other HIV risk groups (Figure 4).

The CDC investigators also assessed 173,870 people who (1) were diagnosed with HIV by the end of 2008, (2) made a clinic visit in the first half of 2009, and (3) were alive at the end of 2010. The aim was to see how many met the US Department of Health and Human Services (HHS) definition of retained in care (at least one CD4 count or viral load test in each 6-month period of a 24-month period, with at least 60 days between tests in two 6-month periods). Of those 173,870 individuals, 119,510 (69%) met the retained HHS definition.


Undetectable Viral Load Rates in 214,734 US Residents With HIV

Undetectable Viral Load Rates in 214,734 US Residents With HIV

Figure 1. A US study of 214,734 people diagnosed with HIV infection found lower rates of reaching an undetectable viral load in those engaged in care (at least one CD4 count or viral load test in 2010) than in those retained in continuous care (at least two CD4 counts or viral load tests done at least 3 months apart during 2010).


Undetectable Viral Load Rates in 214,734 US Residents by Age

Undetectable Viral Load Rates in 214,734 US Residents by Age

Figure 2. Regardless of age, HIV-positive people in 19 US regions who had evidence of more clinic visits (retained in care) proved more likely to reach an undetectable viral load than people with evidence of fewer visits (engaged in care). In both the retained group and the engaged group, undetectable viral load rates rose steadily with age.


Undetectable Viral Load Rates in 214,734 US Residents by Race or Ethnic Origin

Undetectable Viral Load Rates in 214,734 US Residents by Race or Ethnic Origin

Figure 3. Regardless of race or ethnic origin, people with HIV in a large US group reached an undetectable viral load more often if they kept more clinic visits (retained in care) than if they kept fewer (engaged in care). Undetectable viral load rates were lower in blacks than in other groups studied. This chart does not include findings on three other groups, American Indians/Alaska Natives, Native Hawaiian/other Pacific Islander, and multiple races. In all these groups, HIV control rates were higher among those retained in care.


Undetectable Viral Load Rates in 214,734 US Residents by HIV Acquisition Risk

Undetectable Viral Load Rates in 214,734 US Residents by HIV Acquisition Risk

Figure 4. HIV-positive people who kept more clinic visits (retained in care) had higher rates of reaching an undetectable viral load than people who kept fewer visits (engaged in care). This finding held true for every route of HIV infection analyzed. IDU, injection drug user; hetero, heterosexual sex.


Among these 119,510 people retained in care, 78% had an undetectable viral load (at or below 200 copies). Women had lower undetectable viral load rates than men (74% versus 80%). Again, the oldest age group, 55 and older, had the best undetectable viral load rate (85%), followed by 80% for 45-to-54-year-olds, 76% for 35-to-44-year-olds, 72% for 25-to-34-year-olds, and 59% for 13-to-24-year-olds. Asians had higher undetectable viral load rates than whites (90% versus 86%), followed by Hispanics (79%) and blacks (72%).

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