New York City has made tremendous progress in helping people with HIV get diagnosed and on treatment sooner. From 2006 to 2015, the amount of time it took for people living with HIV to learn about their status dropped 28%, while the time between diagnosis and starting treatment dropped 60%.
These results were published in the Dec. 9 issue of Clinical Infectious Diseases.
“Over a decade, we’re seeing pretty impressive declines in the time it takes to get someone on treatment, declines in the time it takes to get someone diagnosed, and declines in the time it takes to start treatment,” said lead author McKaylee Robertson, Ph.D., of the Institute for Implementation Science in Population Health at the Graduate School of Public Health and Health Policy of the City University of New York (CUNY). The study was conducted by a team of investigators at CUNY in collaboration with the New York City Department of Health and Mental Hygiene.
“It’s very encouraging,” Robertson said, and speaks to the city’s extensive HIV outreach efforts. However, the results also indicate that there’s still room for improvement. In 2015, on average, about half of undiagnosed New Yorkers lived with HIV for more than three years before getting tested, according to seroconversion estimates.
“The results are also suggesting that we need better implementation strategies for HIV testing,” Robertson said. “We’re clearly finding some people still too late. Diagnosis and treatment delays matter because there is a lot of research to suggest that people who transmit HIV usually don’t know [their status].”
The main focus of Robertson’s research, she said, was to zero in on the amount of time it takes for New Yorkers to get an HIV diagnosis after they seroconvert. A better understanding of this critical window of time could help move the needle on the global “Treatment for All” initiative. This is also sometimes referred to as “90-90-90,” because it is an effort to get 90% of people with HIV diagnosed, 90% of those on treatment, and 90% of those virally suppressed.
“When you talk about 90-90-90, most people talk about those second and third bars,” she said. “Getting people on treatment right away is great, but you also have to get them diagnosed right away.”
The problem is that diagnosis—the first pillar of the 90-90-90 goals—is poorly understood compared to the second two (treatment and viral suppression). That’s because it’s nearly impossible to know exactly when a person was first exposed to HIV and then seroconverted. It becomes much easier to keep track of their health journey once they start engaging with the medical system, such as with their first HIV test or first antiretroviral prescription.
But Robertson wanted to know how long it takes for undiagnosed HIV-positive New Yorkers to get tested after they seroconvert. To answer that question, she and her colleagues would have to estimate the time of seroconversion.
To do this, they used the well-established HIV-1 seroconversion estimates from the CASCADE Collaboration, a large network of 28 HIV seroconversion cohort studies. They applied those estimates to the population of 28,162 people diagnosed with HIV from 2006 to 2015 in New York City.
In 2006, a typical New Yorker lived with HIV for about 4.6 years before receiving an official diagnosis. Thanks to expanded outreach efforts, by 2015, New Yorkers were being diagnosed much faster—a median of 3.3 years after seroconversion. That’s about a 28% drop in time from seroconversion to diagnosis, according to the researchers’ estimates.
Meanwhile, the time from diagnosis to ART initiation dropped 60%. In 2006, it took about six months for the typical New Yorker to start treatment after being diagnosed, but by 2015, the typical New Yorker was starting treatment within two to three months after diagnosis. Overall, that means the median time from seroconversion to ART initiation dropped 42% within a decade, from 6.4 years in 2006 to 3.7 years in 2015.
Digging into the demographic data even further, almost all groups saw improvements in the amount of time between seroconversion and treatment—but this progress was not evenly distributed.
For example, major strides were made among people who are white and among men who have sex with men. Cisgender women, meanwhile, were less likely to receive prompt treatment, with a median wait time of 4.2 years between estimated time of seroconversion and ART initiation. Similarly, people who were Black, Asian/Pacific Islander, and those who had heterosexual transmission risk were less likely to be treated quickly (median of 4.2 years, 4.6 years, and 4.9 years, respectively).
Collectively, this indicates HIV testing, treatment, and outreach aren’t reaching women of color who are likely contracting HIV from heterosexual sex partners. Robertson noted that testing outreach does appear to be relatively robust among people who inject drugs, with a 58% drop in diagnosis delay from 2006 to 2015 in this population.
“I think that this speaks to the need for targeted HIV-testing approaches, especially for women and people with heterosexual transmission risk, because it seems like we’re probably missing them,” Robertson said.
Overall, Robertson said, “the takeaway here is that New York City has been really at the forefront of these HIV initiatives, and they have a really robust infrastructure to support testing and treatment.”
Even with the progress made from 2006 to 2015, it still takes about three years for the typical New Yorker to receive an HIV diagnosis. In other parts of the country, people are living for even longer with undiagnosed HIV—a fact that doesn’t bode well for the Trump administration’s effort to end the HIV epidemic by 2030.
“The bulk of new infections are coming from people who are not aware of their status,” said Robertson. “New York City is leading in initiatives to end the epidemic. If we still have this kind of work to do, what does it mean in other places?”