Viral Loads Becoming Undetectable in More People Across the United States

Among HIV-positive people in care in the United States, proportions (1) prescribed antiretroviral therapy by their provider and (2) reaching an undetectable viral load rose steadily from 2009 through 2013.¹ Young adults had the biggest gains in proportion with an undetectable viral load, but at the end of the study period, the youngest group still lagged older groups in percent with an undetectable viral load.

Antiretroviral therapy improves the health of people with HIV by making the viral load undetectable in blood and by raising the CD4 count, a measure of immune system health. In 2012 U.S. experts recommended that everyone with HIV infection start antiretroviral therapy, whatever their CD4 count.² If people with HIV and their providers follow that advice, proportions of people taking antiretroviral therapy and proportions with an undetectable viral load should go up. To find out if that’s happening, researchers from the U.S. Centers for Disease Control and Prevention (CDC) conducted this study.

How the Study Worked

CDC researchers used findings from the Medical Monitoring Project, a sample of HIV-positive adults (18 or older) representing all adults in care for HIV across the United States. This analysis focused on people who made at least one HIV office visit in 2009, 2010, 2011, 2012, and 2013. Researchers interviewed each HIV-positive participant and collected additional findings from their medical records.

The CDC team aimed to learn three things about each person studied: (1) whether they were prescribed antiretroviral therapy, (2) whether they had a viral load below 200 copies/mL on their last viral load test, and (3) whether they had a viral load below 200 copies/mL on all viral load tests over the past 12 months. The researchers also figured these rates by sex (male or female), age group (18-29, 30-39, 40-49, 50 or older), race/ethnicity (black, Hispanic, white, other), and sexual orientation (men who have sex with men, men who have sex with women, women who have sex with men). The researchers used standard statistical methods to estimate trends for each of these three outcomes.

What the Study Found

The study involved more than 4000 people with HIV infection in each study year. The percentage of people prescribed antiretroviral therapy rose steadily over the study period, from 88.7% in 2009 to 94.1% in 2013 (Figure 1). The proportion of people with an undetectable viral load on their last test climbed from 71.6% in 2009 to 80.1% in 2013 (Figure 1). And the percentage of people with a viral load below 200 copies/mL on all tests over the past 12 months rose from 57.6% in 2009 to 68.0% in 2013 (Figure 1).

The percentage of people prescribed antiretroviral therapy rose more among women than men over the study period (10% versus 5%). As a result, women nearly caught up with men in proportion prescribed antiretrovirals in 2013 (93.7% and 94.3%). From 2009 through 2013, the antiretroviral therapy rate rose most (24%) in the youngest age group (18-29 years old). But in 2013 the youngest age group still lagged older age groups in percentage being prescribed antiretroviral therapy (by 3 percentage points or more). Over the study period, the antiretroviral therapy rate rose more among blacks (8%) and Hispanics (7%) than among whites (3%). But in 2013 blacks still lagged Hispanics and whites in proportion prescribed antiretrovirals (92.9% versus 95.2%).

The percentage of people with an undetectable viral load over the past 12 months rose more in women than men from 2009 through 2013 (21% versus 16%). But by 2013 a lower percentage of women than men met this 12-month viral load goal (63.5% versus 69.6%). Over the study period, the youngest age group (18-29 years old) made the biggest gains in proportions with an undetectable viral load through 12 months (Figure 2). But in the final year of study, 2013, the youngest age group had not caught up with older age groups by this viral load measure (50.5% versus 73.9% in people 50 or older). Over the 2009-2013 study period, blacks made bigger gains toward this viral load goal than Hispanics or whites. But by 2013 the proportion with an undetectable viral load for the past 12 months was still lower in blacks (61.0%) than in Hispanics (69.9%) or whites (76.0%).

What the Results Mean for You

This large 5-year study of an HIV-positive group representing everyone in care for HIV across the United States made several encouraging findings about growing prescription of antiretroviral therapy and improving rates of undetectable viral loads. All three of the main study outcomes analyzed improved significantly from 2009 through 2013: percentage of HIV-positive people in care prescribed antiretroviral therapy, percentage with an undetectable viral load on their last test, and percentage with an undetectable viral load over the past 12 months. And all of the subgroups studied had improvement in all three measures: women and men, all age groups, all racial/ethnic groups, and all sexual orientation groups.

But in 2013, the final year analyzed in this study, certain subgroups had not caught up with others in reaching the antiretroviral use goal or viral load goals:

Lower proportions of women than men had an undetectable viral load on their last test or over the past 12 months.

Lower proportions in the youngest age group (18-29) were prescribed antiretroviral therapy or had an undetectable viral load on their last test or over the past 12 months.

Lower proportions of blacks than Hispanics or whites were prescribed antiretroviral therapy or had an undetectable viral load on their last test or over the past 12 months.

These between-group differences indicate that HIV clinicians have to work harder to get all their patients onto antiretroviral therapy and to take their antiretrovirals steadily so they reach and maintain an undetectable viral load. At the same time, everyone with HIV should work with their providers to select and start a suitable antiretroviral combination. And once treatment begins, people must take their antiretroviral pills regularly, exactly as their prescriber instructs. If you have difficulty taking your pills on time, talk to your provider about ways to improve your pill taking. If you think your antiretrovirals are causing side effects, your prescriber may help you resolve those problems or may want to prescribe a different antiretroviral combination. People with HIV should keep all scheduled medical visits so their provider can stay up to date on their progress or problems.

The study also produced evidence that increasing antiretroviral prescription over the 2009-2013 study period accounts for some of the improvement in undetectable viral load rates. HIV experts in the United States and around the world now recommend antiretroviral therapy for HIV-positive people at any CD4 count because of its many benefits in preventing AIDS diseases and non-AIDS diseases.² Findings of this CDC study support that advice. The CDC team also suggested that improving viral load results over the years can be partly explained by better pill taking by people with HIV. And better pill taking probably resulted from development of easy-to-take once-daily antiretroviral combinations with fewer side effects.

References

1. Bradley H, Mattson CL, Beer L, Huang P, Shouse RL, Medical Monitoring Project.. Increased antiretroviral therapy prescription and HIV viral suppression among persons receiving clinical care for HIV infection. AIDS. 2016;30:2117-2124.

2. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. July 2016.