This Week in HIV Research: Damming the Cascade of Unmet Needs

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As the calendar flips from 2018 to 2019, the HIV research train keeps chugging, and we continue to mark new milestones in our understanding of HIV clinical science. This week's selections of recently published HIV-related research in peer-reviewed journals include:

  • A strong association between unmet subsistence needs -- particularly transportation -- and clinical outcomes among people with HIV who are discharged from a hospital.
  • Evidence that mental illness, substance use, or unstable housing at HIV diagnosis need not be an obstacle to successful treatment initiation.
  • A report on the potential value of statewide, facility-level HIV care continuum data in improving access to care.
  • Findings that suggest even moderate levels of stimulant use don't eliminate the benefits of antiretroviral therapy in people living with HIV.

Join us for our first review in a new year of scientific progress. To beat HIV, you have to follow the science!

Barbara Jungwirth is a freelance writer and translator based in New York. Follow Barbara on Twitter: @reliabletran.

Myles Helfand is the executive editor and general manager of TheBody and TheBodyPRO. Follow Myles on Twitter: @MylesatTheBody.

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Unmet Needs Undermine Hospital Care for People With HIV

Unmet needs are extremely common among people living with HIV (PLWH) at the time they are discharged from hospitals, but addressing them can improve clinical outcomes, a study published in the Journal of Acquired Immune Deficiency Syndromes found.

Seventy-eight percent of 417 PLWH who were hospitalized and out of care reported at least one unmet need. A lack of dental care was reported by 55%, followed by unmet financial (43%), housing (34%), and transportation (29%) needs. Participants with three or more unmet subsistence needs were significantly less likely to remain in care or improve their viral loads than those whose needs were met.

The provision of transportation assistance was significantly associated with remaining in care and improved viral loads. A similar association was observed with dental services -- likely because of greater engagement with the health care system, researchers speculated.

PLWH’s unmet needs should be assessed during hospital admission and addressed during discharge proceedings to help retain them in care and improve clinical outcomes, study authors recommended.

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Benefits of Additional Support When Starting HIV Treatment

High rates of viral suppression can be achieved even in the face of mental illness, substance use, and lack of stable housing, a pilot program published in AIDS showed.

The RAPID program in San Francisco’s Ward 86 started 216 people (96% of 225 referrals) on antiretroviral therapy within a day or two of their HIV diagnoses and provided additional multidisciplinary evaluations and support. Substance use (51%) and mental health diagnoses (48%) were common among participants, as was unstable housing (31%).

One year after intake, 96% of participants had been virally suppressed at least once during that time, and 92% had viral loads < 200 copies/mL at the last recorded viral load measurement. "Rapid [antiretroviral treatment] for vulnerable populations is acceptable, feasible, and successful with multidisciplinary care and municipal support," study authors concluded. They called for further research into longer-term retention in care, as well as people’s experiences with RAPID treatment start, among other questions.

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The Value of Facility-Level Data for the HIV Care Continuum

An adaptation of the HIV treatment cascade could encourage quality improvement initiatives at individual facilities, researchers reported in Open Forum Infectious Diseases.

New York State currently uses an adapted cascade to identify and re-engage PLWH who are not linked to care when they access other medical services, such as hospital emergency departments. During 2016, the first year the cascade was employed, the study found that 21,509 of 101,341 PLWH who received medical care at one of 222 sites in the state had an unknown HIV care status. (This number may include people whose status was captured in a way other than a dedicated database field, study authors cautioned, adding that they were also unable to remove duplicates.)

Among previously diagnosed PLWH, 94% were prescribed antiretroviral therapy and 80% were virally suppressed. For newly diagnosed PLWH, the corresponding numbers were 76% and 55%, with 52% linked to care.

"The visual display of the facility-level cascade represents a novel strategy to engage providers across inter- and intra-organizational boundaries to leverage locally generated data to achieve epidemic control," study authors wrote.

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Viral Suppression Rates Increase Despite Low-Level Stimulant Use

The odds of viral suppression significantly increased over time among PLWH who only used stimulants such as methamphetamine intermittently, but not among those who used such substances consistently, a San Francisco, California, study published in the Journal of Acquired Immune Deficiency Syndromes found.

All 1,635 participants were on antiretroviral treatment (65% at enrollment and 35% during follow-up) and were followed for a median of 2.3 years. The majority were white (57%); male (87%); and identified as being part of a sexual minority (78%). Median age was 45 years at study entry. Data were divided into pre-universal treatment era (2000-2009) and universal treatment era (2010-2016); 2010 was the year San Francisco adopted a "test and treat" policy in which immediate treatment initiation was recommended for all people newly diagnosed with HIV in the city.

Cumulative stimulant use declined over time (0.8% decrease per year in the cohort), especially during the universal treatment era. Higher levels of cumulative stimulant use were significantly predictive of fewer years spent with a suppressed viral load, but participants with a moderate level of stimulant use -- i.e., usage was reported during 50% of a participant's study visits -- still had a statistically significant greater likelihood of achieving a suppressed viral load over time. The same could not be said for participants who reported stimulant use during 100% of their study visits: Although a trend toward greater viral suppression was seen, the findings did not reach statistical significance.

Results show that antiretroviral treatment should be started in people who use stimulants while also delivering substance use interventions, study authors concluded. They called for further research among more diverse cohorts to determine the odds of viral suppression among subgroups of stimulant users.