This Week in HIV Research: Closing Our Care Chasms

HIV treatment has progressively reduced HIV-related death rates by nearly 90% in U.S. urban areas over the past two decades, according to a review of data from the HIV Outpatient Study (HOPS). That finding is among a number of HOPS highlights recently documented by researchers in Open Forum Infectious Diseases.

HOPS is one of the extremely few continuously operating prospective studies in the U.S. Started in 1993, it includes full medical records, prescribing information, and behavioral surveys for a diverse range of 10,566 people living with HIV (PLWH) receiving care at privately and publicly funded clinics throughout the country. The current study explored data from 1993 through 2017, the first 25 years of HOPS’ existence.

Among the vast array of key findings presented in this study:

• In 1994, mortality among HOPS participants was 121 per 1,000 person-years; by 2017, it had dropped to 16/1,000 person-years (an 87% reduction).
• In 1993, the median CD4 count was 244 cells/mm3; by 2017, it had more than doubled to 640 cells/mm3.
• In 1993, viral suppression data was not even being recorded, and in 2000, among those who received a viral load test, just 46% had a viral load below 200 copies/mL; by 2017, that proportion had increased to 92%.

While the cohort was drawn from across the country, including four target areas for the Ending the HIV Epidemic plan, it does not cover those in rural areas and PLWH who are not in care. Since data come from routine medical visits, information on gender identity or social determinants of health is often missing.

Nonetheless, over time, the HOPS database has helped find emerging trends in HIV progression, identify drug side effects, and document many other issues, the study authors noted. The large cohort also allows for monitoring progress toward Ending the HIV Epidemic goals, they added.

Going forward, the HOPS researchers say they plan to include more non-medical data—such as employment, education, or housing status—to document the interaction between these factors and HIV treatment success (or lack thereof).

While racial and socioeconomic disparities in HIV treatment access still persist in San Francisco, California, the city’s Rapid ART Program Initiative for New Diagnoses (RAPID) has been able to shrink the gap while improving overall rates of connection to HIV care, research published in Clinical Infectious Diseases finds.

The primary goal of RAPID is to link HIV-positive people to care within five days of their diagnosis, and to initiative antiretroviral therapy during their first care visit. The current study examines data spanning from 2013, when RAPID was first piloted, through 2017.

The study showed that by 2017, 28% of people newly diagnosed with HIV in San Francisco had their first HIV care visits within five days of diagnosis and began antiretroviral therapy within a day of that visit. Before the intervention, 2% of newly diagnosed people had met these criteria.

The initiative prioritized implementation in clinics serving underserved populations, which may partly account for its initial success in some subpopulations. From 2013 to 2017, the median time from HIV diagnosis to achievement of viral suppression dropped dramatically across all demographic groups, including from 147 days to 103 days among Black people, 139 days to 79 days among Latinx people, 143 days to 69 days among white people, and 161 days to 66 days among people who are homeless.

In an accompanying commentary, Edward M. Gardner, M.D., and Kellie L. Hawkins, M.D., M.P.H., focused on the potential for RAPID to help overcome disparities. For example, while people experiencing homelessness took longer on average to achieve viral suppression than did the general population, they still did so more quickly than they had prior to RAPID. It’s too early to tell, but “maybe getting people into the continuum quickly, with rapid linkage and [antiretroviral therapy] initiation after initial HIV diagnosis, will improve outcomes in some of the hardest to engage populations over time,” they wrote.

As we noted last week in This Week in HIV Research, an analysis of a model of the U.S. epidemic over the next 10 years predicted that addressing disparities would be crucial to achieving the goals of the Ending the HIV Epidemic plan. In RAPID, the reduced-but-persistent disparities in virologic outcomes show the need for addressing social determinants in addition to medical issues, study authors concluded.

People who inject drugs (PWID) frequently experience disparities in HIV outcomes. Despite a localized HIV outbreak related to needle sharing in Cincinnati and northern Kentucky during 2017 and 2018, many opportunities for HIV testing during injection drug use-related medical visits were missed, researchers reported in Clinical Infectious Diseases.

During 51% of 169 visits in which PWID were eventually diagnosed with HIV—118 of which were to emergency departments—no HIV test was performed, the study found, even though the person had not had such a test within the last 12 months, as recommended by the U.S. Centers for Disease Control and Prevention.

Testing was found to be more likely to occur at one specific participating health care system that featured a funded program for counselors to review emergency department records and offer HIV testing, if warranted. Even absent such programs, however, electronic health records could be used to prompt clinicians to offer HIV testing if people present with certain issues, study authors suggested.

The authors also recommended the adoption of universal opt-out screening in emergency departments. Such screening would not only identify PLWH, but could trigger discussions on HIV prevention, including pre-exposure prophylaxis (PrEP). “Overall, increasing HIV testing through universal screening in emergency departments may be an effective response strategy during HIV outbreaks among PWID and can help achieve the goal of Ending the HIV Epidemic by 2030,” study authors concluded.

Identifying substance use or other behaviors that can inadvertently result in a prescribing cascade may be significantly more challenging if the patient does not trust their provider enough to disclose substance use in the first place, a case study published in AIDS illustrated.

In the current case, a PLWH took a regimen that contained cobicistat, then began to use GHB (gamma-hydroxybutyric acid) during chemsex. As the person’s GHB use rose progressively, GHB bioavailability was further increased by the cobicistat. The person also used topical betamethasone, a corticosteroid, for plaque psoriasis; that ointment interacted with both HIV and recreational drugs. He developed iatrogenic Cushing’s syndrome, which in turn worsened the psoriasis.

To counteract his growing fatigue and weakness, the person began using IV anabolic steroids—which only worsened his condition, since throughout this process, physicians remained unaware of his self-administration of GHB and corticosteroids. Hence, no counseling on these practices occurred and no alternatives, such as appropriate psoriasis treatment, were initially prescribed.

It was only after the patient was diagnosed with severe iatrogenic Cushing’s syndrome that providers became aware of the other drugs he was using. They switched his HIV treatment and prescribed other appropriate medications to begin to resolve his complications.

Study authors recommended caution when prescribing boosted HIV treatment regimens, since they may interact with recreational drugs.