This Week in HIV Research: The Human Touch
We realize this is a strange week to be publishing a “business as usual” recap of the latest and greatest in clinically relevant HIV-related science, what with a relatively significant event taking place in the U.S. and occupying a fair amount of our time, attention, and energy. But it’s also very much true that our efforts to prevent and treat HIV in this country never pause simply because much of the country is holding its collective breath. So we continue on, and push for a better tomorrow.
This week’s collection of recently published research features a heavy focus on the importance of personal connection in providing effective HIV services and improving outcomes among people living with HIV. In brief, we’ll share details of studies that:
- Show direct referrals from health care providers are way better at re-linking people to HIV care than less-personal methods.
- Testify to the link between stable housing and viral suppression.
- Note the (uncommon, but real) persistence of virologic failure risk on modern antiretroviral regimens.
- Suggest the type of pharmacy people use for their HIV drug prescriptions doesn’t appear to significantly affect their treatment outcome.
Let’s stop for a moment, allow ourselves to take that deep breath (heck, maybe even two of them), and carry on. To beat HIV, you have to follow the science!
Provider Referral Appears to be the Most Effective Method for Re-Linking PLWH to Care
Most people living with HIV (PLWH) who were re-linked to care through San Francisco’s LINCS program were referred by health care providers rather than identified through surveillance data or a combination of electronic health records and surveillance data, a program evaluation published in Open Forum Infectious Diseases found.
Overall, 233 (24%) of 954 people referred to the program were enrolled in it; 72% of enrollees had been referred by providers.
However, while the referral lists generated only from surveillance data were the least accurate or efficient, previously unsuppressed PLWH enrolled from that source achieved viral suppression at higher rates than PLWH enrolled from the other two sources. That said, people identified by surveillance data also were less likely to have been virally suppressed before enrollment, use methamphetamine, or experience homelessness compared to people identified by providers or the combination list.
Study limitations included the lack of a control group or expected outcomes against which data could be compared, as well as no mental health data.
To catch people who have recently dropped out of care or are at risk of doing so before they are fully disengaged, study authors recommended using multiple data sources and building relationships with providers. To do so successfully will require appointment reminders, follow-ups on missed appointments, and case management services, as well as differentiated care models that address different levels of need, they added.
Housing Stability = Viral Suppression
Stable housing is a direct pathway to viral suppression, a prospective study and path analysis among 471 unstably housed PLWH enrolled in the HRSA/SPNS Homeless Initiative navigation intervention showed. Results were published in PLOS One.
The intervention employed mobile, interdisciplinary teams of navigators and clinicians. Navigation activities were not directly related to achieving housing stability, likely because navigators addressed other unmet needs (e.g., mental health or substance use treatment) before tackling housing. Nonetheless, those activities were found to be related to viral suppression.
Increased self-efficacy at gaining assistance was associated with stable housing, as was more recent homelessness, less food insecurity, and being virally suppressed at baseline. Self-efficacy, along with a more recent HIV diagnosis and fewer unmet needs, was also associated with retention in care at 12 months. More intense navigation services were related to lower odds of viral suppression, possibly because more pressing needs than adherence counseling had to be addressed first.
Of note, transgender participants (n=18) were less likely to be stably housed than their cisgender counterparts.
Navigation programs should assess clients’ needs and develop a person-centered care plan, train staff in culturally sensitive care for transgender people and in promoting client self-efficacy, and enhance systems coordination, study authors recommended.
Virologic Failure Uncommon—But Not Decreasing—on Modern Antiretroviral Regimens
Virologic failure and acquired drug resistance are rare in people starting HIV treatment on contemporary drugs, but rates are no longer dropping over time, an analysis of data on 2,315 PLWH that was published in Open Forum Infectious Diseases showed.
Data came from health records in a real-world setting: antiretroviral-naive people receiving medical care through Kaiser Permanente Northern California between 2010 and 2018. During a median 36 months of follow-up, 214 participants experienced virologic failure on their first HIV regimen (at a rate of 2.8 per 100 person-years) and 62 people had acquired drug resistance (0.8 per 100 person-years).
The overall virologic failure rate was 9%; roughly a quarter of those failures were among people who never achieved suppression to begin with.
Only 48% of people with virologic failure were tested for resistance mutations, study authors cautioned. Reasons for lack of resistance testing were not known, although a substantial number of virologic failures were related to treatment discontinuation.
Lower CD4 cell count and higher viral load at baseline were associated with both virologic failure and drug resistance, while younger age was associated only with virologic failure. Other studies have shown that failure rates are also higher among people of color.
Study authors recommended that public health efforts focus on younger people of color and/or PLWH who present late to care to get flat, albeit low, virological failure rates to decrease.
Pharmacy Type Doesn’t Affect Viral Suppression
PLWH who received their medications from HIV specialty pharmacies in the U.S. were no more likely to become either virally suppressed or viremic than those who got their drugs from traditional pharmacies, a single-center, retrospective cohort study published in Open Forum Infectious Diseases found.
Data came from the electronic health records of 931 PLWH attending the University of Nebraska Medical Center’s HIV clinic in 2017 and 2018. (Of note: The state did not expand Medicaid eligibility.) While the pharmacy type had no impact on viral suppression, adherence itself–as measured by percentage of days covered by a prescription–did. Thus, the importance of adherence support should not be discounted, study authors noted. Specialty pharmacies often offer refill reminders, expedited delivery, and other services to promote treatment adherence.
The study also found that income above the federal poverty level was significantly associated with becoming virally suppressed, compared to lower income.
“Future studies measuring the overall impact of enhanced pharmacy services offered by specialized pharmacies on maintenance of viral suppression among PWH over longer time periods would be beneficial,” the study authors concluded.