US rates of retention in HIV care may be better than previously assumed

Approximately three-quarters of HIV-positive patients in a large US sample are retained in regular HIV care, according to a study published in the online edition of Clinical Infectious Diseases. The research also showed that 82% of people in care were prescribed antiretroviral therapy, with 78% of these patients achieving viral suppression.

“Our estimate of 71% retained in care is higher than the regularly used meta-analysis estimate of 59%,” comment the authors. Their findings support other research suggesting the proportion of patients retained in care in the US has been underestimated.

Effective antiretroviral treatment means that many people with HIV now have an excellent life expectancy. This treatment also reduces the risk of onward HIV transmission. However, not everyone living with HIV accesses HIV care, meaning they are unable to benefit from antiretroviral therapy.

The US Department of Health and Human Services (DHHS) has approved indicators to monitor patients’ access to care.

Investigators from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) wanted to assess adherence to three key indicators: the proportion of patients who were retained in care; the proportion accessing HIV therapy; and the proportion with virological suppression (viral load below 200 copies/ml). The investigators also wished to see if there were any demographic characteristics associated with these outcomes.

Approximately 3% of all HIV-positive patients in the US are enrolled in NA-ACCORD cohorts, and participants are representative of the wider population of people with HIV in the US.

The investigators analysed the records of 35,000 people who attended at least one follow-up appointment between January and June 2008 to assess adherence to the retention-in-care indicator. Estimates of use of antiretroviral therapy and viral suppression were based on data obtained from 38,000 patients seen in 2009.

Overall, 49% of patients were aged 50 and over, 83% were men, 45% were black and a fifth had a history of injecting drug use.

Just over 70% of patients were retained in care, and 82% were prescribed HIV treatment, with 78% achieving viral suppression.  

Rates of adherence to all three indicators were significantly lower (p < 0.001) among younger patients (40 years and under).

Outcome also differed according to sex, with women significantly less likely than men to access HIV therapy (83 vs 80%, p < 0.001) and achieve an undetectable viral load (78 vs 73%, p < 0.001).

Ethnicity was also shown to be associated with outcomes.

Black patients (81%) were significantly less likely than white (83%) and Hispanic patients (86%) to use antiretrovirals (p < 0.001), and black patients also had lower rates of viral suppression (73 vs 78% [Hispanic]) vs 82% [white]), p < 0.001).

Injecting drug users were significantly less likely than other risk groups to access HIV therapy (p < 0.001). A significantly higher proportion of gay men achieved an undetectable viral load (81%) compared to injecting drug users (74%) and heterosexual people (74%).

“The disparities found highlight: 1) the need for additional research to determine the drivers of these disparities; and 2) the need for programs tailored by age, race/ethnicity, and HIV risk to improve retention, ART use, and viral load suppression,” conclude the authors. “Our results suggest that continued efforts are needed to optimize these measure among patients who have successfully linked into HIV care.”