U.S. trends in antiretroviral therapy use, HIV RNA plasma viral loads, and CD4 T-lymphocyte cell counts among HIV-infected persons, 2000 to 2008

Abstract

Background: The U.S. National HIV/AIDS Strategy targets for 2015 include "increasing access to care and improving health outcomes for persons living with HIV in the United States" (PLWH-US).

Objective: To demonstrate the utility of the NA-ACCORD (North American AIDS Cohort Collaboration on Research and Design) for monitoring trends in the HIV epidemic in the United States and to present trends in HIV treatment and related health outcomes.

Design: Trends from annual cross-sectional analyses comparing patients from pooled, multicenter, prospective, clinical HIV cohort studies with PLWH-US, as reported to national surveillance systems in 40 states.

Setting: U.S. HIV outpatient clinics.

Patients: HIV-infected adults with 1 or more HIV RNA plasma viral load (HIV VL) or CD4 T-lymphocyte (CD4) cell count measured in any calendar year from 1 January 2000 to 31 December 2008.

Measurements: Annual rates of antiretroviral therapy use, HIV VL, and CD4 cell count at death.

Results: 45 529 HIV-infected persons received care in an NA-ACCORD-participating U.S. clinical cohort from 2000 to 2008. In 2008, the 26 030 NA-ACCORD participants in care and the 655 966 PLWH-US had qualitatively similar demographic characteristics. From 2000 to 2008, the proportion of participants prescribed highly active antiretroviral therapy increased by 9 percentage points to 83% (P < 0.001), whereas the proportion with suppressed HIV VL (≤2.7 log10 copies/mL) increased by 26 percentage points to 72% (P < 0.001). Median CD4 cell count at death more than tripled to 0.209 × 109 cells/L (P < 0.001).

Limitation: The usual limitations of observational data apply.

Conclusion: The NA-ACCORD is the largest cohort of HIV-infected adults in clinical care in the United States that is demographically similar to PLWH-US in 2008. From 2000 to 2008, increases were observed in the percentage of prescribed HAART, the percentage who achieved a suppressed HIV VL, and the median CD4 cell count at death.

Primary funding source: National Institutes of Health; Centers for Disease Control and Prevention; Canadian Institutes of Health Research; Canadian HIV Trials Network; and the government of British Columbia, Canada.

Figure 1

Unadjusted percentages of persons living with HIV infection in the 50 states and the District of Columbia who were alive and in care among U.S. clinical cohorts participating in NA-ACCORD (n = 23 884), by state, year-end 2008. Data from the multicenter Veteran’s Aging Cohort Study are excluded because residency information was not available for participants or for their site of clinical care. Two additional cohorts, the HIV Research Network and the HIV Outpatient Study, report residency by the location of clinical care. As of 2008, stable, confidential, name-based systems for reporting persons living with HIV infection to the CDC were used in Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. Estimated totals from these states were adjusted for reporting delays and missing risk factors. The remaining 10 states (California, Delaware, Hawaii, Maryland, Massachusetts, Montana, Oregon, Rhode Island, Vermont, and Washington) and the District of Columbia reported only unadjusted estimates for year-end 2008. NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design. * No NA-ACCORD participants eligible for this analysis were known to be living in the state.

Figure 2

Trends in prescribed ART for HIV infection among participants in U.S. clinical cohort studies in NA-ACCORD, 2000 to 2008. Proportions are noted in the horizontal bars if >1%. P values for the top and middle panels were calculated by using general linear models with generalized estimating equations for repeated measures; for values in the bottom panel, the Cochran Armitage test of trend was used. ART = antiretroviral therapy; HAART = highly active antiretroviral therapy; NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design; NNRTI = nonnucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor. Top. Antiretroviral treatment status among all participants. (P for trend < 0.001 for HAART, ART, off ART, and treatment-naive; P for trend = 0.137 for off HAART.) Middle. Prescribed HAART, by drug class. (P for trend < 0.001 for all groups.) Bottom. Prescribed therapy, by drug class, among treatment-naive participants initiating HAART. (P for trend < 0.001 for all groups.)

Figure 2

Trends in prescribed ART for HIV infection among participants in U.S. clinical cohort studies in NA-ACCORD, 2000 to 2008. Proportions are noted in the horizontal bars if >1%. P values for the top and middle panels were calculated by using general linear models with generalized estimating equations for repeated measures; for values in the bottom panel, the Cochran Armitage test of trend was used. ART = antiretroviral therapy; HAART = highly active antiretroviral therapy; NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design; NNRTI = nonnucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor. Top. Antiretroviral treatment status among all participants. (P for trend < 0.001 for HAART, ART, off ART, and treatment-naive; P for trend = 0.137 for off HAART.) Middle. Prescribed HAART, by drug class. (P for trend < 0.001 for all groups.) Bottom. Prescribed therapy, by drug class, among treatment-naive participants initiating HAART. (P for trend < 0.001 for all groups.)

Figure 2

Trends in prescribed ART for HIV infection among participants in U.S. clinical cohort studies in NA-ACCORD, 2000 to 2008. Proportions are noted in the horizontal bars if >1%. P values for the top and middle panels were calculated by using general linear models with generalized estimating equations for repeated measures; for values in the bottom panel, the Cochran Armitage test of trend was used. ART = antiretroviral therapy; HAART = highly active antiretroviral therapy; NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design; NNRTI = nonnucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor. Top. Antiretroviral treatment status among all participants. (P for trend < 0.001 for HAART, ART, off ART, and treatment-naive; P for trend = 0.137 for off HAART.) Middle. Prescribed HAART, by drug class. (P for trend < 0.001 for all groups.) Bottom. Prescribed therapy, by drug class, among treatment-naive participants initiating HAART. (P for trend < 0.001 for all groups.)

Figure 3

Trends in the proportion of participants with suppressed plasma HIV viral load (≤2.7 log₁₀ copies/mL [≤500 copies/mL]) and midyear plasma HIV VL by ART status among participants in U.S. clinical cohort studies in the NA-ACCORD from 2000 to 2008. For midyear HIV VL, we used the measurement obtained closest to 30 June. (P for trend < 0.001 for overall suppressed HIV VL, missing HIV VL, and mean HIV VL [overall and for HAART recipients]. P values for trends in median HIV VL are not reported.) ART = antiretroviral therapy; HAART = highly active antiretroviral therapy; NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design; VL = viral load.

Figure 4

Median CD4 cell count within 18 months before death among NA-ACCORD participants in U.S. clinical cohort studies from 2000 to 2008. Among the 5144 decedents, 4417 had a CD4 cell count measured at or within 18 months before death. NA-ACCORD = North American AIDS Cohort Collaboration on Research and Design.

Appendix Figure 1

Age distribution of study population, by year.

Appendix Figure 2

Mortality rates per 1000 person-years, by CD4 cell count and age group.

Appendix Figure 2

Mortality rates per 1000 person-years, by CD4 cell count and age group.

Appendix Figure 2

Mortality rates per 1000 person-years, by CD4 cell count and age group.

Appendix Figure 2

Mortality rates per 1000 person-years, by CD4 cell count and age group.

Appendix Figure 2

Mortality rates per 1000 person-years, by CD4 cell count and age group.