Trends and disparities in antiretroviral therapy initiation and virologic suppression among newly treatment-eligible HIV-infected individuals in North America, 2001-2009

Abstract

Background: Since the mid-1990s, effective antiretroviral therapy (ART) regimens have improved in potency, tolerability, ease of use, and class diversity. We sought to examine trends in treatment initiation and resulting human immunodeficiency virus (HIV) virologic suppression in North America between 2001 and 2009, and demographic and geographic disparities in these outcomes.

Methods: We analyzed data on HIV-infected individuals newly clinically eligible for ART (ie, first reported CD4+ count<350 cells/µL or AIDS-defining illness, based on treatment guidelines during the study period) from 17 North American AIDS Cohort Collaboration on Research and Design cohorts. Outcomes included timely ART initiation (within 6 months of eligibility) and virologic suppression (≤500 copies/mL, within 1 year). We examined time trends and considered differences by geographic location, age, sex, transmission risk, race/ethnicity, CD4+ count, and viral load, and documented psychosocial barriers to ART initiation, including non-injection drug abuse, alcohol abuse, and mental illness.

Results: Among 10,692 HIV-infected individuals, the cumulative incidence of 6-month ART initiation increased from 51% in 2001 to 72% in 2009 (Ptrend<.001). The cumulative incidence of 1-year virologic suppression increased from 55% to 81%, and among ART initiators, from 84% to 93% (both Ptrend<.001). A greater number of psychosocial barriers were associated with decreased ART initiation, but not virologic suppression once ART was initiated. We found significant heterogeneity by state or province of residence (P<.001).

Conclusions: In the last decade, timely ART initiation and virologic suppression have greatly improved in North America concurrent with the development of better-tolerated and more potent regimens, but significant barriers to treatment uptake remain, both at the individual level and systemwide.

Figure 1.

Trends in antiretroviral therapy (ART) initiation and virologic suppression among newly treatment-eligible individuals in North America, NA-ACCORD, 2001–2009. Solid circles: ART initiation 6 months after eligibility; hollow squares: virologic suppression 1 year after eligibility; solid squares: virologic suppression 1 year after ART initiation. Error bars represent 95% confidence intervals. Estimates were adjusted for age; race/ethnicity; sex; transmission risk; documented history of non–injection drug abuse, alcohol abuse, and mental illness; CD4⁺ count and viral load at eligibility; jurisdiction of residence; type of cohort; and clinic-specific mechanisms undertaken to assist with access to ART. Unadjusted trends (not shown) were similar.

Figure 2.

Adjusted cumulative incidence of antiretroviral therapy (ART) initiation and virologic suppression, by jurisdiction, 2001–2009. A, ART initiation, through 6 months after eligibility. B, Virologic suppression, through 1 year after eligibility. C, Virologic suppression among ART initiators, through 1 year after initiation. Estimates were adjusted for age; race/ethnicity; sex; transmission risk; documented history of non–injection drug abuse, alcohol abuse, and mental illness; CD4⁺ count and viral load at eligibility; calendar year; type of cohort; and clinic-specific mechanisms undertaken to assist with access to ART. Colors used to identify geographic regions: blue = Northeast United States; green = Western United States; gray = Canada; orange = Midwest United States; red = Southern United States. Abbreviations: ART, antiretroviral therapy; VL, viral load.