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Observational Study
. 2018 Sep 18;169(6):376-384.
doi: 10.7326/M17-2242. Epub 2018 Aug 21.

HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study

Robin M Nance  1 , J A Chris Delaney  1 , Jane M Simoni  1 , Ira B Wilson  2 , Kenneth H Mayer  3 , Bridget M Whitney  1 , Frances M Aunon  1 , Steven A Safren  4 , Michael J Mugavero  5 , W Christopher Mathews  6 , Katerina A Christopoulos  7 , Joseph J Eron  8 , Sonia Napravnik  8 , Richard D Moore  9 , Benigno Rodriguez  10 , Bryan Lau  9 , Rob J Fredericksen  1 , Michael S Saag  5 , Mari M Kitahata  1 , Heidi M Crane  1
Affiliations
Observational Study

HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study

Robin M Nance et al. Ann Intern Med. .

Abstract

Background: Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy.

Objective: To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use.

Design: Longitudinal observational cohort study.

Setting: 8 HIV clinics across the United States.

Participants: PLWH receiving clinical care.

Measurements: To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use.

Results: Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression.

Limitation: Results are limited to PLWH receiving clinical care.

Conclusion: HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention.

Primary funding source: National Institutes of Health.

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Figures

Appendix Figure 1.
Appendix Figure 1.
Map of CNICS sites. CNICS = Centers for AIDS Research Network of Integrated Clinical Systems.
Appendix Figure 2.
Appendix Figure 2.
CNICS inclusion and exclusion criteria. Table 1 and Figures 1 and 2 include all participants with ≥1 VL measurement (n = 31 930) (middle box), whereas Table 2 is limited to those receiving ART (n = 28 520) (bottom box). ART = antiretroviral therapy; CNICS = Centers for AIDS Research Network of Integrated Clinical Systems; VL = viral load.
Appendix Figure 3.
Appendix Figure 3.
Percentage of tests showing viral suppression, with all tests included; limited to 1 random test per person per year; and limited to 1 random test per person per year, with correction for loss to follow-up with inverse probability of censoring weights based on prior viral load values and demographic characteristics.
Figure 1.
Figure 1.
Percentage of tests showing viral suppression over time among all patients.
Figure 2.
Figure 2.
Percentage of tests showing viral suppression over time among all patients, by demographic and clinical characteristics. IDU = injection drug use; MSM = men who have sex with men.
Figure 3.
Figure 3.
Percentage of tests showing viral suppression over time among patients receiving ART, by time of ART initiation. ART = antiretroviral therapy.
See this image and copyright information in PMC

Comment in

  • Ending the HIV Epidemic in the United States: Closing the Implementation Gaps.
    Marston HD, Dieffenbach CW, Fauci AS. Marston HD, et al. Ann Intern Med. 2018 Sep 18;169(6):411-412. doi: 10.7326/M18-1944. Epub 2018 Aug 21. Ann Intern Med. 2018. PMID: 30140920 No abstract available.
  • HIV Viral Suppression Trends.
    Klein P, Mandsager P, Dempsey A, Hauck H, Cheever L. Klein P, et al. Ann Intern Med. 2019 Apr 16;170(8):582. doi: 10.7326/L19-0066. Ann Intern Med. 2019. PMID: 30986839 No abstract available.
  • HIV Viral Suppression Trends.
    Simoni JM, Nance RM, Whitney BM, Saag MS, Crane HM. Simoni JM, et al. Ann Intern Med. 2019 Apr 16;170(8):582-583. doi: 10.7326/L19-0067. Ann Intern Med. 2019. PMID: 30986840 No abstract available.

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