The HIV Outpatient Study-25 Years of HIV Patient Care and Epidemiologic Research

Abstract

Background: The clinical epidemiology of treated HIV infection in the United States has dramatically changed in the past 25 years. Few sources of longitudinal data exist for people with HIV (PWH) spanning that period. Cohort data enable investigating new exposure and disease associations and monitoring progress along the HIV care continuum.

Methods: We synthesized key published findings and conducted primary data analyses in the HIV Outpatient Study (HOPS), an open cohort of PWH seen at public and private HIV clinics since 1993. We assessed temporal trends in health outcomes (1993-2017) and mortality (1994-2017) for 10 566 HOPS participants.

Results: The HOPS contributed to characterizing new conditions (eg, lipodystrophy), demonstrated reduced mortality with earlier HIV treatment, uncovered associations between select antiretroviral agents and cardiovascular disease, and documented remarkable shifts in morbidity from AIDS opportunistic infections to chronic noncommunicable diseases. The median CD4 cell count of participants increased from 244 cells/mm³ to 640 cells/mm³ from 1993 to 2017. Mortality fell from 121 to 16 per 1000 person-years from 1994 to 2017 (P < .001). In 2010, 83.7% of HOPS participants had a most recent HIV viral load <200 copies/mL, compared with 92.2% in 2017.

Conclusions: Since 1993, the HOPS has been detecting emerging issues and challenges in HIV disease management. HOPS data can also be used for monitoring trends in infectious and chronic diseases, immunologic and viral suppression status, retention in care, and survival, thereby informing progress toward the Ending the HIV Epidemic initiative.

Keywords: HIV epidemiology; antiretroviral therapy; clinical outcomes; viral suppression.

Figure 1.

HIV Outpatient Study (HOPS) sites, 1993–2019. Eight currently active sites contributing data: Dupont Circle Physicians Group, Washington, DC (June 1993–); Denver Infectious Disease Consultants (DIDC), Colorado (May 1993–); Northwestern University Medical School, Illinois (September 1994–); State University of New York (SUNY), New York (September 1994–); Temple University School of Medicine; Pennsylvania (March 1997–); University of Illinois at Chicago (UIC), Illinois (December 2000–); APEX Family Medicine, Colorado (August 2012–); St. Joseph’s Hospital Comprehensive Research Institute, Florida (October 2018–). Six currently inactive sites that contributed data through 2017: Infectious Disease Research Institute Inc., Florida (October 1992–December 2017); Fairmont Hospital, San Leandro, California (May 1993–May 2006); Oregon Health Sciences University, Oregon (August 1991–July 1998); Adult Immunology Clinic, Oakland, California (September 1993–June 2005); Southside HealthCare, Inc., Georgia (June 1994–April 1996); National Jewish Health, Colorado (May 1993–June 2015).

Figure 2.

HIV treatments at the end of the year, the HIV Outpatient Study, 1993–2017, n = 10 566. Mono-, dual- & other ART: a mono-, dual, or other regimen not considered to be combination ART; combination ART NRTI-based: a combination ART regimen containing at least 3 NRTIs, without PIs or NNRTIs; combination ART PI- and NNRTI-based: a combination ART regimen that includes at least 1 PI and 1 NNRTI; combination ART PI-based: a regimen considered to be combination ART containing either just 2 PIs with no other ARVs or a combination ART regimen containing at least 1 PI and none of the following: NNRTI, integrase or entry inhibitors; combination ART NNRTI-based: a combination ART regimen containing an NNRTI and none of the following: PI, integrase or entry inhibitors; combination ART entry inhibitor/other agent-based: a combination ART regimen containing either an entry inhibitor, fusion inhibitor, or CCR with no PI or NNRTI or a combination ART regimen categorized as “other HAART”; combination ART integrase inhibitor-based: a combination ART regimen that includes an integrase inhibitor. HOPS cohort definition for whether a regimen is considered effective combination ART: (i) any 3 ARVs that include a PI, NNRTI, fusion, entry, or integrase inhibitor; (ii) any 3 NRTIs that include abacavir or tenofovir, with the exception of the following combinations: ABC + TDF + 3TC and DDI + TDF + 3TC; (iii) 2 full-dose PIs; (iv) a boosted PI and 1 of the following (an NNRTI or fusion inhibitor); and (v) an integrase inhibitor and 1 of the following (PI, NNRTI, entry inhibitor, or integrase inhibitor). If 2 of the ARVs are AZT + D4T, they are subtracted from the total ARV count. Abbreviations: ART, antiretroviral therapy; NRTIs, nucleoside reverse transcriptase inhibitors; NNRTIs, non-nucleoside reverse transcriptase inhibitors; PIs, protease inhibitors.

Figure 3.

Mortality (95% confidence intervals) and median age at death, the HIV Outpatient Study, 1994–2017 (n = 10 566, number of deaths = 2253).