An undetectable viral load within three months of HIV diagnosis should be added as a target to the US National HIV/AIDS Strategy, public health officials from New York City argue in The Journal of Infectious Diseases. They showed that improvement in this target is feasible, with the proportion of people virally suppressed within three months of diagnosis increasing from 9% in 2007 to 39% in 2016.
“We propose an outcome indicator, the percentage of newly diagnosed persons achieving viral suppression within 3 months of diagnosis, and recommend that the Centers for Disease Control and Prevention and local health agencies use this indicator along with the existing process indicator [the percentage linked to care within a month of diagnosis] to monitor the progress of HIV care among persons newly diagnosed with HIV in the United States,” Qiang Xia, Demetre Daskalakis and colleagues write.
The recommendation is strongly endorsed by Julia Dombrowski and Jared Baeten of the University of Washington in an accompanying editorial: “We need this new metric to drive our collective efforts to improve systems of care for persons with newly diagnosed HIV infection. It is time!”
Since 2011, treatment guidelines in the United States have recommended that all HIV-positive people should receive antiretroviral therapy (ART), regardless of CD4 cell count. ART at higher CD4 cell counts has been shown to have health benefits, reducing the risk of serious illness and death. In addition, people on ART with an undetectable viral load cannot transmit HIV to their sexual partners, and “Undetectable = Untransmittable” has been widely endorsed as a prevention strategy.
Shortening the time between diagnosis and viral suppression therefore has both individual and wider public health benefits. As the authors of the editorial say, “A person who reaches viral suppression within 1 month of diagnosis reflects a greater individual and public health success than one who reaches viral suppression 1 year after diagnosis.”
The current targets of the United States National HIV/AIDS Strategy (NHAS) include linking 85% of people to care within a month of diagnosis; retaining 90% of people in care; and viral suppression in 80% of people.
Officials from the New York City Department of Health and Mental Hygiene conducted a retrospective analysis of HIV surveillance data gathered in the city between 2007 and 2017 to determine the proportion of people with viral suppression within three months of initial diagnosis with HIV. Achievement of this target was examined according to sex, age, race/ethnicity and HIV transmission risk group.
A total of 27,520 people were included in the analysis. The annual number of new diagnoses declined by 46% from 3649 in 2007 to 1977 in 2016. Working towards one of the existing strategy targets, the proportion of people linked to care within a month of diagnosis increased steadily from 56% in 2007 to 79% in 2016.
There was also an increase in the proportion of people with viral suppression within three months of diagnosis, from just 9% in 2007 to 37% in 2016. Between 2007 and 2011, the proportion increased by 1% each year, accelerating to a little over 5% each year between 2012 and 2016. This jump coincided with revised treatment guidelines recommending immediate ART for all people, regardless of CD4 cell count.
Men were less likely to be virally suppressed than women in 2007 (8% vs 13%) but this difference had all but disappeared by 2016 (37% vs 39%). Older people had higher rates of viral suppression soon after diagnosis than younger people.
Black people and Hispanic people were more likely than white people to have viral suppression within three months of diagnosis at the start of the study (10% vs 7%). The investigators suggest this is because blacks and Hispanic people were more likely to have a low CD4 cell count at the time of diagnosis thus qualifying for early ART. But the recommendation that ART should be provided to all people reversed this finding. By 2016, 40% of Hispanic people and white people had early viral suppression, compared to 34% of black people.
Achievement of viral suppression within three months of diagnosis also differed by risk group. In 2016, 30% of injecting drug users and 19% of men who have sex with men (MSM) who inject drugs met the target. This compared to 39% of MSM and 40% of heterosexuals.
“During the 10-years analysis period, we observed a dramatic improvement,” comment the researchers. “This increase reflects the improvement in timely linkage of newly diagnosed persons to care, the 2011 change in treatment recommendations to offer ART to any persons living with HIV regardless of CD4 count, and the availability of more potent medications in recent years that result in quicker time to viral suppression.”
They suggest that viral suppression within three months of HIV diagnosis should be the target for all people.
But can this be achieved, given the current political situation in the United States?
The authors of the editorial stress that shortening the time between viral suppression after diagnosis is a shared responsibility between testing sites, health departments, Ryan White programme administrators, HIV clinics and case management organisations. They further suggest that structural factors including racism, poverty, stigma, homophobia, transphobia and inaction by health departments will also have a significant impact.
“But even in the context of these barriers, we can make progress,” comment the authors. “Our HIV public health programs and healthcare systems can work to find avenues to mitigate the impact of these barriers on the health outcomes of persons living with HIV.”