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Younger People with HIV Are Missing Out in the Continuum of Care

Young people with HIV are less likely to access and benefit from HIV care and treatment at all levels of the "care cascade" from testing to starting antiretroviral therapy (ART) to achieving viral suppression, according to findings reported in the June 17, 2013, advance edition of JAMA Internal Medicine. Overall, only about 25% of HIV positive people achieved undetectable viral load.

It is well known that effective ART can dramatically reduce the risk of AIDS-related illness and death, but recent research has shown that only about one-quarter of HIV positive people in the U.S. have been tested, linked to care, started treatment, maintained good adherence, and achieved undetectable viral load. The rest fall between the cracks at various stages of the so-called cascade of care.

H. Irene Hall from the U.S. Centers for Disease Control and Prevention (CDC) and colleagues evaluated disparities in these indicators between different groups of people with HIV categorized by sex, age, race/ethnicity, and transmission category (e.g., men who have sex with men, heterosexual men and women, injection drug users).

Effective treatment not only benefits individuals with HIV, but also prevents transmission of the virus, so disparities in care and treatment may contribute to the higher incidence rates seen in some groups, the study authors noted as background.

Usingdata from the CDC's National HIV Surveillance System, the researchers estimated the number of people with HIV who are aware and unaware of their status. They then calculated the percentage who were linked to care within 3 months of HIV diagnosis, based on CD4 T-cell count and viral load. Finally, they estimated percentages of people who remained in care, were prescribed ART, and achieved viral suppression using data from the Medical Monitoring Project, a surveillance system of people receiving HIV care in selected representative areas.

Results

• Of the estimated 1,148,200 people living with HIV in the U.S. in 2009, the researchers estimated that:

o   82% had been diagnosed as HIV positive;

o   66% were linked to care;

o   37% were retained in care;

o   33% were prescribed ART;

o   25% had viral load suppressed to >200 copies/mL.

• Overall, 76% of people with HIV were men, with 52% in the men who have sex with men transmission category.
• 44% were black/African-American, 33% were white, and 19% were Hispanic/Latino.
• By age, 7% were 13 to 24 years, 15% were 25 to 34 years, 61% were 35-54 years, 14% were 55 to 64 years, and 4% were age 65 or older.
• An estimated 857,276 people with HIV did not achieve viral suppression, including 75% of men, 79% of blacks, 74% of Hispanics/Latinos, and 70% of whites.
• At each step of the care continuum, the percentage of blacks was lower than that of whites, though the differences did not reach statistical significance.
• Looking at age, only 41% of HIV positive 13 to 24 year-olds had received a diagnosis and just 31% were linked to care.
• 28% of people age 25 to 34 were in care, compared with 46% of those in the 55 to 64 year group.
• People in the 25 to 34, 35 to 44, and 45 to 54 year age groups were all significantly less likely to achieve viral suppression than people age 55 to 64.

"Significant age disparities exist at each step of the continuum of care," the researchers summarized. "Additional efforts are needed to ensure that all persons with HIV receive a diagnosis and optimal care to reduce morbidity, mortality, disparities in care and treatment, and ultimately HIV transmission."

"Individuals, health care providers, health departments, and government agencies must all work together to increase the numbers of people living with HIV who are aware of their status, linked to and retained in care, receiving treatment and adherent to treatment," they concluded.

"The sobering numbers of those missing out on effective treatment because they did not know they were infected and those who knew their status but did not seek care spurred collaboration between the HIV treatment and prevention movements, 2 areas with different funding streams that often operated independently of one another," wrote Katerina Christopoulos and Diane Havlir from the University of California at San Francisco in an accompanying commentary. "Already the HIV community has mobilized to further develop and study interventions that address bottlenecks in the cascade. Achieving an AIDS-free generation will be within reach if, and only if, these efforts succeed."

6/19/13

References

HI Hall, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Internal Medicine. June 17, 2013 (Epub ahead of print).

K Christopoulos and D Havlir. Overcoming the human immunodeficiency virus obstacle course (commentary). JAMA Internal Medicine. June 17, 2013 (Epub ahead of print).

Other Source

JAMA Network. Study Details Age Disparities in HIV Continuum of Care. Media advisory for June 17, 2013.