New research was presented at CROI 2020, the annual Conference on Retroviruses and Opportunistic Infections, held virtually from March 8-11 in Boston. The features below highlight some of the studies that emerged from the conference.
Prediction Model Evaluates PrEP Coverage
Evidence suggests that tools for identifying populations who may benefit from PrEP are required for monitoring progress in PrEP scale-up. Using a validated prediction model to estimate HIV risk, researchers evaluated PrEP coverage and disparities in use among nearly 3.3 million patients at high risk of HIV acquisition in a large healthcare system. The team used the prediction model to generate an HIV risk score for each participant based on historical EHR data. Pharmacy fill data were used to assess recent and ever PrEP use by HIV risk score strata. Chi-square tests were used to compare recent and ever PrEP use by demographic characteristics among those with very high risk scores. Among those with low and very high risk scores, recent PrEP use ranged from 0.02% to 40.4%, and ever PrEP use from 0.02% to 51.4%, respectively. “Of those identified by our model as being at very high risk of HIV acquisition, nearly 60% had not recently used PrEP and there were substantial disparities in use,” write the study authors. “Efforts are needed to increase PrEP uptake in insured populations, particularly among females, younger age groups, those with lower socioeconomic status, and Black individuals.”
Sustained Viral Suppression With Rapid Start in Young Patients
Although the linkage-to-care intervention Rapid Start—designed to start patients newly diagnosed with HIV immediately on ART and support equity in care—has been shown by prior data to improve linkages and viral suppression in adults, similar outcomes have not been verified among US youth. To do so, creators of the intervention developed a continuum of care for a young adult (aged 18-24) rapid start population and compared this continuum with an adult population. Patients were linked to a federally qualified health center within 72 hours of HIV diagnosis, with the first ART dose directly observed, patients provided with a 30-day dose pack, labs drawn, and patients undergoing expedited insurance enrollment. Among youth participants, 97% achieved viral suppression with a median of 29 days from diagnosis, 84% remained virally suppressed at 12 months, and 97% remained engaged in care. Comparatively, viral suppression with a median of 28 days from diagnosis, viral suppression at 12 months, and remaining engaged in care were achieved by 98%, 93%, and 98% of adults. Differences between the two groups were not significant. “The intervention outcomes demonstrate that starting adults and youth on ART immediately after diagnosis, before labs are obtained, is safe, well-tolerated, and effective,” write the study authors.
HIV Stigma & Retention in Care
Although evidence indicates that HIV-related stigma appears to be a barrier to engagement in care, large-scale, nationally representative studies prospectively evaluating the effect of stigma on retention in HIV care in the United States are lacking. To assess stigma, researchers added a validated, four-item assessment of internalized HIV stigma (1 = strongly disagree to 5 = strongly agree) to patient surveys administered every 4-6 months at primary care visits for patients seen at seven academic HIV clinics across the US. Among more than 5,800 patients who completed the stigma assessment, the median age was 49, 80% were male, 39% were black, 15% were Hispanic, and 32% identified as heterosexual. The study team controlled for age, gender, race/ethnicity, sexual orientation, time since enrollment in the study cohort, and site of care. The mean stigma level was 1.9, with each unit increase in mean stigma associated with decreased odds of keeping the next primary care appointment (adjusted odds ratio [aOR], 0.93) and decreased odds of keeping all primary care appointments (median of 3) in the subsequent year (aOR, 0.91). The study authors write, “This is the first study to demonstrate prospectively the effect of stigma on retention in care, thereby providing support for the need to address HIV stigma in efforts to optimize retention in HIV care and virologic control.”
Direct-Acting Antivirals & Healthcare Use
Empirical evidence supporting the cost savings associated with direct-acting antivirals (DAAs) in real-world populations, and thus wider access, is limited. To investigate the impact of successful treatment of hepatitis C (HCV) with DAA therapy on healthcare services utilization (HSCU), investigators used data from a study prospectively following nearly 2,000 HIV-HCV co-infected patients. The impact of sustained virologic response (SVR) on HCSU was evaluated among those who achieved SVR after initiating DAA. The model used in the study controlled for pre-treatment trends in HCSU, exposure time, time updated covariates (CD4 cell count, HIV RNA, active injection drug use, significant fibrosis), and fixed covariates (age, sex). Among 455 participants who completed DAA therapy, 424 achieved SVR. Out-patient visits decreased from 12.6 per person-year before DAA initiation to 9.4 post-SVR, while in-patient visits decreased from 2.8 per person-year to 1.4. Prior to DAA initiations, annual rates of emergency room (ER) and specialist visits increased, hospitalization and HIV visits were stable, and general practitioner and walk-in clinic visits decreased over time. Immediately after achieving SVR, hospitalization, ER, and specialist visits reduced and continued, with annual reductions of 13%, 6%, and 18%, respectively.
Post-ACS Outcomes in PLHIV
Based on the hypothesis that HIV-infected individuals have higher rates of mortality following discharge from hospitalization for acute coronary syndrome (ACS), and receive sub-optimal medical management compared with uninfected individuals, researchers assessed data on more than 1.1 million patients admitted to the hospital with ACS between January 2014 and December 2016. While patients in the cohort with HIV were younger (57 vs 67 years) and had a higher burden of comorbidities like diabetes, renal disease, and substance use, ACS type did not differ significantly from those without HIV. However, patients with HIV had a higher adjusted 30-day, all-cause readmission rate (14.3% vs 9.4%), as well as a higher 1-year mortality rate (5.6% vs 5.1%). Yet, those with HIV filled prescriptions for core cardiac mediations at lower rates during the 12 months after discharge, including for statins (66.8% vs 73.7%), beta blockers (67.9% vs 73.9%), nitrates (31.8% vs 35.9%) and antiplatelet agents (46.8% vs 51.8%). “Optimizing use of medical therapy and longitudinal care of this high risk group is greatly needed,” write the study authors.