The incidence of HIV in the United States has remained stable over the last 15 years, while the number of people living with the disease has increased by about 60%. “As more people are living with HIV, it’s important to analyze and assess our efforts to identify people with the infection and ensure that they remain on treatment,” says Stacy M. Cohen, MPH. “With effective care and treatment, individuals with HIV can live long, healthy lives.”

Intriguing New Findings on HIV Diagnoses

Cohen and colleagues had a study published in the December 2011 issue of Morbidity and Mortality Weekly Report that highlights the importance of identifying persons with HIV and making sure they remain in medical care and receive treatment. The investigation estimated the overall proportion of persons with HIV in the U.S. who have achieved viral suppression (see also, The Role of Demographics in HIV Clinical Outcomes). To accomplish this, the research team looked at the estimated numbers of American adults living with and diagnosed with HIV, and evaluated the percentages of those diagnosed with the infection who:

Are receiving HIV care.
Have been prescribed antiretroviral therapy (ART).
Achieved viral suppression.
Received prevention counseling from healthcare providers.

Approximately 77% of people diagnosed with HIV were linked to care within 3 to 4 months of diagnosis, but only 51% were retained in ongoing care. About 89% of adults with HIV who were in care had been prescribed ART. Of these, 77% had a suppressed viral load at their most recent test (Table). Despite effective tools for HIV treatment, only 28% of all HIV-infected people had a suppressed viral load (Figure).

“Too few people with HIV infection have their viral loads suppressed adequately,” Cohen says. She adds that this can be attributed to the fact that about 20% of people with HIV are unaware that they are infected. Additionally, many people who test positive for HIV do not receive regular medical care after the diagnosis.

“Our findings highlight the importance of testing more people to identify unrecognized infections,” says Cohen. “They also illustrate that greater efforts are needed to ensure access to care, retention in care, and adherence to ART.” She says that there also appear to be important discrepancies in the percentages of patients receiving preventive counseling, being prescribed ART, and reaching viral suppression. Possible explanations for these discrepancies may include differences in insurance coverage, prescription drug costs, healthcare providers’ perceptions of patients’ probability to adhere to ART regimens, and other factors associated with adherence that are common to all chronic diseases (see also, Improving Medication Adherence in HIV).

The Physician’s Role in HIV Management

“When HIV is diagnosed late, we lose the opportunity to enable patients to achieve optimal benefits from treatment,” explains Cohen. “Further transmission of the virus can also be avoided with more vigilant testing of patients.” In an effort to increase detection rates, the CDC and the American College of Obstetricians and Gynecologists jointly recommend that all healthcare providers screen their patients for HIV, regardless of risk, in any healthcare setting with at least one new infection per 1,000 patients tested. “HIV testing needs to be offered as a routine part of medical care so that patients can be referred for treatment, and fewer people will transmit the infection to others,” adds Cohen.

Previous research has shown that early ART reduces complications from HIV and improves survival (see also, Antiretroviral Therapy in HIV Infection: A Guideline Update). “Early ART initiation is paramount to decreasing the potential spread of the virus,” Cohen says. “Patients who test positive for HIV infection should be referred to HIV medical care, receive prevention counseling, and be prescribed ART in order to achieve viral suppression. Physicians play a vital role in providing or arranging for appropriate treatment of HIV-infected patients.”

Looking Ahead to Early HIV Treatment

Research has shown that early HIV treatment can improve health and survival, and may substantially reduce the spread of HIV. “Dramatic improvements in HIV prevention and treatment have been made, but we have substantial work ahead of us before we can fully realize the potential benefits of HIV treatment as prevention,” says Cohen. “We must recruit physicians to expand HIV testing and improve the delivery of care, treatment, and prevention services.” According to Cohen, future research should be conducted for specific states and cities to determine areas that could benefit from targeted prevention efforts (see also, Extending Survival for HIV-Infected Patients). “This would include identifying areas with lower percentages of people who are being linked to care,” she says. “Other areas worthy of further exploration include those with lower percentages of people who remain in care and achieve viral suppression. A combination of high-impact prevention approaches for HIV-positive individuals will be needed to break the cycle of HIV transmission in the U.S.”

References

CDC. Vital signs: HIV prevention through care and treatment – United States. MMWR Morb Mortal Wkly Rep. 2011;60:1618-1623. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6047a4.htm?s_cid=mm6047a4_w. Accessed December 8, 2011.

CDC. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2009. HIV surveillance report, Volume 21. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/index.htm. Accessed December 8, 2011.

Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.

CDC. Clinical and behavioral characteristics of adults receiving medical care for HIV infection: Medical Monitoring Project, United States, 2007. MMWR. 2011;60(No. SS-11).

CDC. HIV surveillance—United States, 1981-2008. MMWR. 2011;60:689-693.

Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS. 2010;24:2665-2678.

Tripathi A, Youmans E, Gibson JJ, Duffus WA. The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study. AIDS Res Hum Retroviruses. 2011;27:751-758.

Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793-800.