It’s time to consider the newly diagnosed population as distinct from the HIV-infected population as a whole when measuring viral suppression levels.
It’s become clearer to the scientific community that focuses on HIV that time is of the essence when pursuing treatment. Studies have demonstrated that individuals who are diagnosed with HIV and are linked to early care and treatment often achieve lower levels of viral suppression and experience fewer complications from the disease. Beginning antiretroviral treatment (ART) as soon as possible after diagnosis, therefore, is recommended.
But how many newly diagnosed individuals actually begin ART regimens and see a quick lowering of their viral levels? Right now, the commonly used indicators of progress in HIV therapy don’t measure that information. The US National HIV/AIDS Strategy (NHAS), a government plan that keeps tabs on how we manage HIV in this country, offers several indicators that provide a snapshot of our success.
For people with diagnosed HIV, the process indicator is the percentage that receives medical care for the disease; the goal is for 90% of all of those with HIV to be receiving care by 2020. The outcome indicator is the percentage of those living with HIV who achieve viral suppression; the goal is for 80% of those in this group to be suppressed by 2020. For newly diagnosed individuals, the single process indicator is the percentage that immediately enters HIV medical care (within 4 weeks of diagnosis), with a goal of 85% of newly diagnosed individuals entering care by 2020. There is no outcome indicator, however, for newly diagnosed individuals.
A team at the New York City Department of Health recently completed a study of more than 27,500 individuals—most of them men—who were newly diagnosed with HIV over a 10-year period from early 2007 to late 2016. The subjects’ information had been given to the New York City Department of Mental Health and Hygiene.
The study tracked the patients for 3 months after diagnosis to learn how many were able to reach a viral load of fewer than 200 copies/mL in that time period. From 2007 to 2016, the percentage of individuals who saw their viral load drop to 200 copies/mL or less within 3 months rose from 9% to 37%, with a particular upward trajectory from 2012 to 2016.
Why is such a shortened time to viral suppression important? “Early ART and rapid viral suppression reduce the risk of disease progression and prevent HIV transmission to [a patient’s] sexual or needle-sharing partners,” Qiang Xia, MD, MPH, a research scientist in the Bureau of HIV Prevention and Control in New York City’s Department of Health and Mental Hygiene, and an author of the study, told Contagion®. “A few studies have shown that immediate ART after HIV diagnosis greatly shortens the time from HIV diagnosis to viral suppression and improves retention in care.”
But according to Dr. Xia, a lack of coordination between health care providers, as well as insurance snafus, are barriers to early treatment. People of color face even more obstacles, such as lower levels of health education, poverty, and stigma.
Recognizing that that the medical community needs to pay particular attention to the viral-suppression success or failure of the newly diagnosed population, separate from the HIV-positive population as a whole, Dr. Xia and his team have proposed that the percentage of newly diagnosed HIV patients who achieve viral suppression 3 months or less after diagnosis be adopted as a new outcome indicator.
“We hope that...adding this new indicator in the NHAS will improve cooperation among HIV-diagnosing providers, health departments, Ryan White program administrators, HIV clinics, and case management organizations, to support early initiation of ART,” he said. The Ryan White HIV/AIDS Program is a federal initiative providing care and treatment to people affected by this disease.
Other experts fully support this new proposal. “[For] individual and public health benefits, we should push onward to reduce the time from infection to diagnosis, to further curtail the time an individual is viremic,” write Julia C. Dombrowski, MD, MPH, and Jared M. Baeten, MD, epidemiologists and HIV specialists at the University of Washington, in a supporting editorial in The Journal of Infectious Diseases.
“Achieving these goals will require changing our systems and practices to make testing normalized and convenient, linkage to care streamlined, and initiation of ART rapid and barrier-free, so that the process works in a truly patient-centered way with as few steps, as little hassle, and as much coordination and integration as possible,” they add.
Ms. Saloman is a health writer with more than 20 years of experience working for both consumer-and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.