Addressing Disparities In Achieving Viral Suppression Critical to Ending US HIV Epidemic

The country has come a long way since the Joint United Nations Programme on HIV/AIDS set the 90-90-90 targets—a challenge to diagnose 90% of infections, provide antiretroviral therapy (ART) to 90% of those diagnosed, and for 90% of individuals to achieve viral suppression.

For instance, now, investigators know that daily ART can suppress the virus to undetectable levels and can prevent sexual transmission of the virus to others. However, if there is any hope of achieving the long sought-after goal of ending the epidemic once and for all, it is imperative to understand, address, and bridge gaps that remain in individuals achieving viral suppression.

In a new, longitudinal observational cohort study funded by the National Institutes of Health and published in the journal Annals of Internal Medicine, investigators analyzed trends in HIV viral suppression over time among patients infected with HIV who were receiving care in the United States between 1997 and 2015. They also evaluated the relationship between associated factors, such as characteristics pertaining to demographics and the use of integrase strand transfer inhibiters (ISTI).

To understand trends in viral suppression (indicated as ≤400 copies/mL), the investigators determined annual viral suppression rates within the aforementioned time period. They repeated analyses with tests that were limited to 1 random test per person, per year and used inverse probability of censoring weights to address loss to follow-up, according to the study authors. Using joint longitudinal and survival models as well as linear mixed models of individuals with HIV who were receiving ART, the investigators examined associations between viral suppression or continuous viral load levels and demographic factors, substance abuse, adherence, and ISTI use.

The investigators found that from 1997 to 2015, viral suppression increased from 32% to 86% on the basis of all tests among 31,930 individuals living with HIV in the United States. In adjusted analyses, they report that being older in age and using an ISTI-based regimen was linked with a lower likelihood of having a detectable viral load; black individuals were linked with having higher odds. Furthermore, the team noted similar patterns with continuous viral load levels when they restricted their analyses to data from 2010 to 2015 and adjusted for adherence, substance use, and depression.

Although viral suppression rates significantly increased over that 18-year period, the analysis revealed disparities among those living with HIV who are younger or black that warrant extra attention.

In an accompanying editorial, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases along with his colleagues, stressed that viral suppression plays a critical role in helping to control and potentially end the HIV epidemic. They drove home the fact that as of 2015, the United States fell short of reaching the set 90-90-90 targets, with only 51% of the 1.1 million individuals living with the virus in the country reported to have achieved viral suppression. To boost that percentage, the disparities in viral suppression need to be addressed.

The authors of the editorial call for additional research on the subject as well as the development of targeted treatment interventions for populations with lower viral suppression rates; these interventions should be coupled with tailored prevention packages.