New Yorkers Living With HIV Are Initiating ART Faster

To end the HIV epidemic, prompt initiation of antiretroviral therapy (ART) following diagnosis is necessary. In addition to health benefits for individuals, treatment allows patients to achieve an undetectable viral load and prevent further transmission.

A new study published in Clinical Infectious Diseases found that in New York City the estimated time from HIV seroconversion to ART initiation was reduced by 42% between 2006 and 2015.

The investigators used AIDS and HIV surveillance conducted by the New York City Department of Health and Mental Hygiene, which has conducted AIDS surveillance since 1981 and HIV surveillance since 2000. Since 2005, electronic reporting has been mandatory for all HIV-related laboratory tests, including viral load tests. Investigators used CD4 counts and viral load testing as indicators that an individual was receiving HIV medical care.

The study analysis initially included 32,556 New York City residents diagnosed with HIV from 2006 to 2015 who were aged >13 years at diagnosis and had laboratory information reported through June 30, 2017.

Patients with a viral load >200 copies/ml within 7 days of diagnosis and individuals without a viral load or CD4 test recorded were excluded. The final analytic cohort consisted of 28,162 individuals.

The initiation of ART was defined by either a >1-log drop in detectable viral load over a 3 month period or a detectable viral load followed by an undetectable viral load over any period. The date of ART initiation was estimated as the mid-point between diagnosis and an undetectable viral load test.

Date of seroconversion in newly diagnosed patients was assessed using an estimated rate of CD4 decline. The square root of the CD4 cell count decreases over time among those who have not initiated antiretroviral therapy, and so time since seroconversion can be estimated by applying the estimated rate of CD4 decline to pre-treatment CD4 counts.

Of the 28,162 individuals who were diagnosed with HIV between 2006 to 2015, 89% had initiated ART by June 2017. Within a year of diagnosis, 80% were retained in care.

The median time from estimated seroconversion to initiation of antiretroviral therapy decreased by 42% from 6.4 years in 2006 (interquartile range [IQR]: 3.3-11.4) to 3.7 years (IQR: 0.5-8.3) in 2015.

The time from estimated seroconversion to diagnosis also decreased, by 28%, from a median of 4.6 years (IQR: 0.5-10.5) to 3.3 years (IQR: 0-8.1) from 2006-2015. The time from diagnosis to treatment initiation decreased as well, by 60%, from a median of 0.5 years (IQR: 0.2-2.1) to 0.2 years (IQR: 0.1-0.3).

Some groups, however, had room for improvement with respect to estimated time from seroconversion to initiation of treatment.

“The estimated time from seroconversion to ART initiation was longest among females (4.2 years, IQR: 0.6-9.2), people who were black (4.2 years, IQR: 0.6-9.1) or Asian/pacific islander (4.6 years, IQR: 0.9-8.5), older (age 50+ at diagnosis, 4.9 years, IQR: 0.9-10.9), had heterosexual transmission risk (4.9 years, IQR: 0.7-10.0), or were diagnosed at an inpatient facility (5.5 years, IQR: 1.1-10.8),” the study authors wrote.

The investigators saw expanded HIV prevention and treatment efforts as fruitful given the reduction of time from seroconversion to ART initiation, but pointed to a need for quicker diagnosis upon seroconversion.

“While the time from diagnosis to ART initiation decreased to a median of 0.2 years, the time from seroconversion to diagnosis was 3.3 years among people diagnosed in 2015, highlighting the need for more effective strategies for earlier HIV diagnosis,” study authors concluded.