Research Article: Increased uptake of early initiation of antiretroviral therapy and baseline drug resistance testing in San Francisco between 2001 and 2015

Date Published: March 14, 2019

Publisher: Public Library of Science

Author(s): Hong-Ha M. Truong, Sharon Pipkin, Robert M. Grant, Teri Liegler, Kara J. O’Keefe, Susan Scheer, Bisola O. Ojikutu.

http://doi.org/10.1371/journal.pone.0213167

Abstract

Early initiation of antiretroviral therapy (eiART) can improve clinical outcomes for persons with HIV and reduce onward transmission risk. Baseline drug resistance testing (bDRT) can inform regimen selection upon subsequent treatment initiation. We examined the uptake of eiART and bDRT within 3 months and 30 days of HIV diagnosis.

We analyzed a population-based sample from the San Francisco Department of Public Health HIV/AIDS Case Registry of newly-diagnosed HIV/non-AIDS individuals between 2001 and 2015 who received care at publicly-funded facilities (N = 3,124).

Uptake of eiART within 3 months of diagnosis increased significantly from 2001 to 2015 (p<0.001), peaking at 74% in 2015. bDRT uptake also increased significantly (p<0.001), peaking at 55% in 2012. eiART uptake was observed to be significantly associated with gender, age, race/ethnicity and transmission risk. There were no significant differences observed in demographic and risk characteristics of persons receiving bDRT in the more recent years. Of 990 persons diagnosed between 2010 and 2015, eiART uptake within 30 days of diagnosis increased from 13% to 38% (p<0.001); bDRT uptake increased from 35% to 39% but the change was not significant (p = 0.141). Observed increases in eiART and bDRT uptake from 2010 to 2015 may reflect the adoption of treatment as prevention and a local public health policy statement in 2010 recommending treatment initiation at time of diagnosis irrespective of CD4 count. Concerns about stigma may underlie disparities in eiART, however such concerns would not bear as directly on a provider-initiated laboratory test like bDRT.

Partial Text

HIV treatment guidelines in the US have evolved greatly over the past decade. Historically, antiretroviral therapy (ART) initiation was based on CD4 T cell counts. Prior to 2007, ART initiation was recommended when CD4+ lymphocyte count (CD4 count) dropped below 200 cells/mm3. Treatment guidelines revisions were revised to recommend ART initiation at CD4 <350 in 2007 and CD4 <500 in 2009.[1] We analyzed a population-based sample of San Francisco residents newly-diagnosed with HIV/non-AIDS from 2001 through 2015 who received care at publicly-funded facilities. HIV/non-AIDS was defined as CD4 count ≥200 cells/mm3 and the absence of an AIDS-indicator condition at time of diagnosis. Receipt of care was defined as having either a CD4 count or an HIV viral load laboratory result. Data were obtained from the San Francisco Department of Public Health HIV/AIDS Case Registry, and the AIDS Research Institute (ARI) University of California, San Francisco (UCSF) Laboratory of Clinical Virology (LCV) which performs drug resistance testing for all local publicly-funded clinics. A total of 3,124 persons newly-diagnosed with HIV/non-AIDS in San Francisco between 2001 and 2015 received care at publicly-funded facilities. These included 723 persons diagnosed in Era 1, 753 persons in Era 2, 658 persons in Era 3, 565 persons in Era 4 and 425 persons in Era 5. Demographic and risk characteristics, stratified by eras, are shown in Table 1. Across all eras, the largest proportion of individuals were males, whites, and men who have sex with men (MSM). In the first three eras (2001–2009), the largest proportion of individuals was between the ages of 30 to 39 years at diagnosis compared to other age groups; however, this shifted to ages 20 to 29 years in Eras 4 and 5. The proportion of persons newly-diagnosed with HIV/non-AIDS who initiated ART within 3 months of diagnosis increased significantly from 2004 through 2015. The substantial increase in eiART uptake observed in the more recent years likely reflect adoption of revised local and national guidelines, as well as the strategy of treatment as prevention.[2,3,8,9] The decrease seen in 2002 through 2006 may stem from concerns during that time regarding toxicities associated with ART. Disparities observed from 2004 through 2015 were driven primarily by the lower uptake of eiART among women, blacks, persons who inject drugs, heterosexuals, and other non-MSM groups. These groups are affected by multiple layers of stigma related to HIV status, race, ethnicity, sexual practices, gender, and substance use. Such compounded stigma is a substantial barrier to health care engagement.[10]   Source: http://doi.org/10.1371/journal.pone.0213167

 

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