Background: Since 2007, US Department of Health and Human Services (DHHS) HIV guidelines have advocated timely linkage to medical care (LTC) and progressively earlier initiation of antiretroviral therapy (ART) after diagnosis. A 2010 New York State law required LTC for consenting newly diagnosed persons. Less-immunocompromised and younger adults have historically had lower rates of LTC and viral suppression (VS). Trends in LTC and VS in New York City (NYC) can indicate provider uptake of new guidelines and whether differences in outcomes by immune status and age have been reduced.
Methods: Using NYC HIV surveillance registry data as of 6/30/2014, we calculated timely LTC and VS among residents 18+ years newly diagnosed in 2006-13 who survived >91 days post-diagnosis, overall and by CD4 count and age at diagnosis. Timely LTC was defined as CD4 or viral load (VL) test 8-91 days post-diagnosis. VS was defined as VL ≤400 copies/mL, measured by 6, 9, and 12 months post-diagnosis. CD4 count at diagnosis was imputed from value and timing of first CD4, assuming 50-cell/year decrement, and categorized in intervals of 0-199, 200-349, 350-499, and ≥500 cells. Trends by diagnosis year were assessed by Cochran-Armitage and differences by CD4 and age by Chi-square.
Results: Timely LTC increased overall (68% to 76%, p<0.0001) and across all CD4 intervals and all age groups <55; LTC did not change for persons ≥55. VS also increased overall (24% to 54% by 6 months, 32% to 65% by 9, and 36% to 69% by 12, all p<0.0001) and for all CD4 intervals and age groups. Percent VS by 12 months nearly quadrupled for persons with CD4 ≥350 (19% to 73%) and more than doubled for persons 18-34 (30% to 66%). Concordant with changes in guidelines, increases in LTC were steepest in 2010-11, and increases in VS escalated in 2007-8 for persons with CD4 200-349, 2008-11 for 350-499, and 2010-12 for CD4 ≥500 (Figure). In 2006, LTC and VS at 12 months differed across CD4 intervals and age groups (p<0.0001). However, by 2013, differences were observed only between persons with CD4 <500 and ≥500.
Conclusions: Timely LTC and VS increased over the entire period (2006-13) among persons newly diagnosed and reported with HIV in NYC, overall and in most CD4 and age groups. Some larger year-over-year increases in LTC and in VS by CD4 follow updated recommendations. These favorable trends notwithstanding, as of 2013, NYC was still far from the ideal of timely LTC and VS for all newly diagnosed residents.