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Time spent with HIV viral load >1500 copies/mL among patients in HIV care, 2000-2014
Kate Buchacz1, Maria Mendoza1, Carl Armon2, Frank J. Palella3, Charles Rose1, Ellen Tedaldi4, Richard Novak5, Lytt Gardner1
1CDC, Atlanta, GA, USA,2Cerner Corp, Kansas City, MO, USA,3Northwestern Univ, Chicago, IL, USA,4Temple Univ, Philadelphia, PA, USA,5Univ of Illinois, Chicago, IL, USA
Sexual HIV transmission is more likely to occur when HIV viral load (VL) exceeds 1,500 copies/mL. We assessed percentage of person-time spent with VL above 1500 copies/mL (pPT>1500) for adult patients in HIV care.
We analyzed data from medical records of the HIV Outpatient Study (HOPS) cohort participants seen at nine United States (U.S.) HIV clinics during 2000-2014. Included patients had ≥1 HOPS clinic visit and ≥2 VLs during 2000-2014. We assessed pPT>1500 by analyzing values and time intervals between consecutive VL pairs per published methods (AIDS 2015, 29:947–954) and incorporating ART prescription data. Generalized estimating equations assuming a Poisson model and robust variance estimator were used to test for trend, and estimate the pPT>1500 and the corresponding 95% confidence intervals (CI) for patients in clinical and demographic strata.
The 5,873 patients contributed 37,794 person years [py], 86% on ART, with a median 15 VLs (interquartile range: 7-27) per patient. Overall pPT>1500 was 24% (CI: 23-25), decreasing from 37% in 2000 to 10% in 2014, P for trend <0.001. More patients used ART, including integrase inhibitors, over time (Figure). During the time when ART was prescribed, pPT>1500 was 16% overall, decreasing from 32% in 2000 to 7% in 2014, P for trend <0.001. pPT>1500 was higher in patients <35 vs. ≥50 years old (31% vs. 16%), women vs. men (31% vs. 22%), black vs. white and Latino/Hispanic patients (33% vs. 20% and 24%, respectively), and in patients who started observation (baseline) with public insurance vs. private (31% vs. 21%), CD4 cell counts <500 cells/mm³, and VLs>1500 copies/mL. In adjusted regression analyses, the significant correlates of pPT>1500 included time-updated 'no ART (off ART) status' (Relative Risk [RR] 3.5, CI: 3.3-3.7), and baseline characteristics: VL>1500 (RR 2.3, CI: 2.1-2.4), age <35 years (RR 1.5, CI: 1.4-1.6) and 35-49 years (RR 1.3, CI: 1.2-1.5) vs. ≥50 years, having public insurance (RR 1.2, CI: 1.2-1.3) vs. private, and being non-Hispanic black (RR 1.2, CI: 1.1-1.3) vs. white.
Adult U.S. patients in routine HIV care spent substantially less time with VLs over 1500 copies/mL from 2000 to 2014, a period characterized by the shift toward universal ART initiation and continuous improvements in ART regimens. The observed trends imply a decreasing risk of HIV transmission from persons in HIV care over the last decade and the need to focus interventions on subsets of patients more consistently viremic.