Julia C. Dombrowski

Early Retention in HIV Care and Viral Load Suppression: Implications for a Test and Treat Approach to HIV Prevention

BackgroundAfter HIV diagnosis and linkage to care, achieving and sustaining viral load (VL) suppression has implications for patient outcomes and secondary HIV prevention. We evaluated factors associated with expeditious VL suppression and cumulative VL burden among patients establishing outpatient HIV care. MethodsPatients initiating HIV medical care from January 2007 to October 2010 at the University of Alabama at Birmingham and University of Washington were included. Multivariable Cox proportional hazards and linear regression models were used to evaluate factors associated with time to VL suppression (<50 copies/mL) and cumulative VL burden, respectively. Viremia copy-years, a novel area under the longitudinal VL curve measure, was used to estimate 2-year cumulative VL burden from clinic enrollment. ResultsAmong 676 patients, 63% achieved VL <50 copies per milliliter in a median 308 days. In multivariable analysis, patients with more time-updated “no show” visits experienced delayed VL suppression (hazard ratio = 0.84 per “no show” visit, 95% confidence interval = 0.76 to 0.92). In multivariable linear regression, visit nonadherence was independently associated with greater cumulative VL burden (log10 viremia copy-years) during the first 2 years in care (Beta coefficient = 0.11 per 10% visit nonadherence, 95% confidence interval = 0.04 to 0.17). Across increasing visit adherence categories, lower cumulative VL burden was observed (mean ± standard deviation log10 copy × years/mL); 0%–79% adherence: 4.6 ± 0.8; 80%–99% adherence: 4.3 ± 0.7; and 100% adherence: 4.1 ± 0.7 log10 copy × years/mL, respectively (P < 0.01). ConclusionsHigher rates of early retention in HIV care are associated with achieving VL suppression and lower cumulative VL burden. These findings are germane for a test and treat approach to HIV prevention.

Population-based metrics for the timing of HIV diagnosis, engagement in HIV care, and virologic suppression

Objective:To compare population-based metrics for assessing progress toward the US National HIV/AIDS Strategy (NHAS) goals. Design:Analysis of surveillance data from persons living with HIV/AIDS (PLWHA) in King County, Washington, USA, 2005–2009. Methods:We examined indicators of the timing of HIV diagnosis [intertest interval, CD4 cell count at diagnosis, and AIDS ⩽ 1 year of diagnosis (late diagnosis)]; linkage to initial care (CD4 or viral load report ⩽3 months after diagnosis) and sustained care (a laboratory report 3–9 months after linkage); engagement in continuous care in 2009 (at least two laboratory reports ≥3 months apart); and virologic suppression. Results:Thirty-two percent of persons had late HIV diagnoses, 31% of whom reported testing HIV negative in the 2 years preceding their HIV diagnoses. Linkage to sustained care, but not linkage to initial care, was significantly associated with subsequent virologic suppression. Among 6070 PLWHA in King County, 65% of those with at least one viral load reported in 2009 and 53% of all PLWHA had virologic suppression. Although only 66% of all PLWHA were engaged in continuous care, 81% were defined as engaged using the denominator proposed in the NHAS (at least one laboratory result reported in 2009 excluding persons establishing care in the second half of the year). Conclusions:Proposed metrics for monitoring the HIV care continuum may not accurately measure late diagnoses or linkage to sustained care and are sensitive to assumptions about the size of the population of PLWHA. Monitoring progress toward achievement of NHAS goals will require improvements in HIV surveillance data and refinement of care metrics.

Migration distorts surveillance estimates of engagement in care: results of public health investigations of persons who appear to be out of HIV care.

Background Prevention and clinical efforts are increasingly focused on improving the HIV care cascade, the sequential steps from diagnosis to engagement in care and viral suppression. Monitoring of this cascade is largely dependent on HIV laboratory surveillance data. However, little is known about the completeness of these data or the true care status of individuals for whom no data are reported. Methods We investigated people presumed to be living with HIV/AIDS in King County, WA, who had no laboratory results reported to HIV surveillance for at least 1 year between 2006 and 2010. We determined whether each person had relocated, died, or remained in the county. Results Of 7379 HIV-infected people presumed living in King County, 2545 (35%) had 1 or more 12-month gap in laboratory reporting. Among these individuals, 47% had relocated, 7% died, and 38% remained in King County; we were unable to determine the status of 8%. Of individuals remaining in the area, 91% had evidence of returning to or being in HIV care. Case investigations reduced the proportion of individuals thought to be out of care in 2011 from 27% to 16%. Conclusions Investigations of individuals without laboratory results reported to HIV surveillance identified large numbers of people who are no longer living in the area. Our findings suggest that current estimates of the HIV care cascade may be too pessimistic and that individual case investigations are required to accurately define the size and composition of the population of people living with HIV in local areas.

High levels of antiretroviral use and viral suppression among persons in HIV care in the United States, 2010.

Background:Contemporary data on patterns of antiretroviral therapy (ART) use in the United States are needed to inform efforts to improve the HIV care cascade. Methods:We conducted a cross-sectional study of patients in the Centers for AIDS Research Network of Integrated Clinical Systems cohort who were in HIV care in 2010 to assess ART use and outcomes, stratified by nadir CD4 count (⩽350, 351–500, or >500 cells/mm3), demographics, psychiatric diagnoses, substance use, and engagement in continuous care (≥2 visits ≥3 months apart in 2010). Results:Of 8633 patients at 7 sites who had ≥1 medical visit and ≥1 viral load in 2010, 94% had ever initiated ART, 89% were on ART, and 70% had an undetectable viral load at the end of 2010. Fifty percent of ART-naive patients had nadir CD4 counts >500 cells per cubic millimeter, but this group comprised just 3% of the total population. Among patients who were ART naive at the time of cohort entry (N = 4637), both ART initiation and viral suppression were strongly associated with nadir CD4 count. Comparing 2009 and 2010, the percentages of patients with viral suppression among those with nadir CD4 counts 351–500 and >500 cells per cubic millimeter were 44% vs. 57% and 25% vs. 33%, respectively. Engagement in care was the only factor consistently associated with ART use and viral suppression across nadir CD4 count strata. Conclusions:Our findings suggest that ART use and viral suppression among persons in HIV care may be more common than estimated in some previous studies and increased from 2009 to 2010.

Dramatic increase in preexposure prophylaxis use among MSM in Washington state.

Objective:HIV preexposure prophylaxis (PrEP) is efficacious, but uptake has been slow. In Washington State, most insurance plans, including Medicaid, pay for PrEP, and the state supports a PrEP drug assistance program. We assessed trends in PrEP awareness and use among MSM in Washington. Design and setting:Serial cross-sectional survey conducted annually at the Seattle Pride Parade between 2009 and 2015. Methods:In a convenience sample of MSM who reside in Washington State and deny ever testing HIV positive (n = 2168), we evaluated the association between calendar year and self-report of PrEP uptake and awareness using descriptive statistics and multivariable relative risk and logistic regression. Regression models included HIV risk and demographic covariates. Results:In 2015, 23% [95% confidence interval (CI): 16%, 31%] of high-risk MSM reported currently taking PrEP. The percentage of high-risk MSM who reported ever taking PrEP increased from 5% in 2012 to 31% in 2015. PrEP use among lower-risk MSM was low and stable, between 1 and 3% in 2012–2015. In multivariable analyses, PrEP use was associated with later calendar years (2015 vs. 2012: adjusted relative risk = 2.29, 95% CI: 1.16, 4.52) and elevated HIV risk (adjusted relative risk = 2.92, 95% CI: 2.00, 4.25). The percentage of high and lower-risk MSM who had heard of PrEP increased from 13 to 86% and from 29 to 58%, respectively. Conclusion:PrEP awareness is high and the use has rapidly increased over the last year among MSM in Seattle, Washington, USA. These findings demonstrate that high levels of PrEP use can be achieved among MSM at high-risk for HIV infection.

Comparing azithromycin and doxycycline for the treatment of rectal chlamydial infection: a retrospective cohort study.

Background Centers for Disease Control and Prevention guidelines recommend azithromycin or doxycycline for treatment of rectal chlamydial infection. Methods We created a retrospective cohort of male patients diagnosed as having rectal chlamydia between 1993 and 2012 at a sexually transmitted disease clinic in Seattle, Washington. Men were included in the analysis if they were treated with azithromycin (1 g single dose) or doxycycline (100 mg twice a day × 7 days) within 60 days of chlamydia diagnosis and returned for repeat testing 14 to 180 days after treatment. We compared the risk of persistent/recurrent rectal chlamydial infection among recipients of the 2 drug regimens using 4 follow-up testing time intervals (14–30, 60, 90, and 180 days). Results Of 1835 cases of rectal chlamydia diagnosed in the study period, 1480 (81%) were treated with azithromycin or doxycycline without a second drug active against Chlamydia trachomatis. Of these, 407 (33%) of 1231 azithromycin-treated men and 95 (38%) of 249 doxycycline-treated men were retested 14 to 180 days after treatment (P = 0.12); 88 (22%) and 8 (8%), respectively, had persistent/recurrent infection (P = 0.002). Persistent/recurrent infection was higher among men treated with azithromycin compared with doxycycline at 14 to 30 days (4/53 [8%] vs. 0/20 [0%]), 14 to 60 days (23/136 [17%] vs. 0/36 [0%]), and 14 to 90 days (50/230 [22%] vs. 2/56 [4%]). In multivariate analysis, azithromycin-treated men had a significantly higher risk of persistent/recurrent infection in the 14 to 90 days (adjusted relative risk, 5.2; 95% confidence interval, 1.3–21.0) and 14 to 180 days (adjusted relative risk, 2.4; 95% confidence interval, 1.2–4.8) after treatment. Conclusions These data suggest that doxycycline may be more effective than azithromycin in the treatment of rectal chlamydial infections.

Failure of serosorting to protect African American men who have sex with men from HIV infection.

Background: Serosorting is the practice of choosing sex partners or selectively using condoms based on a sex partners perceived HIV status. The extent to which serosorting protects African American (AA) and Hispanic men who have sex with men (MSM) is unknown. Methods: We analyzed data collected from MSM sexually transmitted diseases clinic patients in Seattle, WA, 2001–2010. Men were asked about the HIV status of their anal sex partners in the prior year and about their condom use with partners by partner HIV status. We defined serosorters as MSM who had unprotected anal intercourse (UAI) only with partners of the same HIV status, and compared the risk of testing HIV positive among serosorters and men who reported having UAI with partners of opposite or unknown HIV status (ie, nonconcordant UAI). We used generalized estimating equations to evaluate the association of serosorting with testing HIV positive. Results: A total of 6694 MSM without a prior HIV diagnosis were tested during 13,657 visits; 274 men tested HIV positive. Serosorting was associated with a lower risk of testing HIV positive than nonconcordant UAI among white MSM (2.1 vs. 4.5%, odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.34–0.61), but not AA MSM (6.8 vs. 6.0%, OR: 1.1, 95% CI: 0.57–2.2). Among Hispanics, the risk of testing HIV positive was lower among serosorters than men engaging in nonconcordant UAI, though this was not significant (4.1 vs. 6.0%, OR: 0.67, 95% CI: 0.36–1.2). Conclusions: In at least some AA MSM populations, serosorting does not seem to be protective against HIV infection.

Use of multiple data sources and individual case investigation to refine surveillance-based estimates of the HIV care continuum

Objectives:To assess the HIV care continuum among HIV-infected persons residing in Seattle and King County, WA, at the end of 2011 and compare estimates of viral suppression derived from different population-based data sources. Methods:We derived estimates for the HIV care continuum using a combination of HIV case and laboratory surveillance data supplemented with individual investigation of cases that seemed to be unlinked to or not retained in HIV care, a jurisdiction-wide population-based retrospective chart review, and local data from the CDCs Medical Monitoring Project and National HIV Behavioral Surveillance. Results:Adjusting for in- and out-migration of persons diagnosed with HIV, laboratory surveillance data supplemented with individual case investigation suggest that 67% of persons diagnosed with HIV and 57% of all HIV-infected persons living in King County at the end of 2011 were virally suppressed (plasma HIV RNA <200 copies/mL). The viral suppression estimates we derived from a population-based chart review and adjusted local Medical Monitoring Project data were similar to the surveillance-derived estimate and identical to each other (59% viral suppression among all HIV-infected persons). Conclusions:The level of viral suppression in King County is more than twice the national estimate and exceeds estimates of control for other major chronic diseases in the United States. Our findings suggest that national care continuum estimates may be substantially too pessimistic and highlight the need to improve HIV surveillance data.

Effect of nucleic acid amplification testing on detection of extragenital gonorrhea and chlamydial infections in men who have sex with men sexually transmitted disease clinic patients

Background In 2010, the Centers for Disease and Control and Prevention recommended using nucleic acid amplification tests (NAATs) for extragenital gonorrhea (GC) and chlamydia (CT) testing because of NAATs’ improved sensitivity compared with culture. Methods In 2011, the Public Health–Seattle & King County Sexually Transmitted Disease Clinic introduced NAAT-based testing for extragenital GC and CT infection in men who have sex with men (MSM) using AptimaCombo2. We compared extragenital GC and CT test positivity and infection detection yields in the last year of culture-based testing (2010) to the first year of NAAT testing (2011). Results Test positivity of GC increased by 8% for rectal infections (9.0%–9.7%) and 12% for pharyngeal infections (5.8%–6.5%) from 2010 to 2011; CT test positivity increased 61% for rectal infections (7.4%–11.9%). Pharyngeal CT was identified in 2.3% of tested persons in 2011 (not tested in 2010). We calculated the ratio of extragenital cases per 100 urethral infections to adjust for a possible decline in GC/CT incidence in 2011; the GC rectal and pharyngeal ratios increased 77% and 66%, respectively, and the CT rectal ratio increased 127%. The proportion of infected persons with isolated extragenital infections (i.e., extragenital infections without urethral infection) increased from 43% in 2010 to 57% in 2011. Conclusions Extragenital testing with NAAT substantially increases the number of infected MSM identified with GC or CT infection and should continue to be promoted.

HIV intertest interval among MSM in King County, Washington

Objectives The authors examined temporal trends and correlates of HIV testing frequency among men who have sex with men (MSM) in King County, Washington. Methods The authors evaluated data from MSM testing for HIV at the Public Health—Seattle & King County (PHSKC) STD Clinic and Gay City Health Project (GCHP) and testing history data from MSM in PHSKC HIV surveillance. The intertest interval (ITI) was defined as the number of days between the last negative HIV test and the current testing visit or first positive test. Correlates of the log10-transformed ITI were determined using generalised estimating equations linear regression. Results Between 2003 and 2010, the median ITI among MSM seeking HIV testing at the STD Clinic and GCHP were 215 (IQR: 124–409) and 257 (IQR: 148–503) days, respectively. In multivariate analyses, younger age, having only male partners and reporting ≥10 male sex partners in the last year were associated with shorter ITIs at both testing sites (p<0.05). Among GCHP attendees, having a regular healthcare provider, seeking a test as part of a regular schedule and inhaled nitrite use in the last year were also associated with shorter ITIs (p<0.001). Compared with MSM testing HIV negative, MSM newly diagnosed with HIV had longer ITIs at the STD Clinic (median of 278 vs 213 days, p=0.01) and GCHP (median 359 vs 255 days, p=0.02). Conclusions Although MSM in King County appear to be testing at frequent intervals, further efforts are needed to reduce the time that HIV-infected persons are unaware of their status.