San Francisco Sees Positive Trends in Early ART Initiation

SEATTLE – HIV-positive patients are increasingly initiating antiretroviral treatment early in the course of their disease, which should improve their outcomes, suggests a study conducted in San Francisco.

However, some groups are clearly not included in this favorable trend, said the study’s lead investigator, Hong-Ha M. Truong, Ph.D., an assistant professor of medicine at the University of California, San Francisco.

Overall, the findings reflect the implementation of a test-and-treat approach recently introduced in San Francisco aimed at increasing early use of antiretroviral therapy (ART) among HIV-positives and reducing CD4 cell loss in the interval between HIV diagnosis and treatment initiation, said Kholoud Porter, Ph.D., session comoderator and senior epidemiologist with the Medical Research Council (MRC) Clinical Trials Unit in London.

"Given the need for good adherence to lifelong ART, it will be crucial to monitor these individuals and document the proportion who remain on ART and maintain viral suppression," she said at the Conference on Retroviruses and Opportunistic Infections.

The disparity in early ART uptake should inform public health policy, she added.

The study involved more than 3,750 adolescents and adults from the city’s HIV/AIDS Case Registry; their infections were diagnosed between 2004 and 2010.

Dr. Truong and her colleagues showed that the proportion of patients initiating ART early, that is, at a CD4 count of greater than 350 cells/mm³, increased dramatically: Among those who had a count above this value at diagnosis and initiated ART during the study period, only about half (48%) initiated early in 2004, whereas nearly all (93%) did so in 2010, she reported.

In adjusted analyses, however, the proportion of patients initiating ART early was significantly lower among racial/ethnic minorities, young individuals, injection drug users, patients whose diagnosis was made in nonprivate facilities, and those living in impoverished areas.

"Early initiation of ART at high CD4 levels was evident in San Francisco starting as early as 2007," said Dr. Truong, noting that this trend predated changes to local treatment recommendations calling for initiation regardless of CD4 count. "However, not all groups are accessing early initiation of ART equally, and therefore [they are] not benefiting from the advantages of early treatment."

"Delays in treatment initiation explain observed disparities in survival among persons living with HIV. Disparities will persist unless treatment gaps are closed," she maintained.

There may be financial barriers to accessing antiretrovirals, she said. Insurance companies may require CD4 counts of a certain level before they will cover antiretrovirals. But more likely, individuals and their motivation to seek treatment are driving this trend, she said. San Francisco also has a countywide health care program that provides access to people who don’t have health insurance.

For the study, the investigators identified 3,778 San Francisco HIV-positive patients aged 13 years or older. Results were largely based on 1,803 having a CD4 count of greater than 350 cells/mm³ at diagnosis, and specifically the 941 who initiated ART.

National guidelines at the start of the study period in 2004 recommended that HIV-positive patients begin ART when their CD4 count dropped below 350 cells/mm³, Dr. Truong noted. (They have since been updated to recommend initiation at 500 cells/mm³ or less, with initiation at higher levels optional.)

"Recognizing the beneficial impact of early treatment on reducing morbidity and transmission, public health clinics and the Positive Health Program in San Francisco revised their guidelines in 2010," Dr. Truong explained. "The new recommendations called for initiating treatment at the time of HIV diagnosis, irrespective of CD4 counts."

The median count at diagnosis remained essentially stable during the 7-year study period, at roughly 550 cells/mm³, whereas that at ART initiation increased, from 365 to 496 cells/mm³ (P less than .001). Thus, the gap between the two values narrowed (P less than .001).

Dr. Truong and Dr. Porter reported having no relevant conflicts of interest.

SEATTLE – HIV-positive patients are increasingly initiating antiretroviral treatment early in the course of their disease, which should improve their outcomes, suggests a study conducted in San Francisco.

However, some groups are clearly not included in this favorable trend, said the study’s lead investigator, Hong-Ha M. Truong, Ph.D., an assistant professor of medicine at the University of California, San Francisco.

Overall, the findings reflect the implementation of a test-and-treat approach recently introduced in San Francisco aimed at increasing early use of antiretroviral therapy (ART) among HIV-positives and reducing CD4 cell loss in the interval between HIV diagnosis and treatment initiation, said Kholoud Porter, Ph.D., session comoderator and senior epidemiologist with the Medical Research Council (MRC) Clinical Trials Unit in London.

"Given the need for good adherence to lifelong ART, it will be crucial to monitor these individuals and document the proportion who remain on ART and maintain viral suppression," she said at the Conference on Retroviruses and Opportunistic Infections.

The disparity in early ART uptake should inform public health policy, she added.

The study involved more than 3,750 adolescents and adults from the city’s HIV/AIDS Case Registry; their infections were diagnosed between 2004 and 2010.

Dr. Truong and her colleagues showed that the proportion of patients initiating ART early, that is, at a CD4 count of greater than 350 cells/mm³, increased dramatically: Among those who had a count above this value at diagnosis and initiated ART during the study period, only about half (48%) initiated early in 2004, whereas nearly all (93%) did so in 2010, she reported.

In adjusted analyses, however, the proportion of patients initiating ART early was significantly lower among racial/ethnic minorities, young individuals, injection drug users, patients whose diagnosis was made in nonprivate facilities, and those living in impoverished areas.

"Early initiation of ART at high CD4 levels was evident in San Francisco starting as early as 2007," said Dr. Truong, noting that this trend predated changes to local treatment recommendations calling for initiation regardless of CD4 count. "However, not all groups are accessing early initiation of ART equally, and therefore [they are] not benefiting from the advantages of early treatment."

"Delays in treatment initiation explain observed disparities in survival among persons living with HIV. Disparities will persist unless treatment gaps are closed," she maintained.

There may be financial barriers to accessing antiretrovirals, she said. Insurance companies may require CD4 counts of a certain level before they will cover antiretrovirals. But more likely, individuals and their motivation to seek treatment are driving this trend, she said. San Francisco also has a countywide health care program that provides access to people who don’t have health insurance.

For the study, the investigators identified 3,778 San Francisco HIV-positive patients aged 13 years or older. Results were largely based on 1,803 having a CD4 count of greater than 350 cells/mm³ at diagnosis, and specifically the 941 who initiated ART.

National guidelines at the start of the study period in 2004 recommended that HIV-positive patients begin ART when their CD4 count dropped below 350 cells/mm³, Dr. Truong noted. (They have since been updated to recommend initiation at 500 cells/mm³ or less, with initiation at higher levels optional.)

"Recognizing the beneficial impact of early treatment on reducing morbidity and transmission, public health clinics and the Positive Health Program in San Francisco revised their guidelines in 2010," Dr. Truong explained. "The new recommendations called for initiating treatment at the time of HIV diagnosis, irrespective of CD4 counts."

The median count at diagnosis remained essentially stable during the 7-year study period, at roughly 550 cells/mm³, whereas that at ART initiation increased, from 365 to 496 cells/mm³ (P less than .001). Thus, the gap between the two values narrowed (P less than .001).

Dr. Truong and Dr. Porter reported having no relevant conflicts of interest.

SEATTLE – HIV-positive patients are increasingly initiating antiretroviral treatment early in the course of their disease, which should improve their outcomes, suggests a study conducted in San Francisco.

However, some groups are clearly not included in this favorable trend, said the study’s lead investigator, Hong-Ha M. Truong, Ph.D., an assistant professor of medicine at the University of California, San Francisco.

Overall, the findings reflect the implementation of a test-and-treat approach recently introduced in San Francisco aimed at increasing early use of antiretroviral therapy (ART) among HIV-positives and reducing CD4 cell loss in the interval between HIV diagnosis and treatment initiation, said Kholoud Porter, Ph.D., session comoderator and senior epidemiologist with the Medical Research Council (MRC) Clinical Trials Unit in London.

"Given the need for good adherence to lifelong ART, it will be crucial to monitor these individuals and document the proportion who remain on ART and maintain viral suppression," she said at the Conference on Retroviruses and Opportunistic Infections.

The disparity in early ART uptake should inform public health policy, she added.

The study involved more than 3,750 adolescents and adults from the city’s HIV/AIDS Case Registry; their infections were diagnosed between 2004 and 2010.

Dr. Truong and her colleagues showed that the proportion of patients initiating ART early, that is, at a CD4 count of greater than 350 cells/mm³, increased dramatically: Among those who had a count above this value at diagnosis and initiated ART during the study period, only about half (48%) initiated early in 2004, whereas nearly all (93%) did so in 2010, she reported.

In adjusted analyses, however, the proportion of patients initiating ART early was significantly lower among racial/ethnic minorities, young individuals, injection drug users, patients whose diagnosis was made in nonprivate facilities, and those living in impoverished areas.

"Early initiation of ART at high CD4 levels was evident in San Francisco starting as early as 2007," said Dr. Truong, noting that this trend predated changes to local treatment recommendations calling for initiation regardless of CD4 count. "However, not all groups are accessing early initiation of ART equally, and therefore [they are] not benefiting from the advantages of early treatment."

"Delays in treatment initiation explain observed disparities in survival among persons living with HIV. Disparities will persist unless treatment gaps are closed," she maintained.

There may be financial barriers to accessing antiretrovirals, she said. Insurance companies may require CD4 counts of a certain level before they will cover antiretrovirals. But more likely, individuals and their motivation to seek treatment are driving this trend, she said. San Francisco also has a countywide health care program that provides access to people who don’t have health insurance.

For the study, the investigators identified 3,778 San Francisco HIV-positive patients aged 13 years or older. Results were largely based on 1,803 having a CD4 count of greater than 350 cells/mm³ at diagnosis, and specifically the 941 who initiated ART.

National guidelines at the start of the study period in 2004 recommended that HIV-positive patients begin ART when their CD4 count dropped below 350 cells/mm³, Dr. Truong noted. (They have since been updated to recommend initiation at 500 cells/mm³ or less, with initiation at higher levels optional.)

"Recognizing the beneficial impact of early treatment on reducing morbidity and transmission, public health clinics and the Positive Health Program in San Francisco revised their guidelines in 2010," Dr. Truong explained. "The new recommendations called for initiating treatment at the time of HIV diagnosis, irrespective of CD4 counts."

The median count at diagnosis remained essentially stable during the 7-year study period, at roughly 550 cells/mm³, whereas that at ART initiation increased, from 365 to 496 cells/mm³ (P less than .001). Thus, the gap between the two values narrowed (P less than .001).

Dr. Truong and Dr. Porter reported having no relevant conflicts of interest.