icon-    folder.gif   Conference Reports for NATAP  
  22nd Conference on Retroviruses and
Opportunistic Infections
Seattle Washington Feb 23 - 26, 2015
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Linkage to HIV care and viral suppression climb steadily in New York City - improvements to 76%, 73%
  CROI 2015, February 23-26, 2015, Seattle, Washington
Mark Mascolini
Linkage to care rose steadily among people newly diagnosed with HIV in New York City (NYC) from 2006 through 2013 [1]. Viral suppression rates also climbed, typically reflecting evolving treatment guidelines. Linkage rates did not improve since 2006 among people 55 and older, usually a group with good linkage and treatment rates.
Since 2007 the US Department of Health and Human Services (DHHS) has advocated timely linkage to care for people newly diagnosed with HIV. A 2010 New York State law requires linkage for consenting newly diagnosed people. DHHS guidelines called for progressively earlier initiation of antiretroviral therapy (ART) across the 2006-2013 study period. NYC Department of Health and Mental Hygiene researchers conducted this analysis of NYC surveillance registry data to see if linkage and viral suppression rates have changed by age and CD4 count at diagnosis.
The study focused on newly diagnosed people older than 17 who survived more than 91 days after HIV diagnosis. Lucia Torian and colleagues defined timely linkage to care as a CD4 count or viral load test 8 to 91 days after diagnosis. They defined viral suppression as a viral load of 400 copies or lower measured 6, 9, and 12 months after diagnosis. The investigators imputed CD4 count at diagnosis from the value and timing of the first recorded CD4 count.
Timely linkage to care jumped from 68% in 2006 to 76% in 2013, a highly significant change (P < 0.0001). The improvement held true for all CD4 strata at diagnosis, including people with a CD4 count of 500 or more at diagnosis. Linkage to care in lowest CD4 group 0-199 was 90% by 2013 and in the 200-349 group 80%. Steady improvement in linkage to care also held true for every age group analyzed--except people 55 or older. This oldest group had the highest linkage rate in 2006--close to 80%--but in 2013 they had the lowest linkage rate, around 70%.
Viral suppression rate 6 months after diagnosis doubled from 24% in 2006 to 54% in 2013, while vaulting from 32% to 65% at 9 months and from 36% to 69% at 12 months (P < 0.0001 for all). Viral suppression rates improved from 2006 through 2013 in all age groups, although 18- to 24-year-olds trailed older age groups consistently across the years. Yet for people 18 to 34 years old, viral suppression at 12 months more than doubled from 30% to 66% over the study period. Among people with a CD4 count at or above 350 at diagnosis, viral suppression rate at 12 months almost quadrupled over the study period from 19% to 73%.
For people with a CD4 count of 500 or more at diagnosis, the viral suppression rate at 6 months began rising steeply in 2010, as support for ART at higher CD4 counts rose. In 2011 the DHHS panel split on whether to recommend ART at a CD4 count above 500; in 2012 DHHS recommended ART for everyone regardless of CD4 count. But by 2013 in NYC, the viral suppression rate in people with 500 CD4s at diagnosis still lagged suppression rates in people with lower CD4 counts at diagnosis.
The NYC team suggested their analysis benefits from its big size, long follow-up, and universal HIV-related lab reporting in the city. Limitations include inability to assess undiagnosed people, lack of data on ART use, and no out-of-city follow-up.
"These favorable trends notwithstanding," Torian and coworkers concluded, "as of 2013, NYC was still far from the ideal of timely linkage to care and viral suppression for all newly diagnosed residents."
1. Wiewel EW, Torian LV, Xia Q, Braunstein SL. Linkage to care and viral suppression among new HIV diagnoses, New York City, 2006-13. CROI 2015. February 23-26, 2015. Seattle, Washington. Abstract 99.