Novel Use of Surveillance Data to Detect HIV-Infected Persons with Sustained High Viral Load and Durable Virologic Suppression in New York City

Abstract

BackgroundMonitoring of the uptake and efficacy of ART in a population often relies on cross-sectional data, providing limited information that could be used to design specific targeted intervention programs. Using repeated measures of viral load (VL) surveillance data, we aimed to estimate and characterize the proportion of persons living with HIV/AIDS (PLWHA) in New York City (NYC) with sustained high VL (SHVL) and durably suppressed VL (DSVL).Methods/Principal FindingsRetrospective cohort study of all persons reported to the NYC HIV Surveillance Registry who were alive and ≥12 years old by the end of 2005 and who had ≥2 VL tests in 2006 and 2007. SHVL and DSVL were defined as PLWHA with 2 consecutive VLs ≥100,000 copies/mL and PLWHA with all VLs ≤400 copies/mL, respectively. Logistic regression models using generalized estimating equations were used to model the association between SHVL and covariates. There were 56,836 PLWHA, of whom 7% had SHVL and 38% had DSVL. Compared to those without SHVL, persons with SHVL were more likely to be younger, black and have injection drug use (IDU) risk. PLWHA with SHVL were more likely to die by 2007 and be younger by nearly ten years, on average.Conclusions/SignificanceNearly 60% of PLWHA in 2005 had multiple VLs, of whom almost 40% had DSVL, suggesting successful ART uptake. A small proportion had SHVL, representing groups known to have suboptimal engagement in care. This group should be targeted for additional outreach to reduce morbidity and secondary transmission. Measures based on longitudinal analyses of surveillance data in conjunction with cross-sectional measures such as community viral load represent more precise and powerful tools for monitoring ART effectiveness and potential impact on disease transmission than cross-sectional measures alone.

Disparities in community viral load among HIV-infected persons in New York city

“…We found that the proportion of undetectable viral load varies by individual and neighbourhood-level characteristics wherein socioeconomically disadvantaged areas have the lowest proportions of persons with undetectable viral load and higher CVL, results consistent with previous findings that uptake and/or adherence may be lower in poorer neighbourhoods [20]. Although mean viral load as a measure of CVL is sensitive to the number of viral load laboratory tests reported and to extreme values, differences found between groups were generally small.…”

“…Also, our analysis is limited to those who are reported to the HSR and in care. Because HIV-infected populations are dynamic and tend to move more often than HIV-uninfected populations, identifying all HIV-infected New Yorkers is difficult [20]. The limitation that 36% were missing a viral load report in 2008 likely influences observed CVL estimates.…”

“…HIV surveillance data, routinely and systematically collected, offer the most complete, standardized view of the NYC epidemic [20]. Because these data best approximate HIV dynamics at the population level, DOHMH data were used in an analysis of patterns of care and patient caseload by health facility to inform the NYC HIV Care Coordination Program, a multimillion dollar initiative to improve patient care outcomes [21].…”

Durable Viral Suppression and Transmission Risk Potential Among Persons With Diagnosed HIV Infection: United States, 2012–2013

“…8–12 This single VL measure, however, does not allow a close examination of VL dynamics over time. 4,13,14 Several studies have begun to evaluate longitudinal VL measures. 4,13–15 Data from six HIV clinics showed that using a single VL measure to estimate the percentage of HIV patients with durable viral suppression (all VLs < 200 copies m/L) overestimated by 16% (relative difference) over a 12-month period.…”

Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care – Washington, DC*

“…Persons with persistently and intermittently high VLs are at higher risk for developing resistant virus (Lucas et al, 1999) and transmitting virus. (Terzian et al, 2012) In this analysis, unsustained virologic control was associated with structural factors including insurance, and unstable housing. These data thus can inform public health decisions regarding strategies to reduce the costs associated with HIV care and reduce HIV associated morbidities.…”