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AIDS 2012: More People Starting HIV Treatment, Lower Viral Load in NA-ACCORD Study

More than 80% of HIV patients in the large North American ACCORD study are receiving combination antiretroviral therapy (ART), about 70% have suppressed viral load -- up from less than 50% in 2000 -- and the median age at the time of death rose by 6 years, researchers reported at the recent XIX International AIDS Conference (AIDS 2012) in Washington, DC.

It is well know that the advent of effective combination antiretroviral treatment dramatically improved the health and survival of people with HIV, but even in wealthy countries a significant proportion do not know they are infected, have not entered care, or have not managed to maintain an undetectable viral load.

Trends in ART Use and Viral Suppression

Keri Althoff from Johns Hopkins Bloomberg School of Public Health and colleagues looked at changing national trends in HIV treatment and outcomes among adults receiving care in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), which includes more than 45,000 participants in over 20 cohorts in the U.S. and Canada.

The researchers analyzed data from 45,529 HIV positive NA-ACCORD participants who had at least 1 plasma HIV viral load or CD4 T-cell measurement in an HIV clinical setting between January 2000 and December 2008.

The investigators calculated percentage of patients on ART, viral load suppression < 500 copies/mL, and median age and CD4 count at the time of death, and compared these across calendar years.

Results

• From 2000 to 2008, the percentage of participants on combination ART rose from 74% to 83%, a significant increase.
• In 2008, among treatment-naive patients, 37% were using protease inhibitor-based and 57% were using non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line regimens.
• The percentage of participants with viral load suppression rose from 46% in 2000 to 72% in 2008, also a significant increase:

o   2000: 46%;

o   2001: 46%;

o   2002: 47%;

o   2003: 49%;

o   2004: 54%;

o   2005: 58%;

o   2006: 61%;

o   2007: 65%;

o   2008: 72%.

• Among 4417 participants who died during the study period, the median age at the time of death increased from 44 years in 2000 to 50 years in 2008.
• Three-quarters of patients who died were under age 50 in 2000, compared with about half% in 2008.
• The median CD4 count at the time of death more than tripled, reaching 209 cells/mm³ in 2008.

Based on these findings, the investigators concluded, "From 2000 to 2008, increases were observed in the percentage prescribed combination ART, the percentage who achieved a suppressed HIV viral load, and the median age and CD4 count at death."

"Our data show improved control of HIV with contemporary management in the U.S. and the utility of NA-ACCORD for monitoring these trends," they added.

Newly Eligible Patients

David Hanna, also from Johns Hopkins, analyzed changes in the rate of ART initiation and resulting viral suppression (again < 500 copies/mL) among NA-ACCORD participants who became newly eligible for treatment between 2001 and 2009.

This study used eligibility criteria based on an older version of U.S. DHHS treatment guidelines in effect until December 2009, that is, the first reported CD4 count below 350 cells/mm³ or AIDS-defining illness. (Current guidelines recommend that everyone diagnosed with HIV should be offered treatment.)

The researchers controlled for a variety of potentially confounding factors including age, sex, race/ethnicity, HIV transmission risk group, CD4 count and viral load at the time of eligibility, state or province of residence, and psychosocial barriers to ART initiation including mental illness, non-injection drug use, and heavy alcohol use.

Results

• Among 10,577 participants analyzed, the adjusted cumulative proportion of people starting ART within 6 months of eligibility increased significantly, from 52% in 2001 to 73% in 2009.
• The overall adjusted cumulative rate of viral suppression at 1 year rose from 55% in 2001 to 81% in 2009, also a significant increase.
• Among 5328 participants who started ART, the rate of viral suppression rose from 83% in 2001 to 92% in 2009.
• The likelihood of ART initiation soon after eligibility rose by 5% per year, while the likelihood of achieving viral suppression increased by 7% per year.

"In the last decade, timely ART initiation and resulting virologic suppression have greatly improved in North America concurrent with the introduction of better regimens," the researchers concluded. "As ART is now being recommended regardless of CD4 cell count, monitoring these trends should continue."

Taken together, these findings indicate that, overall, more people with HIV are starting treatment in a timely manner and achieving good outcomes. But there remain demographic and regional subgroups who do not have as good access to therapy or who are not responding as well, indicating the need for focused efforts to improve treatment success.

9/5/12

References

KN Althoff, K Buchacz, I Hall, et al (North American AIDS Cohort Collaboration on Research and Design). Trends in antiretroviral therapy use, HIV RNA plasma viral load and CD4 T-lymphocyte counts at death among HIV-positive persons in care in the United States, 2000-2008. XIX International AIDS Conference (AIDS 2012). Washington, DC, July 22-27, 2012. Abstract MOPDC0302.

DB Hanna, K Buchacz, KA Gebo, et al. (North American AIDS Cohort Collaboration on Research and Design).Trends in antiretroviral therapy initiation and virologic suppression among newly clinically-eligible HIV-infected individuals in North America, 2001 to 2009. XIX International AIDS Conference (AIDS 2012).  Washington, DC, July 22-27, 2012. Abstract LBPE29.