In 2012, HIV treatment guidelines began recommending initiation of ART as soon as possible after diagnosis regardless of CD4 count. This endorsement became part of the formal DHHS guidelines in February 2013. If providers made this part of standard practice, it should have resulted in a shorter time interval between HIV diagnosis and first viral suppression (Dx-to-VS). The authors of this study used data from the U.S. National HIV Surveillance System, looking at the interval of Dx-to-VS for persons > 13 years old who were diagnosed in 2012 compared to Dx-to-VS for those diagnosed in 2017. Their analysis was stratified based on baseline CD4 ≥500 cells/µL, 200–499 cells/µL, <200 cells/µL, or no CD4 count reported within 3 months after diagnosis. From 2012 to 2017 in 27 U.S. jurisdictions there were 138,759 new HIV diagnoses. In 2012, Dx-to-VS was longest for persons with CD4 ≥500 cells/µL at a median of 9 months compared to 7 months for those with a CD4 count of 200–499 cells/µL and 6 months for those <200 cells/µL. By 2017, the overall median interval to VS was only 4 months for these groups which represented a 12.3% annual decrease. This was compared to 25 months for those with no CD4 count within 3 months after diagnosis. Time to viral suppression for all groups declined with time – consistent with implementation of the DHHS guidelines recommendations for early treatment. The exception was seen in those persons not on treatment within 3 months of diagnosis – underscoring the importance of getting patients link to care and on ART.
This is encouraging data showing that HIV providers gradually implemented the change in practice first recommended in 2012-2013. Some of the additional improvements in VS rates may also be due to the increased use of Integrase inhibitors although this was not addressed in this study. It is rather notable in retrospect that we waited to treat patients until their CD4 counts were < 350 cells/µL – a recommendation based on the best clinical and observational data at the time and also driven in part by concerns of drug resistance and toxicity.
The author has no conflicts of interest to disclose.
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