Increased utilization of antiretroviral therapy (ART), as well as therapeutic regimens comprised of integrase strand transfer inhibitors (ISTIs), have almost tripled HIV viral suppression rates across the United States since 1997, according to a nationwide trends analysis. Greater work is needed, however, in suppressing the virus in younger and black HIV patients, the investigators reported.

“As we strive to end the HIV epidemic in the United States, targeted treatment interventions for populations with low levels of viral suppression, paired with tailored prevention packages, will be essential,” Hilary D. Marston, MD, MPH, and colleagues, wrote in an accompanying editorial.

In the longitudinal observational cohort study led by Heidi M. Crane, MD, MPH, professor of medicine at Harborview Medical Center in Seattle, Washington, patients with HIV receiving clinical care at a total of 8 HIV clinics in the United States were enrolled to retrospectively determine trends in viral suppression (n = 31,930).

Investigators defined viral suppression as reducing viral load to ≤400 copies/mL. Annual viral suppression rates between 1997-2015 were assessed. Additionally, the researchers assessed the associations between HIV patients receiving ART and viral suppression or continuous viral load levels, demographics, substance use, treatment adherence, and use of ISTI.

Between the years 1997 and 2015, viral suppression across all 8 centers increased from 32% to 86%, respectively. Following multivariable adjustment, the investigators found significant associations between a lower odds of having a detectable viral load with older age (odds ratio [OR]; .76 per decade; 95% confidence interval [CI] .74-.78; P<.001) and using an ISTI-based regimen (OR .54; 95% CI .51-.57; P<.001).

Conversely, patients who were black were more likely to have a detectable viral load compared with other races (OR 1.68; 95% CI 1.57-1.80; P<.001). The investigators also found similar associations when limiting the analysis to the years 2010 to 2015 and adjusting for adherence to therapy, depression, and substance use.

Considering patients included in this study were receiving clinical care, the findings may not generalize across the HIV population not receiving such care. Additionally, patients receiving an ISTI-based regimen were 46% less likely to present with a detectable viral load during the study period; however, there were little data available on the timing of ISTI-based treatment initiation to determine the role of this therapy in viral suppression.

As for the disparities in viral suppression across demographic groups, authors of the accompanying editorial believe that the mere knowledge of current trends will be useful for improving future care in all HIV patients. “Identifying and understanding disparities in achieving viral suppression is the first step in addressing them with targeted interventions,” Marston and colleagues reported in their editorial. “However, as we strive to use ART as a tool to help end the HIV epidemic, the Achilles' heel of treatment as prevention is the inability to bring people living with HIV into care. This population is, by definition, difficult to study because they have already fallen through the proverbial cracks.”

Closing this gap relies primarily on the RAPID (Rapid ART Program Initiative for HIV Diagnoses) program, which dictates starting ART on the day of diagnosis. The authors also added that addressing substance use disorder in patients with HIV may ultimately aid in improving suppression rates across the nation.

“Viral suppression is essential for optimal HIV outcomes, therefore, it is imperative to understand current trends and predictors to target public health policy,” Crane said in an interview with MD Magazine®. “This study demonstrated that viral suppression rates are rapidly improving among patients with HIV who are in clinical care. A number of factors are contributing to these improving rates, including higher HIV treatment rates and better-tolerated regimens, such as those with the integrase strand transfer inhibitors. Marked improvement in levels of viral suppression across the United States bodes well for the long-term health outcomes of the current generation of patients with HIV, however, disparities still exist.”

The studies, “HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study,” and “Ending the HIV Epidemic in the United States: Closing the Implementation Gaps,” were published in Annals of Internal Medicine.