Robin M. Nance, MS *; J.A. Chris Delaney, PhD *; Jane M. Simoni, PhD *; Ira B. Wilson, MD, MSc; Kenneth H. Mayer, MD; Bridget M. Whitney, MPH; Frances M. Aunon, MS; Steven A. Safren, PhD; Michael J. Mugavero, MD, MHSc; W. Christopher Mathews, MD, MSPH; Katerina A. Christopoulos, MD, MPH; Joseph J. Eron, MD; Sonia Napravnik, PhD; Richard D. Moore, MD, MHSc; Benigno Rodriguez, MD; Bryan Lau, PhD, ScM, MHS; Rob J. Fredericksen, PhD, MPH; Michael S. Saag, MD; Mari M. Kitahata, MD, MPH; Heidi M. Crane, MD, MPH
Presented in part at the 11th International Conference on HIV Treatment and Prevention Adherence, Fort Lauderdale, Florida, 9–11 May 2016, and at the 23rd Conference on Retroviruses and Opportunistic Infections, Boston, Massachusetts, 22–25 February 2016.
Acknowledgment: The authors thank the providers, the staff, and particularly the patients across all of the CNICS sites for their ongoing support.
Grant Support: This work was supported by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health (U24AA020801, U01AA020793, and U01AA020802). Additional support came from the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (CNICS R24 AI067039, UW CFAR NIAID Grant P30 AI027757, UNC CFAR grant P30 AI50410, JHU CFAR grant P30 AI094189, Providence/Boston CFAR grant P30 AI042853, and UAB CFAR grant P30 AI027767), the National Institute of General Medical Sciences (U54 GM115677), and the National Institute on Drug Abuse (DA U01036935).
Disclosures: Dr. Wilson reports consulting fees from Pfizer outside the submitted work. Dr. Mayer reports grants from Gilead Sciences and ViiV Healthcare outside the submitted work. Dr. Mugavero reports personal fees from the Gilead Foundation and a grant from Bristol-Myers Squibb outside the submitted work. Dr. Christopoulos reports grants and personal fees from Gilead and personal fees from Roche outside the submitted work. Dr. Eron reports personal fees from Merck and grants and personal fees from ViiV Healthcare, Janssen Pharmaceutical, Gilead Sciences, and Bristol-Myers Squibb outside the submitted work. Dr. Moore reports personal fees from Medscape outside the submitted work. Dr. Rodriguez reports personal fees from Gilead during the conduct of the study. Dr. Saag reports grants from Merck, Bristol-Myers Squibb, Gilead, ViiV Healthcare, AbbVie, and Proteus and personal fees from Merck, Bristol-Myers Squibb, and Gilead outside the submitted work. Dr. Crane reports a grant from ViiV Healthcare outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2242.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Investigators interested in the statistical code used to generate the joint longitudinal and survival or other models may contact Ms. Nance (e-mail, email@example.com). Data set: The CNICS cohort strives to have an open-access approach to data. Investigators who are interested in replicating this study or conducting other work within CNICS should visit the CNICS Web site (www.uab.edu/cnics) for information on how to submit a concept proposal to receive data and conduct studies with the data.
Corresponding Author: Heidi M. Crane, MD, MPH, Professor of Medicine, Associate Director Clinical Epidemiology and Health Services Research Core, Center for AIDS Research, Harborview Medical Center, 325 9th Avenue, Box 359931, Seattle, WA 98104; e-mail, firstname.lastname@example.org.
Current Author Addresses: Ms. Nance and Dr. Delaney: Collaborative Health Studies Coordinating Center, University of Washington, Box 354922, Building 29, Suite 210, Seattle, WA 98115.
Dr. Simoni and Ms. Aunon: University of Washington, 3909 Stevens Way NE, Campus Box 351525, Seattle, WA 98195-1525.
Dr. Wilson: Brown University, G-S121-7, 121 South Main Street, Providence, RI 02912.
Dr. Mayer: Fenway Community Health Center, 7 Haviland Street, Boston, MA 02215.
Ms. Whitney: Collaborative Health Studies Coordinating Center, University of Washington, Building 29, Suite 310, 6200 NE 74th Street, Seattle, WA 98115.
Dr. Safren: University of Miami, PO Box 248185, Coral Gables, FL 33124-0751.
Drs. Mugavero and Saag: University of Alabama at Birmingham, 908 20th Street South, Birmingham, AL 35205.
Dr. Mathews: University of California, San Diego, UCSD Medical Center, 8681, 200 West Arbor Drive, San Diego, CA 92103.
Dr. Christopoulos: University of California, San Francisco, 995 Potrero Avenue, 4th Floor, San Francisco, CA 94110.
Dr. Eron: University of North Carolina at Chapel Hill, CB #7030, Bioinformatics Building, 130 Mason Farm Road, 2nd Floor, Chapel Hill, NC 27599-7030.
Dr. Napravnik: University of North Carolina at Chapel Hill, CB #7215, 130 Mason Farm Road, 2101 Bioinformatics Building, Chapel Hill, NC 27599-7215.
Dr. Moore: Johns Hopkins Hospital, Room 8059, 1830 East Monument Street, Baltimore, MD 21205.
Dr. Rodriguez: Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106.
Dr. Lau: Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E7150, Baltimore, MD 21205.
Drs. Fredericksen, Kitahata, and Crane: Center for AIDS Research, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA 98104.
Author Contributions: Conception and design: R.M. Nance, J.M. Simoni, I.B. Wilson, S.A. Safren, J.J. Eron, S. Napravnik, H.M. Crane.
Analysis and interpretation of the data: R.M. Nance, J.A.C. Delaney, J.M. Simoni, I.B. Wilson, K.H. Mayer, B.M. Whitney, F.M. Aunon, M.J. Mugavero, J.J. Eron, B. Lau, M.S. Saag, H.M. Crane.
Drafting of the article: R.M. Nance, J.A.C. Delaney, J.M. Simoni, I.B. Wilson, F.M. Aunon, R.J. Fredericksen, M.M. Kitahata, H.M. Crane.
Critical revision of the article for important intellectual content: R.M. Nance, J.A.C. Delaney, J.M. Simoni, I.B. Wilson, K.H. Mayer, F.M. Aunon, S.A. Safren, M.J. Mugavero, W.C. Mathews, K.A. Christopoulos, J.J. Eron, S. Napravnik, R.D. Moore, B. Rodriguez, B. Lau, M.S. Saag, M.M. Kitahata, H.M. Crane.
Final approval of the article: R.M. Nance, J.A.C. Delaney, J.M. Simoni, I.B. Wilson, K.H. Mayer, B.M. Whitney, F.M. Aunon, S.A. Safren, M.J. Mugavero, W.C. Mathews, K.A. Christopoulos, J.J. Eron, S. Napravnik, R.D. Moore, B. Rodriguez, B. Lau, R.J. Fredericksen, M.S. Saag, M.M. Kitahata, H.M. Crane.
Provision of study materials or patients: K.H. Mayer, M.J. Mugavero, W.C. Mathews, J.J. Eron, S. Napravnik, R.D. Moore, B. Rodriguez, M.S. Saag, H.M. Crane.
Statistical expertise: R.M. Nance, J.A.C. Delaney, J.M. Simoni, B. Lau.
Obtaining of funding: M.J. Mugavero, S. Napravnik, M.S. Saag.
Administrative, technical, or logistic support: J.M. Simoni, S. Napravnik, R.J. Fredericksen, M.S. Saag, H.M. Crane.
Collection and assembly of data: R.M. Nance, B.M. Whitney, M.J. Mugavero, K.A. Christopoulos, J.J. Eron, S. Napravnik, R.D. Moore, B. Rodriguez, R.J. Fredericksen, M.S. Saag, M.M. Kitahata, H.M. Crane.
Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy.
To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use.
Longitudinal observational cohort study.
8 HIV clinics across the United States.
PLWH receiving clinical care.
To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use.
Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression.
Results are limited to PLWH receiving clinical care.
HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention.
National Institutes of Health.
Nance RM, Delaney JC, Simoni JM, et al. HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study. Ann Intern Med. 2018;169:376–384. [Epub ahead of print 21 August 2018]. doi: https://doi.org/10.7326/M17-2242
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Published: Ann Intern Med. 2018;169(6):376-384.
Published at www.annals.org on 21 August 2018
HIV, Infectious Disease.
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