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Good Antiretroviral Therapy Outcomes for a Challenging Patient Population

Today's state-of-the-art antiretroviral therapy (ART) can suppress HIV viral load to an undetectable level in most patients, even when looking at an urban population with demographic and socioeconomic characteristics that have been linked to poor treatment outcomes in the past, according to a report in the September 2011 issue of Clinical Infectious Diseases.

Richard Moore, John Bartlett, and colleagues from Johns Hopkins University School of Medicine performed an analysis of trends in HIV RNA levels over time among people receiving care at a large HIV clinical practice in Baltimore.

The researchers previously demonstrated that as therapy improved over time since the advent of protease inhibitors and multi-class combination highly active antiretroviral therapy (HAART) in 1995-1996, the likelihood of achieving viral suppression has also risen in this clinic population. Since antiretroviral drugs and treatment guidelines have continued to evolve, they aimed to determine if there is an ongoing trend toward better treatment outcomes.

The analysis included 5290 participants (not all at the same time) who entered the Johns Hopkins HIV Clinical Cohort and received care between 1996 and 2010. A majority were men, most were African-American, many were low-income, and a substantial percentage had a history of injection drug use.

Investigators looked at HIVRNA levels measured each year through 2010, and assessed the clinic population’s median HIV viral load and demographic characteristics over time.

Results

• The likelihood of participants using HAART increased over time, from 22% in 1996 to 85% in 2010.
• The proportion of patients who continued receiving care (retention) rose from 86% to 94%, respectively.
• Between 1996 and 2010 the median population HIV RNA level decreased from 10,400 to < 200 copies/mL.
• By 2002, 79% of cohort participants had undetectable HIV viral load, compared with 44% in 1998.
• The proportion of patients who maintained a viral load above 500 copies/mL decreased from 74% to 17% during the same period, even when including patients not yet on ART.
• CD4 cell counts improved as well, with the median rising from 239 to 444 cells/mm³.
• Demographics of the clinic population shifted somewhat over time:
  • Larger proportion of women;
  • Older age: median 38 years in 1996 vs 49 years in 2010;
  • Lower proportion of injection drug users: 46% vs 36%, respectively;
  • Larger proportion infected through heterosexual sex: 43% vs 51%, respectively.

Based on these findings, the study authors concluded, "Our results demonstrate the remarkable impact of increased use of and improved management with HAART in this urban HIV-infected population."

"We believe that our results emphasize that even in an inner urban HIV-infected population with a relatively high proportion of patients who were infected as a consequence of injection drug use, HAART can be highly successful," they elaborated in their discussion.

These results "are a testament to the remarkable effectiveness of HAART in our patient population," they continued. "We believe that our results emphasize the importance of early detection and early and successful referral for HIV care." They added that lowering population viral load may also contribute to reduced HIV transmission in the larger community.

In an accompanying editorial -- entitled Antiretroviral Therapy: Now “It Just Works” --  Paul Sax from Brigham and Women's Hospital and Harvard Medical School noted that while the clinical benefits of ART for individuals with advanced HIV disease were "plainly evident" early on, enthusiasm for treating asymptomatic patients was dampened by short-term side effects, unexpected long-term toxicities, regimen complexity, high cost, and poorer outcomes in "real life" than in clinical trials -- as was the case with a prior analysis of Johns Hopkins clinic patients that found a viral suppression rate of only 37%.

In comparison, modern ART regimens "show an extremely high treatment success rates, even in the context of challenging sociodemographic circumstances," Sax wrote. "Providers faced with potentially difficult cases can be reassured that most of these cases are in patients who will achieve virologic suppression with the effective and well-tolerated regimens now available."

Investigator affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

9/2/11

References

RD Moore and JG Bartlett. DramaticDecline in the HIV-1 RNA Level Over Calendar Time in a Large Urban HIV Practice. Clinical Infectious Diseases 53(6):600-604 (abstract). September 2011.

P Sax. Antiretroviraltherapy: now "it just works". Clinical Infectious Diseases 53(6):606-608 (abstract). September 2011.