The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection

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Abstract

For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention.

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Most cited references 54

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Estimation of HIV incidence in the United States.

H. Irene Hall, Ruiguang Song, Philip Rhodes … (2008)

Incidence of human immunodeficiency virus (HIV) in the United States has not been directly measured. New assays that differentiate recent vs long-standing HIV infections allow improved estimation of HIV incidence. To estimate HIV incidence in the United States. Remnant diagnostic serum specimens from patients 13 years or older and newly diagnosed with HIV during 2006 in 22 states were tested with the BED HIV-1 capture enzyme immunoassay to classify infections as recent or long-standing. Information on HIV cases was reported to the Centers for Disease Control and Prevention through June 2007. Incidence of HIV in the 22 states during 2006 was estimated using a statistical approach with adjustment for testing frequency and extrapolated to the United States. Results were corroborated with back-calculation of HIV incidence for 1977-2006 based on HIV diagnoses from 40 states and AIDS incidence from 50 states and the District of Columbia. Estimated HIV incidence. An estimated 39,400 persons were diagnosed with HIV in 2006 in the 22 states. Of 6864 diagnostic specimens tested using the BED assay, 2133 (31%) were classified as recent infections. Based on extrapolations from these data, the estimated number of new infections for the United States in 2006 was 56,300 (95% confidence interval [CI], 48,200-64,500); the estimated incidence rate was 22.8 per 100,000 population (95% CI, 19.5-26.1). Forty-five percent of infections were among black individuals and 53% among men who have sex with men. The back-calculation (n = 1.230 million HIV/AIDS cases reported by the end of 2006) yielded an estimate of 55,400 (95% CI, 50,000-60,800) new infections per year for 2003-2006 and indicated that HIV incidence increased in the mid-1990s, then slightly declined after 1999 and has been stable thereafter. This study provides the first direct estimates of HIV incidence in the United States using laboratory technologies previously implemented only in clinic-based settings. New HIV infections in the United States remain concentrated among men who have sex with men and among black individuals.

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Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel.

Melanie Thompson, Judith Aberg, Pedro Cahn … (2010)

Recent data regarding the consequences of untreated human immunodeficiency virus (HIV) infection and the expansion of treatment choices for antiretroviral-naive and antiretroviral-experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adults with HIV infection. To provide updated recommendations for management of HIV-infected adults, using antiretroviral drugs and laboratory monitoring tools available in the international, developed-world setting. This report provides guidelines for when to initiate antiretroviral therapy, selection of appropriate initial regimens, patient monitoring, when to change therapy, and what regimens to use when changing. A panel with expertise in HIV research and clinical care reviewed relevant data published or presented at selected scientific conferences since the last panel report through April 2010. Data were identified through a PubMed search, review of scientific conference abstracts, and requests to antiretroviral drug manufacturers for updated clinical trials and adverse event data. New evidence was reviewed by the panel. Recommendations were drafted by section writing committees and reviewed and edited by the entire panel. The quality and strength of the evidence were rated and recommendations were made by full panel consensus. Patient readiness for treatment should be confirmed before initiation of antiretroviral treatment. Therapy is recommended for asymptomatic patients with a CD4 cell count 500/microL. Components of the initial and subsequent regimens must be individualized, particularly in the context of concurrent conditions. Patients receiving antiretroviral treatment should be monitored regularly; treatment failure should be detected and managed early, with the goal of therapy, even in heavily pretreated patients, being HIV-1 RNA suppression below commercially available assay quantification limits.

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Less than 95% adherence to nonnucleoside reverse-transcriptase inhibitor therapy can lead to viral suppression.

David R Bangsberg (2006)

For antiretroviral therapy, the 95% adherence "threshold" is based on nucloside-exposed patients who are receiving partially suppressive, unboosted protease inhibitor regimens. Using unannounced pill counts and electronic medication monitoring, viral suppression is common with a 54%-100% mean adherence level to nonnucleoside reverse-transcriptase-inhibitor regimens. Although perfect adherence is an important goal, viral suppression is possible with moderate adherence to potent regimens.

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Author and article information

Journal

Title: Clinical Infectious Diseases

Abbreviated Title: Clinical Infectious Diseases

Publisher: Oxford University Press (OUP)

ISSN (Print): 1058-4838

ISSN (Electronic): 1537-6591

Publication date Created: March 01 2011

Publication date Created: March 15 2011

Publication date (Electronic): March 01 2011

Publication date (Print): March 15 2011

Volume: 52

Issue: 6

Pages: 793-800

Article

DOI: 10.1093/cid/ciq243

PMC ID: 3106261

PubMed ID: 21367734

SO-VID: 428a7162-fc28-4070-8ae2-0cc1466b825a

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Self URI (article page): https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciq243

The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection

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Abstract

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Decoding Infection and Transmission

Most cited references 54

Estimation of HIV incidence in the United States.

Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel.

Less than 95% adherence to nonnucleoside reverse-transcriptase inhibitor therapy can lead to viral suppression.

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