It’s Time to Make the Time to Viral Suppression After HIV Diagnosis a Metric of HIV Care Success
Year: 2018
Type: editorial
Abstract: (See the Breif Report by Xia et al on pages 851–5.) Viral suppression in persons living with human immunodeficiency virus (HIV) saves lives and prevents new infections [1, 2]. Recently, the “undetectable=untransmittable” (U=U) concept has been embraced by community advocates and widely endorsed by scientific and public health agencies as a stigma-combating message grounded in rigorous science [3]. As the science behind U=U has fallen into place, so too has the drive to ensure that persons in which HIV infection has been newly diagnosed achieve viral suppression quickly. However, neither of the 2 flagship strategies guiding HIV prevention and care in the United States (the Joint United Nations Program on AIDS [UNAIDS] 90-90-90 targets [4] and the US National HIV/AIDS Strategy [NHAS] [5]) incorporates a time element. The numeric goals of UNAIDS and the NHAS—81% and 80% viral suppression, respectively, among persons with a diagnosis of HIV infection—measure only a cross-sectional snapshot of the population. Yet a person who reaches viral suppression within 1 month of diagnosis reflects a greater individual and public health success than one who reaches viral suppression 1 year after diagnosis. In the current issue of The Journal of Infectious Diseases, Xia et al propose a new metric for the HIV care continuum in the United States that incorporates a target interval: the percentage of persons in whom HIV infection is newly diagnosed who achieve viral suppression within 3 months of diagnosis [6]. Using surveillance data in New York City, the authors report that the cumulative percentage of all persons with an HIV infection diagnosis who achieved this goal increased from 9% in 2007 to 37% in 2016. The metric is conceptually simple, clear, and, because the United States has a robust population-based surveillance system, relatively easy to measure. As opposed to the viral suppression target in the overall population, the new metric can show year-to-year improvements in a shorter time if measured using newly diagnosed cases. Thus, this new metric is a rapidly available lead measure that provides an early signal for the lag measure of cross-sectional population viral suppression. In considering the proposed metric, it is crucial to consider what the metric is measuring, beyond simply how the percentage is calculated, and how knowing the results of that metric will inform public health action. The percentage of newly diagnosed cases that reach viral suppression within 3 months is fundamentally a measure of the effectiveness of the health system. It reflects the degree to which diagnosing and treating providers coordinate, administrative processes for care entry are streamlined, HIV care providers are available, clinics accommodate new patients, and all parties facilitate rapid ART initiation. In much of the United States currently, the steps between HIV diagnosis and viral suppression require procession through multiple disjointed steps that place too much onus on the person with newly diagnosed infection to navigate a complex system. This often reflects organizational and funding silos layered on top of the general complexity of the US healthcare system. Although everyone in each part of the system may be trying to do their part well, put together, the system is not patient centered. Shortening the time to viral suppression after HIV diagnosis is a shared responsibility of HIV testing sites, health departments, Ryan White program administrators, HIV clinics, and case management organizations. This is not to say that only health system factors influence the time to viral suppression within a population. Without doubt this metric is also influenced by structural factors, such as poverty, racism, homophobia, transphobia, HIV stigma, the decision by state governments not to expand Medicaid, and other public policies. These factors fuel health inequities. But even in the context of these barriers, we can make progress. Our HIV public health programs and healthcare systems can work to find avenues to mitigate the impact of these barriers on the health outcomes of persons living with HIV. Like other measures of the HIV care continuum, results of the new metric will inevitably vary widely across jurisdictions, and comparisons between jurisdictions must account for the vast differences in resources available for HIV prevention and care. New York City, the site of the report in this issue, has a long history of demonstrable political will to fight HIV. New York State not only expanded Medicaid eligibility in 2014, but also released a plan to end the AIDS epidemic, backed by $10 million in the 2015–2016 budget year. The situation is entirely different in many southern states, where resources to address HIV are more limited, HIV morbidity remains high, and rates of new HIV infections, especially in young men of color who have sex with men, are alarming. Importantly, geographic disparities in HIV care continuum estimates should not be used to blame and shame people working on the front lines of HIV care and prevention in areas with both high HIV morbidity and scant resources. Xia et al propose that the new metric be incorporated into the NHAS, but the status of the strategy was uncertain during the first year of the Trump Administration. The website of the Office of National AIDS Policy, under the auspices of which the NHAS was released in 2010 and updated in 2015, was taken down and archived [7]. President Trump has not appointed a new director since the most recent one stepped down, in January 2017. In August 2017, the President’s Advisory Council on HIV/AIDS (PACHA) wrote a public letter to the Secretary of Health and Human Services, expressing concern about whether the NHAS was still the national strategy and calling on the administration to provide clear direction to federal agencies [8]. All members of PACHA were subsequently dismissed and have yet to be replaced as of this writing. Despite these events and the initial lack of clarity, the NHAS remains the prevailing HIV strategy for the United States. The Department of Health and Human Services released the most recent NHAS update, in which the NHAS goals and vision were affirmed, in May 2018 [9]. Thus, as Xia et al suggest, we should hold ourselves and our systems accountable by advocating for and adopting a metric in the NHAS that is focused on rapid achievement of viral suppression. In the era of U=U, we must focus not just on increasing viral suppression, but also on shortening the time to viral suppression after diagnosis. And for individual and public health benefits, we should push onward to reduce the time from infection to diagnosis, to further curtail the time an individual is viremic. Achieving these goals will require changing our systems and practices to make testing normalized and convenient, linkage to care streamlined, and initiation of ART rapid and barrier free, so that the process works in a truly patient-centered way with as few steps, as little hassle, and as much coordination and integration as possible. We need this new metric to drive our collective efforts to improve systems of care for persons with newly diagnosed HIV infection. It is time! Financial support. This work was supported by the National Institutes of Health (NIH) through a grant to the University of Washington Center for AIDS Research (P30AI027757) that includes support from the following NIH institutes and centers: the National Institute of Allergy and Infectious Diseases; the National Cancer Institute; the National Institute of Mental Health; the National Institute on Drug Abuse; the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute on Aging; the National Institute of General Medical Sciences; and the National Institute of Diabetes and Digestive and Kidney Disease). Potential conflicts of interest. J. C. D. has conducted research unrelated to this work that is supported by grants to the University of Washington from Hologic, Curatek, and Quidel. J. M. B. has served on advisory boards for Gilead Science and Merck and has received donated study medication from Gilead and IPM, all of which are unrelated to this work. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Authors: Julia C Dombrowski, Jared M Baeten
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
Funders: Gilead Sciences, University of Washington, National Institutes of Health, Center for AIDS Research, University of Washington, National Heart, Lung, and Blood Institute, National Institute of Mental Health, National Cancer Institute, National Institute of General Medical Sciences, National Institute of Allergy and Infectious Diseases, National Institute of Child Health and Human Development, Eunice Kennedy Shriver National Institute of Child Health and Human Development
OpenAlex ID: W2897879011