Antiretroviral Prescription and Viral Suppression in a Representative Sample of HIV-Infected Persons in Care in 4 Large Metropolitan Areas of the United States, Medical Monitoring Project, 2011–2013 : JAIDS Journal of Acquired Immune Deficiency Syndromes

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Antiretroviral Prescription and Viral Suppression in a Representative Sample of HIV-Infected Persons in Care in 4 Large Metropolitan Areas of the United States, Medical Monitoring Project, 2011–2013

Wohl, Amy Rock MPH, PhD*; Benbow, Nanette MPH; Tejero, Judith MPH*; Johnson, Christopher PhD; Scheer, Susan PhD§; Brady, Kathleen MD, MPH; Gagner, Alexandra MPH; Hughes, Alison MPH, PhD§; Eberhart, Michael MPH; Mattson, Christine MPH, PhD; Skarbinski, Jacek MD, MPH

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: October 1, 2017 - Volume 76 - Issue 2 - p 158-170
doi: 10.1097/QAI.0000000000001482
  • Free

Abstract

INTRODUCTION

Improved antiretroviral therapy (ART) has revolutionized HIV care worldwide over the last decade, resulting in widespread reductions in HIV-related comorbidities and mortality.1,2 Newer regimens offer improvements in tolerability, dosing, and potency, and offer new mechanisms of action.3 Despite the advances in treatment, however, there is far from universal ART prescription or use among HIV-infected persons in the United States. Estimates from the now widely recognized HIV continuum showed that among all people living with HIV in the United States at the end of 2011, only 52% were prescribed ART and 47% had achieved viral suppression.4 Among persons in care, however, the proportions are much higher (93% prescribed ART and 77% virally suppressed).5 These data demonstrate the need for improvements in HIV testing, access to care, and sustained use of ART to fully realize the potential gains from advanced treatment options for HIV-infected persons.

In the United States, persons living in large metropolitan areas (population of 500,000 or greater) have HIV diagnoses and prevalence rates that are 2 times higher than persons living in smaller metropolitan areas (population of 50,000–499,999) and over 3 times higher than nonmetropolitan areas.6 Although national estimates of the HIV care continuum, including ART prescription and viral suppression are now available,4,7 there are limited data on differences in ART prescription or viral suppression by urban area. Understanding differences in ART prescription and viral suppression in large metropolitan areas with high HIV prevalence is useful for targeting resources.

The Centers for Disease Control and Prevention (CDC)-funded Medical Monitoring Project (MMP) was designed to assemble a representative sample of adults in HIV care in the United States using a standardized methodology for data collection across 23 state and local jurisdictions,8 each of which assembled its own representative sample. MMP data provide a unique opportunity to examine differences in ART prescription and viral suppression among a representative sample of persons receiving HIV care using a standardized methodology across jurisdictions. MMP was cited by the Institute of Medicine (IOM) as one of the key data sources for monitoring HIV care in the United States9 and has been used by CDC to measure progress toward key objectives of the National HIV/AIDS Strategy.4,10

We present estimates of the prevalence of ART prescription and viral suppression for 4 large US metropolitan areas participating in MMP: the city of Chicago (population 2,722,389), Los Angeles County (LAC) (population 10,116,705), the city of Philadelphia (population 1,560,297), and the city/county of San Francisco (population 852,469).11 We describe how the prevalence of these 2 outcomes varies by sociodemographic and behavioral factors in these cities and in the combined cohort. In addition, we examine the sociodemographic and behavioral characteristics associated with ART prescription and viral suppression within and across the 4 urban areas combined.

METHODS

Study Design and Population

MMP uses probability-proportional-to-size sampling methodology to select samples that are representative both nationally and locally of HIV clinics and patients living with HIV. Patients aged 18 years or older were recruited through their medical providers or directly by the respective health department from 2011 to 2013 and administered a standardized interview survey by trained interviewers on sociodemographic, behavioral, clinical, and prevention factors. A medical record abstraction was also completed for each participant and included information on demographics, medical visits, hospitalizations, diagnoses, medications, prophylaxis, procedures, pregnancy, laboratories, and resistance testing. Although the CDC has determined that MMP is a public health surveillance activity,12 participating jurisdictions obtained local institutional review board approval to conduct MMP when required, and voluntary informed consent was obtained from all participants who were interviewed.

Chicago, LAC, Philadelphia, and San Francisco were selected for inclusion in this analysis because of sufficiently high provider and patient response rates. Data were weighted based on probabilities of selection at facility and patient levels and additionally to adjust for nonresponse using predictors of patient-level response.13–15 Analyses are limited to patients with both interview and medical record abstraction data available. Across the 4 areas, facility response rates ranged from 81.5% to 100% in 2011, from 81.0% to 100% in 2012 and from 84.0% to 100% in 2013. Patient response rates, adjusted for eligibility, ranged from 54.9% to 61.7% in 2011, from 49.6% to 56.3% in 2012, and from 52.1% to 62.7% in 2013.

Measures

Sociodemographic and Behavioral Characteristics

Sociodemographic and behavioral characteristics were obtained from interview data and included age, race/ethnicity, sex, education, injection drug use (IDU) in the previous 12 months, noninjection drug use (non-IDU) in the previous 12 months, health insurance (public, private, or uninsured), any homelessness in the past 12 months, and income above or below the federal poverty guidelines (FPG).16 Marijuana was excluded from the non-IDU variable. A sexual behavior variable was created that combined sex, sex of sex partners, and sexual orientation, and classified respondents as men who have sex with men (MSM), men who have sex with women only (MSW), women who have sex with men, and other (women who have sex with women, transgender persons, and persons who provided no information on sexual behavior or sexual orientation).

ART Prescription and Viral Suppression

The outcome variables, ART prescription and viral suppression, were abstracted from patients' medical records. ART prescription was defined as any ART prescription documented in the 12 months before the interview. Patients were considered virally suppressed if the most recent viral load test result within the past 12 months was less than 200 copies/mL.

Statistical Analyses

For each metropolitan area and in the combined cohort, we calculated prevalence estimates (weighted population percentages) and 95% confidence intervals (CIs) for ART prescription and viral suppression. We conducted bivariate analyses to examine associations between each outcome variable and the sociodemographic and behavioral characteristics, followed by multiple logistic regression with predicted marginals for each metropolitan area and the combined cohort for each outcome. For combined cohort analyses, models with and without the inclusion of city as a predictor were compared with very similar results, and we report results for the models without city. Sociodemographic or behavioral characteristics that were significantly associated with an outcome variable (P ≤ 0.05) in the bivariate analyses for any area were included in the regression models for each metropolitan area and for the combined cohort. Since sex and sexual behavior were collinear, we only used one of these variables in each model: Sex was associated with ART prescription, and sexual behavior variable was associated with viral suppression. In the multivariable models, IDU was excluded because of small cell sizes resulting in unstable estimates (coefficient of variation ≥30%). Adjusted prevalence ratios (aPRs) and 95% CIs are presented for each sociodemographic and behavioral predictor in each metropolitan area and in the combined cohort.

Analyses incorporated the complex sample design and unequal selection probabilities using the survey procedures in SAS (version 9.3; SAS Institute Inc, Cary, NC) and SUDAAN (version 11; RTI International, Research Triangle Park, NC).

RESULTS

A total of 2676 respondents from the 4 metropolitan areas (640 in Chicago, 701 in LAC, 641 in Philadelphia, and 694 in San Francisco) were included. Patient sociodemographic and behavioral characteristics are shown in Table 1 by each metropolitan area separately and in the combined cohort. Measured by average estimated population size for the 3 years, the sum of respondents' analysis weights, the areas varied in size: 9900 in Philadelphia, 10,900 in San Francisco, 13,500 in Chicago, 26,800 in Los Angeles. Because results are population based, Los Angeles had greater influence than Philadelphia, for example, with each area's representation in estimates for the cohort commensurate with its population size. Across all 4 areas, most patients were aged 30 years or older. Although the overall majority of patients were men (83.6%), there were differences in the proportion by sex by metropolitan area. There were also differences by race/ethnicity by metropolitan area: Patients in San Francisco were primarily non-Hispanic white (61.7%) compared with patients in Chicago and Philadelphia who were primarily non-Hispanic black (58.3% and 65.4%, respectively). Latinos (39.9%) were the largest racial/ethnic group in LAC.

T1
TABLE 1.:
Sociodemographic and Behavioral Characteristics of HIV-Infected Patients in Care in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013
table1-a
TABLE 1-A.:
Sociodemographic and Behavioral Characteristics of HIV-Infected Patients in Care in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013

Most patients in each metropolitan area had an education beyond high school and nearly 60% of patients reported an income above the FPG. The proportion of patients experiencing homelessness in the past 12 months ranged from 6.4% in Chicago to 12.2% in San Francisco. Health insurance by metropolitan area varied: The largest proportion of patients in Philadelphia (61.6%), Chicago (44.4%), and LAC (47.2%) had public insurance, whereas most patients (51.3%) in San Francisco had private insurance. Most patients were MSM in all areas except Philadelphia, where only 39.0% were MSM compared with the highest proportion of MSM (84.7%) in San Francisco. IDU in the past 12 months among these populations was fairly low (ranging from <2% in Philadelphia to 8.3% in San Francisco). Non-IDU ranged from 13.6% in Philadelphia to 34.7% in San Francisco. Chi-square tests (data not shown here) indicated significant differences (P < 0.05) in all the sociodemographic and behavioral characteristics, with the exception of homelessness, among the 4 metropolitan areas (Table 1).

ART Prescription

ART prescription among persons in HIV care in each of the 4 metropolitan areas is presented in Table 2. Overall, 92.6% of patients in the combined cohort were prescribed ART. There were no significant differences by metropolitan area.

T2
TABLE 2.:
HIV-Infected Patients in Care Who Were Prescribed ART by Sociodemographic and Behavioral Characteristics in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013
table2-a
TABLE 2-A.:
HIV-Infected Patients in Care Who Were Prescribed ART by Sociodemographic and Behavioral Characteristics in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013

In the combined cohort, persons who were aged 18–29, 30–49, white or black, had private insurance only, reported IDU, or reported non-IDU were less likely to have been prescribed ART compared with persons who were 50+, Hispanic, had public insurance only, reported no IDU, or reported no non-IDU, respectively (Table 2).

Factors associated with ART prescription varied by metropolitan area in the bivariate analyses. Pairwise comparisons indicated that in LAC, persons who were aged 30–49 years, were white, had private insurance, reported IDU, or reported non-IDU were less likely to have been prescribed ART compared with persons who were aged 50 or older, were Hispanic, had public insurance only, reported no IDU, and reported no non-IDU, respectively (P < 0.05). In other areas, differences were marginally significant for only a few factors, possibly because of small sample sizes.

In the multiple logistic regression model (Table 3) for the combined cohort, persons aged 30–49 (aPR = 0.97, CI: 0.94 to 0.99) and persons who reported non-IDU (aPR = 0.94, CI: 0.90 to 0.98) were less likely to have been prescribed ART compared with persons aged 50 years or older and persons who reported no non-IDU. Compared with non-Hispanic whites, Hispanics (aPR = 1.04, CI: 1.01 to 1.08) were more likely to have been prescribed ART. In LAC, after controlling for all other variables, persons aged 30–49 (aPR = 0.94, CI: 0.90 to 0.98) were less likely to have been prescribed ART compared with persons aged 50 years or older. In Chicago, Philadelphia, and San Francisco, there were no significant differences in ART prescription by sociodemographic and behavioral characteristics, after controlling for other variables.

T3
TABLE 3.:
Predictors of ART Prescription Among HIV-Infected Patients in Care in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013

Viral Suppression

Viral suppression prevalence among patients prescribed ART is shown by metropolitan area in Table 4. Viral suppression ranged from 78.6% in Philadelphia to 88.1% in San Francisco and was 82.0% in the combined cohort. Pairwise comparisons indicated that viral suppression in Chicago, LAC, and Philadelphia was significantly lower than in San Francisco (P < 0.05). Philadelphia also had significantly lower viral suppression compared with Chicago.

T4
TABLE 4.:
Proportion of HIV-Infected Patients in Care and Prescribed ART Who Are Virally Suppressed by Sociodemographic and Behavioral Characteristics in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013
table4-a
TABLE 4-A.:
Proportion of HIV-Infected Patients in Care and Prescribed ART Who Are Virally Suppressed by Sociodemographic and Behavioral Characteristics in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013

Overall, in the combined cohort, persons who were aged 18–29, black, had incomes below FPG, had been homeless in the past 12 months, had only public insurance or Ryan White or were uninsured, or were of the “Other” sexual behavior group were less likely to be virally suppressed compared with persons who were aged 50+, white, had incomes above FPG, had private insurance, or were MSM, respectively.

Factors associated with viral suppression varied by metropolitan area in the bivariate analyses. In Chicago, persons who were black, had incomes below FPG, had been homeless in the past 12 months, had only public insurance, or were MSW were less likely to be virally suppressed than persons who were white, had incomes above FPG, had not been homeless in the past 12 months, had private insurance, or were MSM, respectively. In LAC, persons who had been homeless were less likely to be virally suppressed than persons who had not been homeless; MSW were more likely than MSM to be virally suppressed. In Philadelphia, persons who were aged 18–29 were less likely to be virally suppressed than those aged 50 years or older, and the likelihood of viral suppression increased with level of education. In San Francisco, persons who had incomes below FPG, had been homeless in the past 12 months, had only public insurance, were of the “Other” sexual behavior group, or had injected drugs in the past 12 months were less likely to be virally suppressed than their respective comparison groups. The likelihood of viral suppression increased with level of education.

Results from the multiple logistic regression for viral suppression among patients prescribed ART are presented in Table 5. In the combined cohort, after controlling for all the other variables, non-Hispanic blacks (aPR = 0.93, CI: 0.87 to 0.99) and persons who reported homelessness in the past 12 months (aPR = 0.87, CI: 0.80 to 0.95) were less likely to be virally suppressed compared with non-Hispanic whites and persons who reported no homelessness. In Chicago, non-Hispanic blacks (aPR = 0.90, CI: 0.83 to 0.99) and MSW (aPR = 0.89, CI: 0.80 to 0.99) were less likely to be virally suppressed compared with non-Hispanic whites and MSM. In LAC, persons who reported homelessness in the past 12 months were less likely to be virally suppressed compared with persons with no history of homelessness (aPR = 0.80, CI: 0.67 to 0.94), and MSW were more likely to be virally suppressed compared with MSM (aPR = 1.13, CI: 1.04 to 1.23). In Philadelphia, persons 18–29 (aPR = 0.77, CI: 0.60 to 0.99) and those with less than a high school education (aPR = 0.80, CI: 0.67 to 0.95) were less likely to be virally suppressed compared with their respective comparison groups. In San Francisco, after adjusting for all factors, there were no significant differences in viral suppression by sociodemographic or behavioral characteristics.

T5
TABLE 5.:
Predictors of Viral Suppression* Among HIV-Infected Patients in Care and Prescribed ART in Chicago, LAC, Philadelphia, San Francisco, and the 4 Metropolitan Areas Combined, Medical Monitoring Project, 2011–2013

DISCUSSION

To our knowledge, this is the first time that data derived using a standardized methodology from a representative sample of patients in HIV care have been used to describe and compare ART prescription and viral suppression in urban metropolitan areas in the United States. We found significant variability in sociodemographic distributions, including age, sex, race/ethnicity, income, insurance status, education levels, sexual behaviors, and both injection and non-IDU in ART prescription and viral suppression across the metropolitan areas. These findings highlight the need for unique approaches to improve ART prescription and viral load suppression among subpopulations of patients living with HIV and across US metropolitan areas. In addition, the aggregated data in the combined cohort allow for characterization of patients in HIV care in several United States urban areas and show that most were aged 30 years or older, male, educated beyond high school, had incomes above the FPG, and had not experienced homelessness or engaged in IDU or non-IDU apart from marijuana in the past 12 months.

Although ART prescription was high (93% in the combined cohort) and there were no significant differences found across the 4 areas, viral suppression ranged from 79% in Philadelphia to 88% in San Francisco, a difference that was significant. The percentage of urban patients who were prescribed ART and virally suppressed were similar to 2011 data for patients with HIV overall in the United States (92% and 82%, respectively),4 and higher than estimates from previous studies of patients in care in urban settings.17,18 The aggregated MMP data show a higher proportion of patients prescribed ART and virally suppressed compared with an LAC study of patients in the Ryan White Care System in 2009 in which 90% were prescribed ART and 73% were virally suppressed.17 In addition, the ART prescription rate for the 4 cities is the same, and the viral suppression rate is higher than a similar national MMP analysis, suggesting consistency to the United States as a whole for the 4 cities on ART prescription with higher rates of viral load suppression in US urban areas compared with the United States as a whole.19 Taken together, these data suggest that ART prescription rates are similar, and viral suppression may be higher in US urban areas compared with the United States as a whole and possibly improving over time in urban settings.

In the combined cohort, age, race/ethnicity, and non-IDU drug use were all significantly associated with ART prescription in the multiple logistic regression model. Persons aged 30–49 were less likely to be prescribed ART compared with those aged 50 years and older; however, when examining ART prescription by metropolitan area, age was significantly associated with ART prescription only in LAC. Although younger persons 18–29 actually had lower percentages on ART compared with the older age groups, the differences were not significant in the multiple logistic regression models. This may be due to the smaller 18–29 age group sample size in all 4 areas, and subsequently wider CIs. Age-related differences in ART prescription are consistent with other research showing that younger HIV-infected persons are less likely to be on ART compared with older adults18,20–22 due to a myriad of complex factors, such as family dynamics, societal norms, treatment regimens, and emotional development.23

We found significant racial/ethnic differences in ART prescription in the combined cohort: Hispanics were significantly more likely to be prescribed ART compared with whites, but we found no significant differences in ART prescription between whites and blacks. This finding was not consistent with other research that found that blacks were less likely to be prescribed ART or report ART use compared with whites.20,24 However, some recent population-based research reported no differences between Hispanics and whites in self-reported ART adherence,24 whereas others have found that Hispanics were more likely to be prescribed ART compared with whites.25,26

Our finding that non-IDU (excluding marijuana) was a significant predictor of lower ART prescription in the combined area cohort is consistent with other findings that showed an association with both ART prescription and self-reported ART use.26,27 Although national guidelines recommend ART prescription for all HIV-infected patients, providers may delay initiation of ART prescription when there are issues that may affect adherence, such as substance abuse and mental health comorbidities.28

Although sex, insurance status, and homelessness were not predictive of ART prescription in the regression models in this analysis, they have been shown to be associated with ART prescription in other studies.20,21 In addition, we also did not find any relationship between socioeconomic status variables and ART prescription, a finding that may be attributable to the availability of Ryan White and ADAP funding, which supports care and treatment for low-income and uninsured persons in the United States.21 Previous research on the association between socioeconomic status and ART prescription or adherence, measured in various ways, has been mixed in the literature.21,29

Our findings are consistent with previous studies that have found that African American or other minority race, young age, less education, unstable housing, substance use, and inconsistent care and adherence to treatment were all associated with unsuppressed viremia among patients prescribed ART.17,18,30,31 National findings from the MMP indicated that 89% of HIV-infected adults in care prescribed ART in the United States in 2012 complied with their dosing regimen over the previous 72 hours, with 76% reporting schedule compliance.5 Estimates of the level of adherence necessary to maintain viral suppression vary between 80%–95% depending on drug class.32 Furthermore, national MMP findings and other studies report that less prescription of ART is associated with younger age, minority race/ethnicity, female sex, and receipt of public assistance.33,34 These findings underscore the need for continued support and interventions to improve ART prescription and adherence to promote sustained viral suppression for patients with HIV in care.

Although factors associated with ART prescription and viral suppression varied across metropolitan area, there were fewer differences in ART prescription across sociodemographic groups compared with viral suppression. This may in part be a result of the 2012 national guidelines that expanded recommendations for ART prescription for all HIV-infected persons.35

Our analysis has limitations. First, although MMP uses a population-based sampling approach and rigorous data collection methods, weights derived for analysis may not completely compensate for nonresponse bias.8,13 Estimates for smaller groups may be unstable because of sample size in this analysis and, therefore, should be interpreted with caution. Other studies have found that some of these smaller groups, such as transgender persons and younger persons, are less likely to adhere to ART or be virally suppressed.36 The population studied by MMP during these years was adults receiving medical care for their HIV; our results may not generalize to persons not in care, among whom levels of ART prescription and viral suppression are lower, and among whom these factors may have different associations with those outcomes.

Second, in March 2012, a significant change in the US national guidelines for HIV treatment recommended universal ART prescription regardless of CD4 count for all persons infected with HIV. Because this analysis included persons receiving care in 2011–2013, some individuals who were not prescribed ART may have not met the previous CD4 count threshold at that time.

Furthermore, ART classification is based on evidence of a prescription in the patient's medical record; however, ART adherence was not used in this analysis, resulting in a possible overestimate of ART use because a subset of prescriptions is not filled and/or is not always taken according to dosing requirements. Comparisons of ART prescription and viral suppression to other groups and studies are limited by measurement differences and study population parameters.37–39 Finally, although the outcome variables (ART prescription and viral suppression) were based on medical record data, the independent predictor variables are self-reported and potentially biased by factors, such as recall and social desirability.40

Although there is research that compares HIV care delivery and health outcomes in patients in urban versus rural settings, less research has been devoted to examination of differences among and across large urban settings.41 This analysis reveals that despite many commonalities, the varied challenges faced by the 4 urban areas suggest the need for region-specific strategies to improve testing, linkage, engagement, retention, ART prescription, and viral load suppression consistent with the stated goals of the National HIV/AIDS Strategy.42

ACKNOWLEDGMENTS

The authors thank the MMP participants, providers, and staff at participating facilities and all the MMP interviewers and abstractors. We also thank Rhodri Dierst-Davies for his assistance in reviewing initial drafts of this manuscript.

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Keywords:

ART; viral suppression; disparities; demographics; metropolitan areas

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