Immediate HIV treatment initiation: Increased but not yet universal in NYC

A new study published in the Journal of Infectious Diseases found that immediate treatment initiation for HIV infection has improved since local and federal guidelines began to recommend universal treatment for all persons diagnosed with HIV, regardless of their disease stage.

Despite notable improvements, nearly 25 percent of New York City residents with a new HIV diagnosis in 2015 had not initiated treatment within six months of their diagnosis. Another key study finding was that only 35 percent of people diagnosed with HIV had less advanced HIV disease. The study's authors concluded that "continued efforts are needed to expand and better target HIV testing to promote earlier diagnosis and treatment initiation".

The study was conducted by a team of investigators, in collaboration with the New York City Department of Health and Mental Hygiene, and used population-based HIV surveillance data to understand if the timeliness of HIV diagnosis and antiretroviral treatment (ART) initiation improved since 'universal treatment' was first recommended. They found that, among 9,987 NYC residents diagnosed with HIV from 2012 to 2015, 35 percent were diagnosed early, and the annual proportion of persons diagnosed sooner after HIV infection did not increase appreciably. Six months after diagnosis, only 62, 67, 72, and 77 percent of persons diagnosed in 2012, 2013, 2014 or 2015 respectively had initiated ART.

Voluntary HIV testing followed by immediate ART initiation is an integral part of strategies to eliminate HIV and control the HIV/AIDS epidemic because individuals with HIV have a lower risk of transmitting the virus and developing AIDS or serious illness if they start ART as soon as possible after HIV infection. In New York City, the 'universal treatment' recommendation, immediate treatment for all persons diagnosed with HIV, was made in late 2011.

To understand and influence how quickly testing programs are diagnosing HIV and getting individuals on treatment, the timeliness of diagnosis and ART initiation would ideally be measurable and carefully monitored at the population level. Yet, population-based data on ART initiation are generally not systematically collected and thus unavailable in the US. And neither implementors nor researchers have adequately focused on the elapsed time from HIV infection to diagnosis and to ART initiation. The elapsed time matters because this represents time when an individual misses out on the benefits of treatment.

"Although patients are increasingly receiving ART upon diagnosis, this study shows that treatment is neither universal nor immediate. To reach the monumental goal of ending the HIV epidemic, it is important to continue to expand and target HIV testing in order to achieve earlier diagnosis and treatment for people with undiagnosed HIV infection," said McKaylee Robertson, the study's lead author and an epidemiology doctoral student at the CUNY Graduate School of Public Health and Health Policy.

"A fundamental premise underlying public health implementation efforts aimed at 'ending HIV epidemics' around the globe is that the most effective way to reduce HIV-related deaths and onward transmission of the HIV virus is to diagnose and treat all persons with HIV as soon as possible after infection occurs. This study shows that we have made significant improvements in quickly getting people on treatment, but that we still have a long way to go", said Dr. Denis Nash, the senior author on the study and Executive Director of the CUNY Institute for Implementation Science in Population Health.