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HIV patients are getting linked to care faster, but there are still cracks in the system that swallow vulnerable populations, researchers said at the .

Following 2012 U.S. guidelines that recommended everyone with an HIV diagnosis begin antiretroviral therapy, the overall percentage of people starting treatment within 30 days of being linked to care rose steadily from 42% in 2012 to 82% by 2018, the last year with available data, reported Jun Li, MD, PhD, an epidemiologist in the CDC's HIV/AIDS Prevention division.

"Timely antiretroviral therapy has substantially improved for all patients regardless of CD4 count after the release of the 2012 HIV treatment guidelines," Li said in his oral presentation at the conference.

Li and colleagues analyzed the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) that included multiple sites in the United States and Canada, developing a cohort of recently diagnosed HIV patients newly entering care. Among the inclusion criteria were viral loads that were greater than 500 copies/mL at the time of entry into the program and no prior antiretroviral therapy.

The researchers then determined if they had received "timely antiretroviral therapy," defined as starting HIV drug treatment within 30 days after entry into care. Patients were stratified by age, race/ethnicity, geographic region, sex and other factors.

A total of 11,853 participants were enrolled, 48% of them men who had sex with men; 77% were younger than 50; 45% were Black; 15% were Latino/Hispanic; 51% lived in the U.S. South and 28% lived in the West. During the 30-day window, 6,688 individuals were linked to care and achieved timely antiretroviral therapy. The median time to receiving timely therapy was 9 days.

At the time of entry into the study, 5% of the cohort had already received a clinical AIDS diagnosis; 8% had a history of alcohol abuse or dependence; 11% had a history of drug abuse or dependence; 24% had been given a mental health diagnosis; 30% had CD4-positive cell counts below 500 cell/mm³, indicating advanced HIV disease.

During 2012-2015, which included 8,494 individuals, Black patients were receiving timely antiretroviral therapy significantly less often than whites. But in 2016-2018, with 3,359 individuals, the difference shrank and was no longer significant, Li said.

He also noted a change in geographic patterns. In 2012-2015, timely antiretroviral therapy was significantly less common in the Northeast compared with the West, but that had flipped in the 2016-2018 period where the Northeast was providing timely antiretroviral therapy better than the West.

However, when Li and colleagues looked at the participants with drug abuse or dependence, they observed that this vulnerable group lagged in getting timely antiretroviral therapy. In the 2012-2015 period, about 50% of those without drug dependence had gotten timely therapy compared to about 40% of people with drug abuse issues. In the 2016-2018 analysis, about 75% of people who did not have drug abuse problems were receiving timely therapy compared with less than 60% of those with drug abuse issues – a widening gap, Li noted.

Li noted that the study was limited in several ways:

• It might overestimate the cumulative incidence of timely antiretroviral therapy because it required at least 2 clinic visits to be counted in the study.
• The researchers were not able to assess influence of timely antiretroviral therapy by the level of severity or drug or alcohol abuse or dependence.
• The researchers could not distinguish if the delayed antiretroviral therapy was due to the provider's choice or the choice of the patient.

Sharon Hillier, PhD, of the University of Pittsburgh School of Medicine, who moderated a press conference where Li described the study, acknowledged the apparent success but cautioned that it might be too early to take a victory lap.

"I think it is possible we might have regression of these advances during the past year when we have been dealing with the pandemic. These results just go through 2018," she told 番茄社区app.

She also suggested that more work needs to be done in getting timely therapy for the most vulnerable and hard-to-treat populations.