Multilevel Analysis of Individual, Neighborhood, and Health Care Facility Characteristics Associated with Achievement and Maintenance of HIV Viral Suppression Among Persons Newly Diagnosed with HIV in New York City

Objective To investigate the effect of individual, health care facility, and neighborhood characteristics on achievement and maintenance of HIV viral suppression, among New York City residents aged 13 years and older diagnosed with HIV between 2006 and 2012. Methods I used individual-level data from the New York City HIV surveillance registry and Case Surveillance-Based Sampling, facility-level data from the surveillance registry, and neighborhood-level data from the U.S. Census and American Community Survey. The outcomes of interest were first viral suppression after diagnosis (Aims 1 and 3; ≤400 copies/mL) and virologic failure after first suppression among persons who achieved suppression (Aim 2; viral load ≥1,000 copies/mL or no viral load test for 12 consecutive months). Aim 3 was limited to persons interviewed for Case Surveillance-Based Sampling. Multivariable proportional hazards regressions were used to assess the likelihood of suppression or failure for individual, facility, and neighborhood characteristics, accounting in Aims 1 and 2 for clustering of outcomes. Results Of 12,547 persons newly diagnosed with HIV in 2006–2010, 44% achieved suppression within 12 months of diagnosis. In adjusted analyses, persons 13-49 years old, men, blacks and Hispanics, US-born, heterosexuals, and persons diagnosed in 2006 and 2008 were less likely to achieve suppression than persons 60 years old and older, women, whites, foreign-born, men who have sex with men, and persons diagnosed in 2010, respectively. Suppression rates were also lower among persons who were not eligible for treatment, or who were diagnosed at facilities that diagnosed 10-74 patients per year, were screening/diagnosis/referral sites, or within one mile of the person’s home. No neighborhood factors were associated with suppression. Out of 8,927 persons newly diagnosed with HIV in 2006–2010 who achieved viral suppression, 18.2% experienced virologic failure within 12 months of suppression. After adjustment, the following groups were the least likely to maintain suppression: younger persons (≥60), blacks and Hispanics, US- and US-dependency born persons, heterosexuals and injection drug users, persons with CD4 counts ≥500 cells/mL at suppression, persons receiving care at facilities that were not large outpatient facilities or large private practices, and residents of high- or very-high-poverty neighborhoods. Suppression within 12 months of diagnosis was achieved by 65% of persons newly diagnosed with HIV in 2006–2012 and interviewed by Case Surveillance-Based Sampling (n=92). Perceived neighborhood social cohesion was not associated with suppression. Conclusions Persons who were younger, black or Hispanic, US-born, heterosexual, diagnosed in earlier years, not treatment-eligible, living within one mile of their health care facility, diagnosed or cared for at certain types of facilities such as those with fewer HIV-positive patients, and living in a higher-poverty neighborhood were less likely to achieve and/or maintain suppression. Assistance with post-diagnosis linkage to and retention in care, ART prescribing, or adherence that is targeted to groups with characteristics associated with poorer outcomes may improve achievement and maintenance of viral suppression in New York City

Novel Use of Surveillance Data to Detect HIV-Infected Persons with Sustained High Viral Load and Durable Virologic Suppression in New York City

Background: Monitoring of the uptake and efficacy of ART in a population often relies on cross-sectional data, providing limited information that could be used to design specific targeted intervention programs. Using repeated measures of viral load (VL) surveillance data, we aimed to estimate and characterize the proportion of persons living with HIV/AIDS (PLWHA) in New York City (NYC) with sustained high VL (SHVL) and durably suppressed VL (DSVL). Methods/Principal Findings: Retrospective cohort study of all persons reported to the NYC HIV Surveillance Registry who were alive and $12 years old by the end of 2005 and who had$2 VL tests in 2006 and 2007. SHVL and DSVL were defined as PLWHA with 2 consecutive VLs $100,000 copies/mL and PLWHA with all VLs #400 copies/mL, respectively. Logistic regression models using generalized estimating equations were used to model the association between SHVL and covariates. There were 56,836 PLWHA, of whom 7 % had SHVL and 38 % had DSVL. Compared to those without SHVL, persons with SHVL were more likely to be younger, black and have injection drug use (IDU) risk. PLWHA with SHVL were more likely to die by 2007 and be younger by nearly ten years, on average. Conclusions/Significance: Nearly 60 % of PLWHA in 2005 had multiple VLs, of whom almost 40 % had DSVL, suggesting successful ART uptake. A small proportion had SHVL, representing groups known to have suboptimal engagement in care. This group should be targeted for additional outreach to reduce morbidity and secondary transmission. Measures based o

Characteristics of HIV-infected New Yorkers with ≥2 viral load tests and all persons diagnosed and presumed living, New York City¹.

<p>VL, viral load. NYC, New York City. PLWHA, persons living with HIV/AIDS. MSM, men who have sex with men. IDU, intravenous drug users.</p>1<p>Data as reported to the NYC DOHMH by December 31, 2009.</p>2<p>Includes persons who had heterosexual sex with an HIV-infected person, an injection drug user, or a person who has received blood products. For females only, heterosexual sex also includes sex with a male and at least one of the following: history of commercial sex work, multiple male sex partners, sexually transmitted disease, crack/cocaine use, sex with a bisexual male, probable heterosexual transmission as noted in a medical chart, or negative history of injection drug use.</p>3<p>NYC DOHMH collects race and ethnicity data that meet federal standards of classification and maintains ethnicity data separately from race information. Persons of Hispanic or Latino ethnicity have a separate race classification. Due to small numbers, persons reporting more than one race, Native Americans or Alaska Natives, Hawaiian Natives, Asian, and Pacific Islanders were classified as ‘Other’.</p>4<p>Borough of residence refers to the residence at HIV diagnosis for persons living with HIV (non-AIDS) or residence at AIDS diagnosis for PLWHA.</p

Characteristics of HIV-infected New Yorkers with sustained high viral load (SHVL) and durable virologic suppression and all persons diagnosed and presumed living, New York City¹.

<p>VL, viral load. NYC, New York City. PLWHA, persons living with HIV/AIDS. MSM, men who have sex with men. IDU, intravenous drug use. IQR, interquartile range. NA, not available.</p>1<p>Data as reported to the NYC DOHMH by December 31, 2009.</p>2<p>Includes persons who had heterosexual sex with an HIV-infected person, an injection drug user, or a person who has received blood products. For females only, heterosexual sex also includes sex with a male and at least one of the following: history of commercial sex work, multiple male sex partners, sexually transmitted disease, crack/cocaine use, sex with a bisexual male, probable heterosexual transmission as noted in a medical chart, or negative history of injection drug use.</p>3<p>NYC DOHMH collects race and ethnicity data that meet federal standards of classification and maintains ethnicity data separately from race information. Persons of Hispanic or Latino ethnicity have a separate race classification. Due to small numbers, persons reporting more than one race, Native Americans or Alaska Natives, Hawaiian Natives, Asian, and Pacific Islanders were classified as ‘Other’.</p>4<p>Borough of residence refers to the residence at HIV diagnosis for persons living with HIV (non-AIDS) or residence at AIDS diagnosis for PLWHA.</p

HIV-infected New Yorkers grouped by VL trend, 2006–2007.

<p>HIV-infected New Yorkers grouped by VL trend, 2006–2007.</p

Eligibility flow chart on HIV-infected New Yorkers, 2006 and 2007.

<p>Eligibility flow chart on HIV-infected New Yorkers, 2006 and 2007.</p