HIV Treatment Program Improves Outcomes in All Risk Strata

October 1, 2012 — A Baltimore HIV clinic has improved the clinical outcomes of patients across all strata of demographic and behavioral risk groups through a multilevel treatment program with supplemental funding from a federal government program, according to an article published online September 26 in Clinical Infectious Diseases.

Richard D. Moore, MD, MHS, from Johns Hopkins University in Baltimore, Maryland, and colleagues analyzed the records of 6366 patients with HIV who were under the care of the Johns Hopkins HIV/AIDS Service during a 15-year period between 1995 and 2010. The clinic represents the fifth-highest incidence of HIV infection in US urban centers in a state that has the third-highest incidence of HIV infection of all states. A high proportion of patients were infected through injection drug use (IDU), and most patients' incomes fall below the poverty line.

Of the 6366 patients, representing 27,941 patient-years (PY), 87% were receiving antiretroviral therapy, median HIV-1 RNA levels were lower than 200 copies/mL, opportunistic illness (OI) rates were 2.4 per 100 PY, mortality rates were 2.1 per 100 PY, and median CD4 amounted to 475 cells/mm³. No differences existed among demographic characteristics or HIV-risk groups, including IDU and men who have sex with men. Among the study population, 76% were black, 22% were white, 2% were other races, and 32% were women. Expected longevity was 73 years.

"Our clinic-wide analysis shows that substantial improvements have occurred in the health of those infected with HIV irrespective of HIV transmission risk group, race, and sex," the researchers write. "As of calendar year 2010, there is no difference by demographic or behavioral risk groups in ART prescription, OI rates, or mortality rates. This likely reflects the remarkable advances in the development of ART, coupled with continual improvements in the management of HIV-infected individuals based on evidence-based guidelines."

With a Little Help

Another reason for the improvement is supplemental federal funding from the Ryan White HIV/AIDS program, they write. That program, administered by the Health Resources and Services Administration of the US Department of Health and Human Services since 1990, "has provided federal financial assistance to the clinic to deliver HIV care using a care model that combines primary, specialty (substance abuse and mental health), and supportive care (case management, nutrition, treatment adherence, emergency assistance, transportation) into an integrated multidisciplinary program of care," the researchers write. The funding has covered economically disadvantaged individuals who might otherwise have not received care.

Of the patients in the Baltimore clinic, 73% were below federal poverty guidelines, and another 19% were just above. The program is up for congressional renewal in 2013.

A limitation of the study, the researchers point out, is the possible lack of generalizability resulting from the fact that the patients were consistently cared for, unlike many patients with HIV, who do not receive consistent care.

Nevertheless, the results reflect "what is possible when HIV care is delivered based on state-of-the-art care guidelines with support from the Ryan White HIV/AIDS Program to address the challenge to deliver treatment that is highly effective, but also expensive, complex, and requires continuous patient engagement by populations that are often underserved by healthcare disparities."

"Contemporary HIV care can markedly improve the health of persons living with HIV regardless of their gender, race, risk group, or socioeconomic status," Dr. Moore said in a journal news release.

"The lesson learned from the remarkable outcomes within the HIV Clinic at Johns Hopkins and other Ryan White–supported clinics in the United States is that supplemental funding for primary care is needed to overcome health disparities widely evident in our current system," Michael S. Saag, MD, from the University of Alabama at Birmingham Division of Infectious Diseases, writes in an accompanying editorial. "In this case, Moore is not less. Viva No différence!"

This study was supported by a National Institutes of Health grant. The editorialist has received funding from the Health Resources and Services Administration. The article's authors and the editorialist have disclosed no relevant financial relationships.

Fonte: www.medscape.com