Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson

The Marion County Public Health Department’s¹ Ryan White Services Program (RWSP)² oversees Ryan White Part A, Part C (Outpatient Early Intervention Services) and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected with HIV, living with HIV/AIDS (PLWH/A) and out of care, and/or uninsured or medically underserved. RWSP goals are based on the HIV continuum of care (Link to HIV continuum) and the National HIV/AIDS Strategy.³ The goal discussed this month is prescription of HIV antiretroviral therapy (ART) to PLWH/A.

Importance of Antiretroviral Therapy – ART reduces viral replication leading to delayed disease progression, preservation of immune function and reduced likelihood of viral resistance.⁴ This results in improved quality and length of life,^5,6 and reduction of HIV transmission to newborns and sex partners.^4,7,8 It is important to increase access to and utilization of ART among PLWH/A in the MSA.

RWSP Target – Among MSA residents living with HIV and aware of their status on December 31, 2013, only 45.1% (2,439 of 5,411) had ever received a prescription for ART.⁹ Even when considering only those in care,¹⁰ only 47.8% (1,846 of 3,859) had received ART. RWSP strives to ensure access to ART for 100% of PLWH/A in the MSA. Because some are out of care or opt out of ART, RWSP’s goal is to increase the percentage of PLWH/A who receive a prescription for ART during FY 2015-2016 to 95% of those who are in care.

Antiretroviral Therapy Recommendations – Current guidelines recommend ART for all HIV-infected individuals.⁴ While the strength of this recommendation varies based on CD4 T lymphocyte (CD4) count, it is strongly recommended for all to prevent transmission of HIV. Some situations require further consideration prior to ART administration.

• Pregnancy – Special considerations arise in the treatment of HIV during pregnancy; however, guidelines strongly recommend that all HIV-infected pregnant women receive, “a maximally suppressive antiretroviral regimen to reduce the risk of perinatal transmission of HIV.”^11,12 In addition, Indiana’s Communicable Disease Rule requires discussion of and access to ART in the treatment of HIV-infected pregnant women.¹³
• Perinatal and/or Infant HIV – If perinatal HIV exposure occurs, antiretroviral prophylaxis should be initiated immediately.¹⁴ Additionally, it is strongly recommended that all HIV-infected infants (<1 year), as well as any child with AIDS or significant symptoms, receive ART.¹⁴ For ART-naïve children one or older, strong recommendation of ART depends on age and CD4 count and/or percent; however, guidelines provide a moderately strong recommendation of ART for all children, regardless of CD4 value.¹⁴
• Older Patients – Approximately half the PLWH/A in the MSA are 50+ years of age. ART is important in these patients due to weakened immune systems;¹⁵ however, close monitoring is recommended because of increased risk of adverse events and drug interactions.¹⁴
• Comorbidities – Certaincomorbid conditions present treatment providers with special considerations with regard to ART. Current guidelines should be referred to in the treatment of such cases. Threecomorbidities common in the MSA include:
  • An estimated 25%-30% have been diagnosed with hepatitis C (HCV)^16,17
  • More than 4% were diagnosed with chlamydia, gonorrhea or early syphilis during 2013^9,18,19
  • At least 1% of PLWH/A have been diagnosed with Mycobacterium tuberculosis (TB)²⁰

Improving Adherence to ART – Reluctance to begin, or poor adherence to, ART can result from many situations. HIV medication is expensive and sometimes requires complicated regimens that are difficult to maintain. Many have side effects that are not well tolerated. Stigma, mental health, substance abuse and other issues can also lead to poor adherence. Strategies to improve adherence can be found in the guidelines’ Limitations to Treatment Safety and Efficacy: Adherence to Antiretroviral Therapy (p. K-1). In addition, a summary of recent International Association of Physicians in AIDS Care (IAPAC) suggestions²¹ can be found online.²²

“If it wasn’t documented, then it didn’t happen.” – This adage is true with regard to ART as recorded in eHARS. ART is a control factor used in the prevention of AIDS.^4,23 As such, it is important to provide your local health department and/or Indiana State Department of Health with information regarding prescription of ART (i.e., patient ID, date, medication name). If this information is not provided, true prevalence of ART prescriptions cannot be ascertained. Please take a few moments to report prescriptions of ART to your local health department and/or Indiana State Department of Health.

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Sources:

1 Marion County Public Health Department, http://www.mchd.com/

2 Ryan White Services Program, http://www.ryanwhiteindytga.org/

3 National HIV/AIDS Strategy, https://www.aids.gov/federal-resources/national-hiv-aids-strategy/

4 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

5 Schackman, B. R., Gebo, K. A., Walensky, R. P., Losina, E., Muccio, T., Sax, P. E., . . . Freedberg, K. A. (2006). The lifetime cost of current human immuno-deficiency virus care in the United States. Medical Care. 2006(44): 990-997.

6 Antiretroviral Therapy Cohort Collaboration. (2008) Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008(372): 293-299.

7 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 365(6): 493-505.

8 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment. Available at http://www.cdc.gov/hiv/prevention/research/tap/.

9 According to the Center for Disease Control and Prevention’s Enhanced HIV/AIDS Reporting System (eHARS).

10 Persons with an HIV diagnosis and at least one CD4 or viral load test during CY 2013

11 U.S. Department of Health & Human Services. (2014). Recommendations for use of antiretroviral drugs in pregnant HIV-1-Infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/peri_recommendations.pdf.

12 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: Considerations for antiretroviral use in special patient populations acute and recent (early*) HIV infection. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

13 Indiana General Assembly. (2014). Indiana administrative code: Title 410 Indiana State Department of Health: Article 1. Communicable disease control: Rule 7. HIV counseling and testing of pregnant patients (410 IAC 1-7-7.3). Available at http://www.in.gov/legislative/iac/T04100/A00010.PDF.

14 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in pediatric HIV infection. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/pedarv_recsonly.pdf.

15 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: HIV and the older patient. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

16 Indiana State Department of Health. (2014). Hepatitis B and C among residents of the TGA. Alexander, L. Epidemiology, 26-Aug-2014.

17 National Alliance of State & Territorial AIDS Directors. (2011). HIV and viral hepatitis co-infection. Available at http://nastad.org/Docs/031236_HIV%20VH%20CoInfection%20Final.pdf.

18 Includes primary, secondary and early latent stages of syphilis

19 Indiana State Department of Health. (2014). State wide investigating, monitoring and surveillance system (SWIMSS).

20 Nelson, T. L. (2014). Epidemiologic profile of HIV/AIDS, Indianapolis transitional grant area: 2013. Indianapolis: Marion County Public Health Department. Available at http://www.ryanwhiteindytga.org/wp-content/uploads/2014/06/DR2277-RWG-Epi-Profile-Presentation_2014-06-05_Final.pdf.

21 Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., Gross, R., . . . Nachega, J. B. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an international association of physicians in AIDS care panel. Ann Intern Med.156(11): 817-833.

22 IAPAC Summary, http://www.iapac.org/uploads/IAPAC_Entry_Retention_Adherence_Guidelines_Summary_Table_05JUN12.pdf

23 Heymann, D. L. (Ed.). (2008). Control of communicable diseases manual. Washington, DC: American Public Health Association.