HIV primary care visit intervals up to 9 months do not worsen viral load

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Gaps of up to 9 months between primary care visits for patients with HIV did not result in significant increases in viral load, according to researchers at the division of HIV/Aids prevention, Centres for Disease Control and Prevention, Atlanta, Georgia.

Current guidelines recommend that intervals between primary care visits with viral load monitoring should not exceed 6 months. However, intervals exceeding 6 months are common. To assess the effect of visit interval on changes in viral load and determine the length at which viral load increases significantly, data from 6399 patients with visit intervals >6 months from 6 US hospitals were analysed.

Visit intervals were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, and viral load measurements were matched to the opening and closing dates for the gaps. Two viral load measurements were studied in relation to visit interval: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially had viral suppression but lost viral suppression by close of the care gap).

Gaps of <9 months did not result in significant increases in viral load and only 10% or fewer patients lost viral suppression. When gaps increased to ≥12 months, there was a significant increase in viral load and 23% of patients lost viral suppression.

The detrimental effects on viral load were greatest among young patients, black patients, and those without private health insurance. These patient groups also had longer gaps between visits than white, older, and privately insured patients, which may lead to less adherence with antiretroviral therapy regimens. Investigators recommend that specific interventions tailored to these groups may be of use.

The study is limited in its generalisability outside of the 6 hospitals sampled and cannot represent the general US population. These results are also averages across groups of patients and therefore should not be used to suggest anything about optimal spacing of visits for an individual patient.

Investigators do believe that the results “have an important implication for patient reengagement efforts” and that these efforts should begin once an interval has exceeded 6 months. They also state that the data shown here “suggest that visit intervals of 6 to 9 months for select patients may be appropriate without endangering the health of patients or the public.”

 

Abstract
Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.

Authors
Gardner Lytt I, Marks Gary, Patel Unnati, Cachay Edward, Wilson Tracey E, Stirratt Michael, Rodriguez Allan, Sullivan Meg, Keruly Jeanne C, Giordano Thomas P

Infectious Disease Adviser
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