title: The effect of a "universal antiretroviral therapy" recommendation on HIV RNA levels among HIV-infected patients entering care with a CD4 count greater than 500/μL in a public health setting.
abstract: BACKGROUND
  On 1 January 2010, a large, publicly funded clinic in San Francisco announced a "universal ART" approach to initiate antiretroviral therapy (ART) in all human immunodeficiency virus (HIV)-infected persons. The effect of changing guidance on real-world patient outcomes has not been evaluated.
  
  
  METHODS
  We evaluated untreated adult patients (defined as going >90 days without ART use) visiting clinic from 2001 to 2011. The cumulative incidence of HIV RNA suppression (viral load, <500 copies/mL), stratified by CD4 cell count at entry and calendar dates representing guideline issuance, were estimated using a competing risk framework. A multivariate Poisson-based model identified factors associated with HIV RNA suppression 6 months after clinic entry.
  
  
  RESULTS
  Of 2245 adults, 87% were male, and the median age was 39 years (interquartile range, 33-45 years). In 534 patients entering clinic with a CD4 cell count of >500 cells/µL, the 1-year incidence of HIV RNA suppression was 10.1% (95% confidence interval [CI], 6.6%-14.6%) before 4 April 2005; 9.1% (95% CI, 3.6%-17.4%) from 4 April 2005 to 1 December 2007; 14.1% (95% CI, 7.5%-22.8%) from 1 December 2007 to the universal ART recommendation and 52.8% (95% CI, 38.2%-65.4%) after. After adjustment, the SFGH policy was associated with a 6-fold increase in the probability of HIV RNA suppression 6 months after clinic entry.
  
  
  CONCLUSIONS
  Recommendations to initiate ART in all HIV-infected patients increased the rate of HIV RNA suppression for patients enrolling in care with a CD4 cell count of >500 cells/µL and may foreshadow national trends given the March 2012 revision of national treatment guidelines to favor ART initiation for persons with CD4 cell counts of >500 cells/µL.
authors.affiliation: Division of HIV/AIDS at San Francisco General Hospital, Department of Medicine, University of California, San Francisco, California, USA. genge@php.ucsf.edu
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
authors.forename: C Bradley
authors.initials: CB
authors.lastname: Hare
authors.forename: James O
authors.initials: JO
authors.lastname: Kahn
authors.forename: Vivek
authors.initials: V
authors.lastname: Jain
authors.forename: Tracy
authors.initials: T
authors.lastname: Van Nunnery
authors.forename: Katerina A
authors.initials: KA
authors.lastname: Christopoulos
authors.forename: Steven G
authors.initials: SG
authors.lastname: Deeks
authors.forename: Monica
authors.initials: M
authors.lastname: Gandhi
authors.forename: Diane V
authors.initials: DV
authors.lastname: Havlir
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D015497:HIV-1 / Q000235:genetics*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011634:Public Health / Q000379:methods; D012367:RNA, Viral / Q000097:blood*; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents; D012367:RNA, Viral