|
Since the widespread use of highly active antiretroviral
therapy (HAART), the number of persons diagnosed
with AIDS declined dramatically during 1996
and 1997, and then leveled through 2000. The number
of deaths in persons with AIDS also declined dramatically
during 1996 and 1997; annual declines in
deaths in persons with AIDS have continued through
2000 but are smaller in magnitude. Proportionate declines
in both AIDS cases and deaths vary by race/ethnicity, risk, and sex. Differences in proportionate
declines in AIDS diagnoses and deaths may be due to
late test seeking behaviors, limited access to or use of
health care services, limitations of current therapies
among persons receiving treatment or suboptimal
drug adherence. Monitoring the proportions of HIV-infected
population that are receiving the standard of
care can help in understanding observed differences
in morbidity and mortality associated with HIV infection.
These data are useful in identifying populations
with met and unmet needs for strategies to improve
resource allocation in Ryan White CARE Act and HIV
prevention community planning processes.
This report presents selected measures of treatment
and receipt of recommended prophylaxis from
four supplemental surveillance studies. These supplemental
studies are conducted in selected geographic
areas and are useful to address questions related to
the prescription and use of antiretroviral and prophylactic
medications in the population, and clinical procedures
that may contribute to delays in disease
progression, but cannot be answered by routine HIV/
AIDS case reporting data. Data presented in this report
are from 1) the Adult/Adolescent Spectrum of HIV
Disease (ASD) project, a longitudinal medical record
review study conducted in >100 selected facilities in
11 major U.S. cities; 2) the Survey of HIV Disease and
Care (SHDC), a cross-sectional, population-based
medical record review project conducted in 3 areas
(sites A, B, and C); 3) the Supplement to HIV/AIDS
Surveillance (SHAS) project, an interview project of
persons with HIV/AIDS conducted by 12 state/local
health departments; and 4) the Missed Opportunities
for Tuberculosis Prevention (MOPTB) study, a medical
record review of a population-based sample of
persons newly diagnosed with HIV or AIDS in 3 major
US cities (see Technical Notes). The time period described
varied by study, but all data were from the period
1995 through 1999. Persons enrolled in ASD and
SHAS are patients receiving medical care. The inclusion
of several large public hospitals and clinics that
treat HIV/AIDS patients in both ASD and SHDC likely
contributes to higher proportions of patients being provided
the standard of care across insurance types.
The technical notes describes the methods of data
collection and analysis as well as the time period for
each of these studies.
This report is organized in 3 sections: 1) antiretroviral
medications; 2) Pneumocystis carinii
pneumonia;
and 3) tuberculin skin test. Readers should consider
several issues in interpreting data in this report:
- Summaries of data presented here do not allow determinations of
appropriate prescription of antiretroviral therapy across strata by
race/ethnicity, insurance status, and sex. All HIV infected persons should
receive treatment in accordance with current treatment guidelines.
- Pneumocystis carinii
pneumonia was the first opportunistic
illness associated with HIV infection; however,
the incidence of PCP declined substantially, in
part due to the implementation of U.S. Public Health
Service/Infectious Diseases Society of America (PHS/IDSA) prophylaxis recommendations. Guidelines in
place during the period studied indicate that HIV-infected
persons with CD4+ counts <200 cells/microliter
should receive PCP prophylaxis, but discontinuation
of prophylaxis is possible among persons responding
to HAART.(1)
- Guidelines in place during the period studied for
the prevention of tuberculosis as an opportunistic illness
among HIV infected persons recommended annual
skin testing (TST) beginning immediately following
HIV diagnosis.(1)
The intent of this report is to identify if findings are
consistent across the different studies in the areas of
access, treatment and receipt of prophylaxis. Readers
are cautioned against numerically summing data
from different tables, as their methods are different
and combining results is inappropriate. The goal is to
inform public health organizations, patient advocates,
and the public health community of several indicators
of the quality of care being provided to patients with
HIV and AIDS. Examination of these data sources together
provides an opportunity to examine similarities
and differences in data obtained from medical record
reviews and patient interviews and validates findings
from individual projects.
Key Findings
- Overall, the proportion of patients enrolled in
these studies who were ever prescribed antiretroviral
therapy was 91–95%; 83-88% were currently prescribed
antiretroviral therapy; 61-64% were currently
prescribed highly active antiretroviral therapy
(HAART).
- In both ASD and SHAS, similar proportions of
males and females were ever prescribed antiretroviral
therapy (95% of both males and females in ASD;
91% of males and 88% of females in SHAS), and currently
prescribed ART (83% of males and 79% of females
in ASD; 91% of males and 84% of females in
SHAS). Similar proportions of males compared with
females were
currently
prescribed HAART in ASD
(62% of males and 58% of females) and SHDC Sites
A and B (68% of males and 67% of females; 64% of
males and 66% of females, respectively).
- Current receipt of antiretroviral therapy was highest
among patients with private insurance in ASD and
SHDC, and higher among patients with public insurance
compared with those with no insurance for all
data sources. Prescription of HAART was generally
highest for privately insured patients.
- Of patients interviewed in SHAS in 1999 or who
had follow-time in 1999 for ASD and 1998 for SHDC,
the proportion of patients ever diagnosed with Pneumocystis carinii
pneumonia (PCP) ranged from 6% to
19%. Higher proportions of males compared with females
were ever diagnosed with PCP across all studies.
In ASD and 1 SHDC site, lesser proportions of
patients with private insurance were prescribed primary
PCP prophylaxis compared with patients with public
insurance or no insurance, and in ASD and 2 of 3
SHDC sites, similar proportions of patients with public
insurance and no insurance were prescribed PCP
prophylaxis. High proportions of patients with public
insurance or no insurance prescribed PCP prophylaxis
may be due to the inclusion of several large public
hospitals and clinics that treat HIV/AIDS patients in
both studies.
- Among eligible patients in ASD, a higher proportion
of males (62%) than females (60%) were prescribed
primary PCP prophylaxis, but a greater
proportion of females (63%, 67%, 76%) were prescribed
prophylaxis compared with males (52%, 54%,
67%) in the three SHDC sites. Similar proportions of
patients were prescribed primary PCP prophylaxis by
race/ethnicity in all data sources, with the proportion in
SHDC Site C slightly higher.
- The proportion of patients receiving a TST
ranged from 34% before or during 1998 in SHDC to
75% ever receiving a TST after HIV diagnosis in
SHAS. Similar proportions of males and females from
all data sources received a TST; little variation was
found by race/ethnicity.
Suggested reading
- Centers for Disease Control and Prevention.
Guidelines for the use of antiretroviral agents in HIV-infected
adults and adolescents. MMWR 1998;47(No. RR-5):42-82. Updated as the living document February
2001 on the HIV/AIDS Treatment web site,
www.hivatis.org.
- Centers for Disease Control and Prevention.
USPHS/IDSA guidelines for the prevention of opportunistic
infections in persons with human immunodeficiency
virus.
MMWR 1999, 46(No. RR-10):4-7.
- Karon JM, Fleming PL, Steketee RW, DeCock
KM. HIV in the United States at the turn of the century:
an epidemic in transition. Am J Public Health.
2001;91:1060-1068.
- Kaplan JE, Hanson D, Dworkin MS, Frederick T,
Bertolli J, Lindegren ML, Holmberg S, Jones JL. Epidemiology
of human immunodeficiency virus-associated
opportunistic infections in the United States in
the era of highly active antiretroviral therapy. Clin Infect
Dis 2000; 30 (Suppl 1):S5-14.
|
