The Shifting Picture of HIV Treatment, Comorbidity and Substance use Among US MSM Living With HIV

G D'Souza; L Benning; V Stosor; MD Witt; J Johnson; M Friedman; AG Abraham


HIV Medicine. 2021;22(7):538-546. 

In This Article


The 141 recent initiators in this sample included 72 ART-naïve men who initiated ART while in study follow-up and 69 men who enrolled in MACS between 2010 and 2018 and were known to have initiated ART within the year before enrolment. These 141 recent initiators were frequency-matched to 197 earlier treatment initiators. Median age at ART initiation was 33 years (range 18–61) in recent initiators and was similar for early initiators (36 years, range 18–60). Race for recent initiators included a mix of white non-Hispanic (46%), African-American non-Hispanic (37%) and Hispanic (17%) individuals; among earlier initiators, 35% were non-Hispanic white. Socioeconomic status of recent initiators varied but was higher than that among earlier initiators. The proportion of recent initiators who had had an individual gross income < $20 000 was 44% (compared with 56% for early imitators, P = 0.03), and 38% of recent initiators were college graduates (compared with 29% of earlier initiators, P = 0.08).

HIV-related Characteristics

Recent initiators had a significantly higher CD4 cell count at ART initiation (median = 451 cells/mL, IQR: 314–654) compared with the 307 cells/μL among earlier initiators (P < 0.0001; Table 1). The log10HIV viral load (IQR) at initiation remained unchanged between the groups at 4.7 (4.0–5.1) copies/mL. Recent initiators had a relatively low median time from HIV diagnosis to ART initiation (5.4 months, IQR 1.7–23.1 months). Further, 17% of recent initiators started therapy within 1 month of HIV diagnosis. Date of HIV diagnosis was not collected among earlier initiators, so median time from HIV diagnosis to ART initiation could not be compared.

The proportion of those achieving viral suppression within a year of starting ART was significantly higher in recent than in earlier initiators (92% vs. 74%, P < 0.001; Table 1). Among virally suppressed men, virological failure within 2 years was rare and appeared lower, although not statistically different, in recent vs. earlier initiators (12% vs. 21%, P = 0.08). Recent initiators were also significantly more likely to report having health insurance than earlier initiators (93% vs. 70%, P < 0.001).

However, even among recent initiators there were men who did not get treated soon after diagnosis. Eleven (8%) ART-naïve men initiating therapy during the past decade were diagnosed with HIV more than 10 years prior to initiation; these men had a median (IQR) CD4 of 480 (IQR 207–737) cells/μL at the time of initiation, although some had far lower CD4s that indicated late initiation as opposed to slow progression of disease (lowest was CD4 of 150 cells/μL). The most common drug regimen used at ART initiation among recent initiators was II-ART without PI or NNRTI (43%), which was not available to many earlier initiators. The second most common regimen was NNRTI-ART without PI, reported in 37% of recent initiators, compared with 57% of those initiating ART during 2000–2009 (Table 1).

Risk Behaviours

At the visit nearest ART initiation, 86% of recent initiators reported being sexually active in the past 6 months, and 32% reported two or more recent partners, similar to earlier initiators (Table 2). Notably, 50% of recent initiators reported recent unprotected sex. Recent initiators were significantly more likely to report recent condomless sex [odds ratio (OR) = 1.78, 95% confidence interval (CI): 1.14–2.78] and recently being diagnosed with a sexually transmitted infection (STI) during the past 6 months (OR = 1.77, 95% CI: 1.05–2.99), compared with earlier initiators (Table 2).

Substance use was stable across time periods, and was common among recent initiators, including daily alcohol (88%), cigarette (40%) and marijuana (46%) use (Table 2). The prevalence of illicit drug use was generally low, with the exception of continued use of poppers (24%) (Table 2). Trends in use were generally stable across time periods with the exception of cocaine use, which was lower in recent initiators (10% vs. 21%, P = 0.01).

Comorbidity and Mental Health

Obesity (24%), hypertension (25%) and kidney disease (15%) were all common in recent initiators (Table 3). The prevalence rates of obesity (OR = 2.14, 95% CI: 1.21–3.80) and chronic kidney (OR = 2.96, 95% CI: 1.38–6.36) were significantly higher in recent than in earlier initiators, while prevalence rates of liver disease, hypertension, diabetes and metabolic syndrome were similar across time periods. By contrast, the prevalence of hepatitis B and C exposure declined, with chronic hepatitis B infection down to 21% (from 52%; OR = 0.24, 95% CI: 0.14–0.39) and ever having hepatitis C infection down to 4% (from 12%; OR = 0.34, 95% CI: 0.13–0.85).

Notably, the prevalence of depression was significantly lower in recent than in earlier initiators (OR = 0.55, 95% CI: 0.35–0.86; Table 3), although more than a third of recent initiators (37%) were depressed. Improvements in mental health were commensurate with an increase in reporting very good or excellent quality of life (OR = 1.87, 95% CI: 1.06–3.30; 41% vs. 32%).