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


Effective therapies have transformed HIV into a chronic condition and many individuals acquiring HIV today in the US can anticipate near normal life spans, especially if they initiate therapy early. This study suggests improvements over the past decade in getting individuals onto effective ART at an early stage, before CD4 cell counts drop substantially. Our findings on those initiating therapy between 2010 and 2018 build on earlier papers suggesting that CD4 count at initiation was increasing, but suggest further improvements in the timing of getting PLWH into care compared with data from 1997–2007 where CD4 was still < 350 cells/mL at initiation.[15] These data further suggest that recent ART initiators are less likely to fail therapy, which is probably the result of second-generation PIs and NRTIs, as well as new classes of drugs that have little to no cross-resistance with older therapies and circulating resistance. The switch to II-based regimens among recent initiators (comprising > 43% of regimens) emphasizes this trend. These metrics for recent initiators reflect the shift towards initiation of therapy earlier in the course of infection and the development of more tolerable, effective therapies. Our data support and update previous US findings suggesting earlier initiation of therapy at higher CD4 cell counts and higher likelihood of achieving viral suppression.[16]

Beginning in 2012, clinical guidelines recommended ART initiation for all patients regardless of CD4 count. Ambitious Joint United Nations Programme on HIV/AIDS '90-90-90' goals are targeted to increase the number of PLWH who know their serostatus to 90%, increase ART prescription to 90% of diagnosed HIV cases, and aimed to achieve and maintain viral suppression in 90% of treated PLWH.[17] In the US, c. 75% of PLWH successfully link into HIV care within a year of diagnosis.[18] This observational study provides a picture of PLWH outside of a healthcare setting and includes men who initiated ART early, as well as others who delayed therapy. Previous studies have reported longer time to ART initiation among women than among men, and among younger individuals, suggesting that these results may not extrapolate to other subgroups of PLWH.[19,20]

While this study suggests improvements in mental quality of life for PLWH, the prevalence of depression remains a concern and should be considered in health planning for those ageing with HIV. Drug use, which was as common among recent initiators as it was in earlier initiators, can be both a cause and a consequence of depression.[21] However, 41% of recent initiators report very good or excellent quality of life, a gain of 9% compared with earlier initiators. Better linkages to mental healthcare and coordination of depression treatment with drug treatment could further improve quality of life among PLWH.

The observed increase in unprotected sex and recent STI acquisition among recent HAART initiators is concerning, and consistent with some other studies suggesting increased sexual risk-taking.[22] High prevalence of unprotected anal sex has been reported among US MSM living with HIV in the National HIV Behavioral Surveillance (NHBS), with 77% reporting condomless anal sex in the past year in data from 2008–2014,[13] compared with 54–58% in data from 2003–2008.[23,24] New research into effective risk communication among the current population of ageing PLWH could shed light on how to reduce sexual risk-taking.

Our data suggest increasing prevalence among recent initiators of some chronic conditions like obesity and kidney disease and continued high prevalence of hypertension and metabolic syndrome. This builds on several previous studies showing increasing incidence and prevalence of comorbidity in treated PLWH[7,25,26] to provide a snapshot of high comorbidity burden among PLWH that underscores the care management challenges of MSM ageing with HIV. The sustained high prevalence of alcohol, tobacco and drug use among ART initiators indicates that there has been little progress in reducing these behavioural risk factors for chronic comorbidities despite the growing comorbidity burden.

This study had several strengths and also some limitations. Participants were from multiple sites across the US and longitudinally followed with the same protocol as part of the MACS cohort. However, the MACS represents a subset of the PLWH in the US who may have better access to care, and so these findings may not represent trends in some other populations in the US living with HIV, including younger men and transwomen.

This study suggests that progress towards the '90-90-90' goals with > 90% of recent ART initiators having undetectable HIV viral load within 12 months of initiation. Further, among those who were suppressed, low (12%) subsequent failure rate and no (0%) deaths occurred in the following 2 years. While these improvements in HIV-related disease characteristics will lead to longer life spans and hopefully improved quality of life, this study confirms high prevalence of comorbidity, substance use and poor mental health among recent ART initiators in the US, underscoring some of the challenges to be faced in those currently ageing with HIV. Growing awareness of the need for integrated physical, mental and behavioural care to address the complex health needs of this population an implementation of novel care strategies could lead to substantial gains in quality of life for PLWH.