BACKGROUND: Low-income New York City (NYC) residents with HIV are eligible for subsidized or free housing through Housing Opportunities for Persons with AIDS (HOPWA). Stable housing supports continuous care and antiretroviral therapy (ART) adherence, which promotes viral suppression; suppression improves individual health and prevents transmission. Beginning in 2010, HOPWA programs prioritized viral suppression as a goal for clients. In 2012, US guidelines recommended ART be considered in all HIV-infected persons, regardless of disease severity. To better understand the impact of changing HOPWA priorities and treatment guidelines, we measured trends in viral suppression among NYC HOPWA clients during 2009-2014 and assessed whether factors associated with suppression in 2014 differed from those in 2009.
METHODS: NYC Department of Health and Mental Hygiene (DOHMH)-administered HOPWA data and HIV surveillance data were merged to obtain demographic, clinical (CD4 count and viral load (VL)), and housing (program type and residential stability) data for persons receiving HOPWA services during 2009-2014. Clients were considered to be virally suppressed in a given year if they had ≥1 VL test that year and the latest VL that year was undetectable (≤400 copies/mL). The Cochran-Armitage test indicated trends in percent suppressed. Multivariable logistic regression with viral suppression as the outcome was conducted for 2009 and 2014.
RESULTS: DOHMH-administered HOPWA clients numbered 1,960-2,607 annually. Viral suppression increased overall from 61% in 2009 to 81% in 2014 (p<0.0001) and increased in all demographic, clinical, and housing subgroups (p<0.05). During 2009 and 2014, lower odds of suppression were seen in persons with lower CD4 counts (e.g., in 2009, 350-499 vs. ≥500 cells/μL, adjusted odds ratio [AOR]=0.68; 95% confidence interval [CI]=0.52-0.89]), younger ages (e.g., in 2009, 40-49 years old vs. ≥50; AOR=0.71[0.57-0.87]), and non-foreign place of birth (in 2009, vs. foreign-born, AOR=0.48[0.39-0.59]). In 2014 only, the odds of suppression among the second-highest CD4 group (350-499 cells/μL; AOR=0.72[0.49-1.07]) and second-oldest age group (40-49 years; AOR=0.78[0.57-1.06]) did not differ from those among the highest-CD4 group and oldest age group, and there were no differences in odds of suppression by housing characteristics.
CONCLUSIONS: Viral suppression increased among NYC HOPWA clients during 2009-2014, overall and in all subgroups, potentially resulting from changes in treatment guidelines and an emphasis within HOPWA on suppression. More HOPWA clients, especially the relatively healthy and young or those with residential instability, appear to be successfully taking ART. However, more work is needed to increase suppression among persons with lowest CD4 counts and youngest ages.