An audit of HIV treatment outcomes in a UK inner city cohort

Abstract

We describe the demographics and treatment outcomes of a HIV-infected cohort from Croydon University Hospital, London, UK. We showed that the Croydon Cohort had good viral load suppression (98.6% with viral load < 100 copies/ml and 99.0% with viral load < 200 copies/ml) despite being a potentially challenging cohort in a deprived area of London. The viral load outcomes are better than the Public Health England data from 2014 and the latest British HIV Association audit using data from 2009.

Keywords

HIV HIV treatment outcomes antiretroviral therapy audit medium-sized clinic

Background

The British HIV Association (BHIVA) guidelines for successful antiretroviral therapy (ART) in adults have set a goal for viral load (VL) under the detection limit within 3–6 months of starting treatment, and maintenance of this level thereafter.¹ The BHIVA audit of treatment outcomes describes a subset of patients from across the UK in 2009 to assess achievement of this goal.² Our HIV clinic at Croydon University Hospital is a medium-sized unit.² The Economic Deprivation Index in Croydon is 15.6% compared with 13.5% in England as a whole, and 44.9% of the Croydon population is of non-white ethnicity compared with 14.6% overall in England.³ The HIV prevalence in Croydon is 5.1 per 1000 (aged 15–59) compared with a prevalence in England of 2.8 per 1000.⁴ We describe our HIV clinic treatment outcomes and use the BHIVA audit and the latest Public Health England (PHE) surveillance data for comparison.⁴

Methods

We performed a retrospective case note review of all HIV-positive patients seen at least once at our clinic from 1 January until 31 December 2014. Patients who were not seen during that time frame, despite active recall, were defined as lost to follow-up (LTFU) and excluded, along with those known to have transferred out or died. Anonymised demographic and clinical data, including CD4 cell count at diagnosis and most recent CD4 cell count and viral load (VL) were collected from paper and electronic records. Definitions of demographic groups were based on the BHIVA audit definitions.²

Results

Demographics and data at diagnosis

The total cohort of patients was 848, with 16 LTFU, two dying and 39 transferring, leaving 791 for analysis. Demographics and HIV risk factors are described in Table 1. The median age was 45 years (interquartile range [IQR] 37–51). The median CD4 cell count at diagnosis was 240 cells/mm³ (IQR 65–424), and VL was 58,000 copies/ml (IQR 10,000–206,000). Of those with available data at diagnosis, 48.0% (340/709) had a CD4 cell count < 200 cells/mm³ (classified as presenting with advanced HIV disease⁵) and 66.9% (474/709) had a CD4 cell count < 350 cells/mm³ (classified as presenting with late diagnosis⁵).

Table 1.

Demographic and risk factor characteristics of patients at Croydon HIV clinic, the BHIVA audit and PHE.

Demographics	Croydon data	BHIVA audit²	PHE data⁴ (PLWH^a)
Female	402 (50.8%)	4917 (37.9%)	34,400 (33.1%)
Age 40+ years	565 (71.4%)	7931 (61.4%)
Ethnicity
White	183 (23.1%)	6729 (51.9%)
Black African	472 (59.7%)	5075 (39.1%)	38,700 (35.9%)
Route of HIV acquisition
Heterosexual	614 (77.6%)	7404 (57.1%)	59,500 (55.2%)
MSM	147 (18.6%)	4533 (34.9%)	43,500 (40.3%)

BHIVA: The British HIV Association; MSM: men who have sex with men; PHE: Public Health England.

People living with HIV (PLWH) includes diagnosed and undiagnosed people.

Antiretroviral therapy and latest VL

A total of 708 (89.5%) patients were receiving ART, 16 patients were excluded as they had initiated ART within the last six months, leaving 692 for ART outcome analysis. A total of 682 patients (98.6%) achieved a VL < 100 copies/ml and 99.0% (685) had VL < 200 copies/ml. One percent (seven) had VL > 200 copies/ml, all of whom had longstanding history of poor adherence and are receiving a protease inhibitor-based regimen.

Discussion

The demographic distribution of the Croydon clinic differs from the national cohorts. In the Croydon cohort, there is a higher percentage of black African, heterosexual, female and patients over 40 years compared to the BHIVA audit.² We believe that this demographic mix of our cohort could potentially lead to poorer virological outcomes as recent studies showed that women, heterosexual men and older patients have poorer virological outcomes, with higher virological failures and higher rates of treatment switches and discontinuations.^6–8

Overall, 66.9% (474/709) of the Croydon cohort were diagnosed late and in 2013, 62.5% (25/40) were diagnosed late compared with 42% nationally in 2013;⁸ this group again is potentially harder to manage, as it is known to have poorer outcomes and higher chance of death, especially within the first year.^9,10

Despite the challenging demographics of our cohort, we observed a higher viral suppression rate compared to the BHIVA audit and PHE data; this may be partly explained by a patient-centred multidisciplinary team (MDT) approach. Patients with complications are identified early and discussed in weekly consultant-led MDT meetings, which include specialist nurses, pharmacists, health advisors and social workers. Crucially, the MDT provides support in both clinic and community, including home visits and close liaising with the local council and housing association. This helps patients to improve their social circumstances and in turn their engagement and adherence to treatment regimens.

To conclude, good HIV treatment outcomes are achievable in a medium sized unit, even in the context of a cohort with late HIV presentation and challenging patient demographics, by utilising the broad skill mix of the MDT and liaising with community services.

Table 2.

Latest viral load (VL) and CD4 cell count for the Croydon clinic and BHIVA outcomes audit findings.²

	Croydon data	BHIVA audit²	PHE data⁴
Viral load
VL < 40 copies/ml	676 (97.7%)	7546 (83.2%)
VL < 100 copies/ml	682 (98.6%)	8489 (93.6%)
VL < 200 copies/ml	685 (99.0%)		72,800 (94.6%)
CD4 cell count
CD4 > 200 cells/mm³	747 (94.4%)	10,026 (94.9%)
CD4 > 350 cells/mm³	638 (80.6%)	8536 (80.8%)

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

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