Race and sex differences in antiretroviral therapy use and mortality among HIV-infected persons in care

Empowering adolescents living with perinatally-acquired HIV: tailored CD4+ count assessment for optimized care, the EDCTP READY-study

Background

The elevated rate of AIDS-related mortality in Sub-Saharan Africa among adolescents living with HIV (ALHIV) is influenced by various factors, notably immunosuppression, within a framework of limited therapeutic alternatives. We aimed to enhance the management of pediatric HIV by assessing the immune response and associated factors in perinatally-infected ALHIV on antiretroviral therapy (ART) in Cameroon.

Methods

A cohort study was conducted from 2018-2020 among 271 ART-experienced ALHIV in Cameroon. Sociodemographic data, immunological (CD4), and virological (plasma viral load, PVL) responses were measured at enrolment (T0), 6-months (T1), and 12-months (T2) using PIMA CD4 (Abbott/Pantech (Pty) Ltd) and Abbott Applied Biosystem platform (Real-Time PCR m2000RT) respectively. Immunological failure (IF) was defined as absolute CD4 < 250 cells/mm3, and Virological failure (VF) as PVL ≥ 1,000 copies/ml. A linear mixed-effects model with R version 4.4.1 was used to estimate both fixed and random effects, with significance set at p < 0.05.

Results

Of the 271 perinatally-infected ALHIV enrolled over three phases, females were predominant (55.7, 55.1, and 56.0%); median age was 14 (IQR: 12-17); majority of the participants were followed-up in urban areas (77.5, 74.5, and 78.6%); and the age distribution favored older adolescents (48.7, 61.2, and 58.5%). Most participants achieved clinical success (93.1, 89.7, 88.9%), predominantly on first-line ART (80.8, 66.2, and 53.0%), with good adherence (64.2, 58.9, and 64.5%). Most participants had secondary education (67.2, 70.1, and 67.5%). Median CD4+ counts fluctuated overtime, with values of 563 (IQR: 249.0-845.0), 502 (IQR: 319.0-783.5), and 628 (IQR: 427.5-817.5), respectively. Of note, being male was linked to a reduction in CD4+ count compared to females, [-200.63 (-379.32 to -21.95), p = 0.028]. Similarly, late adolescence was associated with lower CD4+ counts compared to early adolescence, [-181.08 (-301.08 to -61.09), p = 0.003]. Moreover, participants experiencing VF showed significantly lower CD4+ counts compared to those with undetectable viral loads, [-353.08 (-465.81 to -240.36), p < 0.001]. Additionally, there was a marginally significant interaction between male gender and secondary educational level, [209.78 (-6.94-426.51), p = 0.058].

Conclusion

Among perinatally-infected ALHIV, age, gender, educational level, and virological status are key factors influencing their immune health and treatment outcomes. Prioritizing targeted interventions and close monitoring within these subgroups is crucial for optimal management, employing holistic care strategies that consider not only medical interventions but also psychosocial support and education.

Explaining inequity in knowledge, attitude, and services related to HIV/AIDS: a systematic review

BACKGROUND

Equitable service provision and coverage are important responses to end the threat of the HIV/AIDS pandemic. Understanding inequity supports policies and programmes to deliver tailored interventions. There is continuous evidence generation on inequity in HIV/AIDS services. However, there was a lack of evidence on the global picture of inequity in behavioural and biomedical services related to HIV/AIDS. This systematic review assessed inequities in knowledge, attitude, HIV testing, and ART coverage across individual-level social groups and multiple (dis)advantage categories.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, with a PROSPERO registration number CRD42024521247. The risk of bias was assessed by using Hoy et al's and Joanna Brigg's quality appraisal checklists for cross-sectional quantitative and qualitative studies, respectively. The search date was from inception to the final database search date (May 29, 2023). The included articles were either quantitative or qualitative studies. We used mixed-methods approach to analyse the data from the review articles. Quantitative descriptive analysis was conducted to estimate frequency of articles published from different countries around the world. Qualitative content analysis of the findings from the original studies was conducted using the PROGRESS plus framework which stands for: place of residence, occupation or employment status, gender, religion, education status, socioeconomic status, and social capital.

RESULTS

Out of 6,029 articles that were accessed and screened, only 72 articles met the inclusion criteria. More articles on HIV-related equity in knowledge, attitude, testing, and ART were published in developed countries than in developing countries. Individuals from higher-income households had better knowledge about HIV/AIDS. Unfavourable attitudes towards people living with HIV and HIV/AIDS-associated stigma were common among women. HIV/AIDS service coverage (HIV testing or ART coverage) was higher among richer and urban residents. HIV/AIDS-associated stigma and lower levels of knowledge about HIV/AIDS were observed among multiple disadvantageous groups due to the intersection of two or more identities.

CONCLUSIONS

The current review revealed that there have been disparities in HIV/AIDS services between social classes. Ending service disparity towards the global threat of HIV/AIDS demands tailored interventions based on socially disadvantaged groups (e.g., poor, rural dwellers, and women) and intersectional determinants. There is a need to understand the deep-rooted causes of inequity and the challenges that an equity-oriented system faces over time. More studies on inequity are needed, including intersectional inequity, which has been rarely studied in developing countries.

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

Exploring the impact of therapeutic advances in HIV-related mortality in the United States

Objectives

Mortality from HIV has significantly declined with the introduction of highly active antiretroviral therapy (HAART). This study sought to examine the longitudinal trends in mortality from HIV-related diseases by race, sex, geographical region, and over time as HAART trends changed.

Methods

We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database and performed serial cross-sectional analyses of national death certificate data for all-cause mortality with comorbid HIV from 1999 to 2020. HIV diseases (International Classification of Diseases, Tenth Revision codes B20-B24, O98.7, R75) were listed as the contributing cause of death. We calculated the age-adjusted mortality ratio (AAMR) per 1,000,000 individuals and determined mortality trends using the Joinpoint Regression Program. Subgroup analyses were performed by sex, race, region, and organ system. The study period was further stratified into three groups when specific drug regimens were more prevalent.

Results

In the 22-year study period, 251,759 all-cause mortalities with comorbid HIV were identified. The leading cause of death was infectious disease (84.0%, N = 211,438). Men recorded a higher AAMR than women (4.66 vs 1.65, P < 0.01). African American individuals had the highest AAMR (13.46) compared to White, American Indian, and Asian individuals (1.70 vs 1.65 vs 0.47). The South region had the highest AAMR (4.32) and urban areas had a higher AAMR compared to rural areas (1.77 vs 0.88).

Conclusions

More than 80% of deaths occurred because of infectious disease over the last 2 decades with a decreasing trend over time when stratified by race, sex, and geographical region. Despite advances in HAART, mortality disparities persist which emphasizes the need for targeted interventions in these populations.

Statistical analysis on the incidence and predictors of death among second-line ART patients in public hospitals of North Wollo and Waghemira Zones, Ethiopia, 2021

Acquired immune deficiency virus, caused by the human immunodeficiency virus, is a significant global health concern. Sub-Saharan Africa particularly Ethiopia faces a high prevalence of human immunodeficiency virus. In low-income settings like Ethiopia, early mortality rates are elevated due to severe opportunistic infections and advanced disease at Anti-retroviral treatment initiation. Despite available treatments, delayed treatment initiation among Human Immunodeficiency Virus -infected individuals in Africa, including Ethiopia, leads to disease progression and increased mortality risk. This study aimed to identify the factors contributing to the death of HIV patients under treatment at second line regimen in public hospitals of North Wollo and Waghemira Zones. A retrospective cohort study with 474 patients was conducted in selected hospitals of North Wollo and Waghemira Zones. A parametric Weibull regression model was employed, and the adjusted hazard ratio served as the measure of association. Variables significantly affected the outcome of the study was determined at a p-value < 0.05, along with a 95% confidence interval for the variables. The patients were within the average age of 38.6(standard deviation ± 12.5) years and majority (45.57%) had no formal education. The overall death incidence rate among second-line anti-retroviral treatment patients was 1.98 per 100-person years [95% CI 1.4-2.9%]. Poor adherence to antiretroviral treatment, male gender, and being underweight significantly increased the hazard of death. Conversely, increased anti-retroviral treatment duration had a significant and negative impact, reducing the hazard of death among patients. The study reveals a high incidence of death among second line anti-retroviral treatment users. Independent predictors include poor adherence, male gender, and underweight status, all significantly increasing the risk of death. On the positive side, the hazard of death decreases with longer anti-retroviral treatment duration. A critical concern and counseling should be given for better ART adherence, to change their nutritional status and for males.

Access to Federally Qualified Health Centers and HIV Outcomes in the U.S. South

INTRODUCTION

Federally Qualified Health Centers may increase access to HIV prevention, care, and treatment for at-risk populations.

METHODS

A pooled cross section of ZIP Code Tabulation Areas from cites in the U.S. South with high HIV diagnoses were used to examine Federally Qualified Health Center density and indicators of HIV epidemic control. The explanatory variable was Federally Qualified Health Center density-number of Federally Qualified Health Centers in a ZIP Code Tabulation Areas' Primary Care Service Area per low-income population-high versus medium/low (2019). Outcomes were 5-year (2015-2019 or 2014-2018) (1) number of new HIV diagnoses, (2) percentage late diagnosis, (3) percentage linked to care, and (4) percentage virally suppressed, which was assessed over 1 year (2018 or 2019). Multiple linear regression was used to examine the relationship, including ZIP Code Tabulation Area-level sociodemographic and city-level HIV funding variables, with state-fixed effects, and data analysis was completed in 2022-2023. Sensitivity analyses included (1) examining ZIP Code Tabulation Areas with fewer non-Federally Qualified Health Center primary care providers, (2) controlling for county-level primary care provider density, (3) excluding the highest HIV prevalence ZIP Code Tabulation Areas, and (4) excluding Florida ZIP Code Tabulation Areas.

RESULTS

High-density ZIP Code Tabulation Areas had a lower percentage of late diagnosis and virally suppressed, a higher percentage linked to care, and no differences in new HIV diagnoses (p<0.05). In adjusted analysis, high density was associated with a greater number of new diagnoses (number or percentage=5.65; 95% CI=2.81, 8.49), lower percentage of late diagnosis (-3.71%; 95% CI= -5.99, -1.42), higher percentage linked to care (2.13%; 95% CI=0.20, 4.06), and higher percentage virally suppressed (1.87%; 95% CI=0.53, 2.74) than medium/low density.

CONCLUSIONS

Results suggest that access to Federally Qualified Health Centers may benefit community-level HIV epidemic indicators.

Mental Health, Social Connectedness, and Fear During the COVID-19 Pandemic: A Qualitative Perspective from Older Women with HIV

Older women with HIV (WWH) confront significant biopsychosocial challenges that may be exacerbated by the COVID-19 pandemic. Between May 2020 and April 2021, following a resiliency intervention conducted as part of a randomized parent trial, 24 cisgender WWH (M = 58 years old) completed quantitative assessments and qualitative interviews exploring the impact of COVID-19 on mental health. Qualitative data were analyzed via rapid analysis. Most participants were Black (62.5%) and non-Hispanic or Latina (87.5%). Emergent themes included (1) increased anxiety and depression; (2) a loss of social connectedness; (3) fear of unknown interactions among COVID-19, HIV, and other comorbidities; and (4) the use of largely adaptive strategies to cope with these issues. Findings suggest that older WWH face significant COVID-19-related mental health challenges, compounding existing stressors. As the pandemic persists, it will be important to assess the impact of these stressors on wellbeing, identify effective coping strategies, and provide increased support to mitigate COVID-19-related mental health issues over time. Trial Registration: ClinicalTrials.gov identifier: NCT03071887.

Adapting, testing, and refining a resilience intervention for older women with HIV: An open pilot study

Half of persons with HIV in the United States (US), many of whom are women, are over age 50. Aging women with HIV (WWH) face unique biopsychosocial challenges, including stigma, the physiological effects of aging, and illness-associated stressors. Resilience interventions can build awareness of such stressors and aid in facilitating the relaxation response; however, no existing interventions specifically cater to the needs of older WWH. The content of the Relaxation Response Resiliency Program, which teaches positive psychology strategies, relaxation techniques, and cognitive behavioral skills, was adapted for older WWH. Thirteen WWH over 50 participated in an open pilot of the adapted intervention to iteratively refine the program and its procedures. Participants attended either 8 or 10 weekly group sessions; three groups were conducted in total. Pre- and post-intervention assessments and qualitative exit interviews were conducted. Among completers, an increase in resilience was observed. Though significance testing was not conducted, social support also increased, and depression, anxiety, and HIV stigma decreased from pre- to post-intervention. Over half of eligible women enrolled; completers reported high satisfaction with the program. However, retention was difficult; six participants withdrew or were lost to follow-up. Mean number of sessions attended was 3.5 in the 8-session group and 5 in the 10-session groups. In this small sample, the adapted intervention led to a clinically meaningful increase in resilience, though recruitment and retention were challenging. Further refinements to the intervention are needed to minimize attrition and increase acceptability before additional testing is initiated.

HIV mortality trends among older adults in the United States, 1999-2020

BACKGROUND

Despite the progress made in managing HIV, the mortality trends among older adults in the US remains understudied. The lack of evidence in this demographic hampers the ability to implement evidence-based interventions. Our aim is to analyze the trends in HIV-related mortality among US citizens aged 65 years and above by demographic characteristics such as age, gender, race/ethnicity, and census region.

METHODS

We abstracted national mortality data from the underlying cause of death files in the CDC WONDER database. The ICD-10 Codes- B20-B24 were used to identify HIV deaths among US older adults from 1999 to 2020. Trends in age-adjusted mortality rate (AAMR) were assessed using a five-year simple moving average and Joinpoint analysis. Results were expressed as annual percentage changes (APC), average annual percentage changes, and 95% confidence intervals (CI).

RESULTS

Between 1999 and 2020, a total of 15,694 older adults died from HIV in the US (AAMR= 1.7 per 100,000; 95% CI: 1.6 - 1.7). Overall mortality trends increased at an annual rate of 1.5% (95% CI: 1.2, 1.8) from 1999 through 2020. The trends increased among Non-Hispanic Whites, stabilized among Non-Hispanic Blacks, and decreased among Hispanics from 1999 to 2020. Further, the trends increased consistently across categories of age (65 to 74 years; 75 to 84 years), sex, and census region.

CONCLUSIONS

HIV mortality among older adults in the US has risen overall from 1999 to 2020, but with varying trends by race and ethnicity. This highlights the need for enhanced public health surveillance to better understand the scope of HIV mortality among older adults and identify high-risk demographic and regional subgroups for targeted interventions. Improving timely diagnosis, managing comorbidities, and stigma surrounding HIV among older adults are crucial to reducing HIV mortality in this population.

Sex and Race Disparities in Mortality and Years of Potential Life Lost Among People With HIV: A 21-Year Observational Cohort Study

Background

Since the availability of antiretroviral therapy, mortality rates among people with HIV (PWH) have decreased; however, this does not quantify premature deaths among PWH, and disparities persist.

Methods

We examined all-cause and premature mortality among PWH receiving care at the Vanderbilt Comprehensive Care Clinic from January 1998 to December 2018. Mortality rates were compared by demographic and clinical factors, and adjusted incidence rate ratios (aIRRs) were calculated using multivariable Poisson regression. For individuals who died, age-adjusted years of potential life lost (aYPLL) per total person-years living with HIV were calculated from US sex-specific life tables, and sex and race differences were examined using multivariable linear regression.

Results

Among 6531 individuals (51% non-Hispanic [NH] White race, 40% NH Black race, 21% cis-gender women, 78% cis-gender men) included, 956 (14.6%) died. In adjusted analysis, PWH alive in the most recent calendar era (2014-2018) had decreased risk of mortality compared with those in the earliest calendar era (1998-2003; aIRR, 0.22; 95% CI, 0.17-0.29), and women had increased risk of death compared with men (aIRR, 1.31; 95% CI, 1.12-1.54). Of those who died, Black women had the highest aYPLL (aIRR, 592.5; 95% CI, 588.4-596.6), followed by Black men (aIRR, 470.7; 95% CI, 468.4-472.9), White women (aIRR, 411.5; 95% CI, 405.6-417.4), then White men (aIRR, 308.6; 95% CI, 308.0-309.2). In adjusted models, higher YPLL remained associated with NH Black race and cis-gender women, regardless of HIV risk factor.

Conclusions

Despite marked improvement over time, sex disparities in mortality as well as sex and race disparities in YPLL remained among PWH in this cohort.

The shifting picture of HIV treatment, comorbidity and substance use among US MSM living with HIV

OBJECTIVES

People living with HIV (PLWH) have increased risk of chronic disease and poor mental health. We aimed to explore HIV disease indicators, comorbidity, and risk behavior of recent antiretroviral therapy (ART) initiators to inform current needs of PLWH.

METHODS

Men who have sex with men (MSM) in the Multicenter AIDS Cohort Study (MACS) who initiated ART between 2010 and 2018 (recent initiators) were compared with age-, race- and geographic location-matched men who initiated ART during 2000-2009 (early initiators). Measures of HIV disease, behavior, comorbidity and mental health were collected prospectively every 6 months using standardized forms.

RESULTS

Recent initiators had higher current CD4 (median CD4 451 vs. 307 cells/μL, P < 0.0001) and nadir CD4 (451 vs. 300 cells/μL, P < 0.0001) than earlier initiators. The proportion achieving viral suppression within a year of starting ART was significantly higher in recent compared with earlier initiators (92% vs. 74%, P < 0.0001). Median [interquartile range (IQR)] time from HIV diagnosis to ART initiation was 5.4 (1.7-23.1) months in recent initiators. Comorbidity prevalence was high in recent initiators, including obesity (24%), hypertension (25%) and kidney disease (15%). Substance use continues to be common, including cigarette use (40%), daily alcohol use (88%) and marijuana use (46%).

CONCLUSIONS

Improvements in getting individuals onto ART at an early stage have led to substantially higher CD4 cell counts at initiation. However, the high burden of comorbidity, substance use and poor mental health affecting MSM living with HIV in the US underscore ongoing challenges and our need to adapt and coordinate care.

Race and satisfaction with pain management among patients with HIV receiving long-term opioid therapy

INTRODUCTION

Management of chronic pain is an essential aspect of HIV primary care. Previous literature in the general population has elucidated racial disparities in the evaluation and treatment of pain. This study examined racial/ethnic differences in patient satisfaction and barriers to pain management among a cohort of PWH receiving LTOT.

MATERIALS AND METHODS

Patient-reported survey and EMR data were compared between non-white (n = 135; 81.3 %) and white (n = 31; 18.7 %) patients in a cohort of 166 PWH receiving LTOT in two clinics in Atlanta and Boston. Quantile and linear regression were used to evaluate the association between race and pain management outcomes: 1) satisfaction with pain management (0-10) and 2) patient-related barriers to pain management, including patient perceptions of pain medications, fatalism, and communication about pain. Models were adjusted for sex, age, clinical site, and baseline general health.

RESULTS

Non-white participants were noted to receive chronic opioids for a shorter mean duration of time than white participants (6.0 versus 11.0 years, p < 0.001) and lower mean morphine equivalent daily dose (MEDD) than white participants (28.1 versus 66.9 mg, p < 0.001). In adjusted analyses, there was no significant difference in satisfaction with pain management among non-white and white participants (p = 0.101). There was no significant difference in barriers to pain management in unadjusted (p = 0.335) nor adjusted models (p = 0.397).

CONCLUSION

While non-white PWH were noted to have received lower doses of chronic opioids and for shorter duration than white PWH, satisfaction with pain management was similar. Patient-related barriers to pain management were similar among non-white and white PWH.

Raking and regression calibration: Methods to address bias from correlated covariate and time-to-event error

Medical studies that depend on electronic health records (EHR) data are often subject to measurement error, as the data are not collected to support research questions under study. These data errors, if not accounted for in study analyses, can obscure or cause spurious associations between patient exposures and disease risk. Methodology to address covariate measurement error has been well developed; however, time-to-event error has also been shown to cause significant bias, but methods to address it are relatively underdeveloped. More generally, it is possible to observe errors in both the covariate and the time-to-event outcome that are correlated. We propose regression calibration (RC) estimators to simultaneously address correlated error in the covariates and the censored event time. Although RC can perform well in many settings with covariate measurement error, it is biased for nonlinear regression models, such as the Cox model. Thus, we additionally propose raking estimators which are consistent estimators of the parameter defined by the population estimating equation. Raking can improve upon RC in certain settings with failure-time data, require no explicit modeling of the error structure, and can be utilized under outcome-dependent sampling designs. We discuss features of the underlying estimation problem that affect the degree of improvement the raking estimator has over the RC approach. Detailed simulation studies are presented to examine the performance of the proposed estimators under varying levels of signal, error, and censoring. The methodology is illustrated on observational EHR data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic.

Factors Associated with State Variation in Mortality Among Persons Living with Diagnosed HIV Infection

In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

Gender and ethnic differences in rates of immune reconstitution, AIDS diagnosis, and survival

In this work, we use 2011-2013 Texas HIV surveillance data (N=2,175) and apply hierarchical linear and Cox regression modeling to characterize the association of gender and race/ethnicity with rate of immune recovery and determine whether immune recovery contributes to gender and racial/ethnic disparities in AIDS diagnosis and survival. The associations between gender and rate of immune recovery and between race/ethnicity and rate of immune recovery were not statistically significant (p > 0.05). In the multivariate survival analyses, there was no statistically significant association between gender and AIDS diagnosis (Adjusted Hazard Ratio (AHR) = 1.06, p = 0.61, 95%=0.85-1.32) and between race/ethnicity and AIDS diagnosis (Blacks vs Whites: AHR = 1.10, p = 0.24, 95% CI = 0.94-1.30; Hispanics vs Whites: AHR = 1.06, p = 0.46, 95% CI = 0.91-1.24). Similarly, there were no statistically significant associations with death (males vs females: AHR = 0.88, p = 0.73, 95% CI = 0.43-1.81; Blacks vs Whites: AHR = 0.68 p = 0.25, 95% CI = 0.36-1.30; Hispanics vs Whites: AHR = 0.96, p = 0.88, 95% CI = 0.55-1.67). However, the direction of the point estimates were in the reverse direction when compared to the rate of immune recovery or the AIDS diagnosis models. Our findings suggest that differences in rate of immune recovery may better explain disparities in AIDS diagnosis than disparities in survival. Future studies with longer follow-up may potentially generate statistically significant results.

HIV-Related Stigma and Viral Suppression Among African-American Women: Exploring the Mediating Roles of Depression and ART Nonadherence

We used baseline data from a sample of African-American women living with HIV who were recruited to participate in a stigma-reduction intervention in Chicago and Birmingham (2013-2015) to (1) evaluate the relationship between HIV-related stigma and viral suppression, and (2) assess the role of depression and nonadherence to antiretroviral therapy (ART) as mediators. Data from women were included in this secondary analysis if they were on ART, had viral load data collected within 8-weeks of study entry and had complete covariate data. We used logistic regression to estimate the total effect of HIV-related stigma (14-item Stigma Scale for Chronic Illness) on viral suppression (< 200 copies/mL), and serial mediation analysis to estimate indirect effects mediated by depressive symptoms (8-item Patient Health Questionnaire) and ART nonadherence (number of days with missed doses). Among 100 women who met study inclusion criteria, 95% reported some level of HIV-related stigma. In adjusted models, higher levels of HIV-related stigma were associated with lower odds of being virally suppressed (AOR = 0.93, 95% CI = 0.89-0.98). In mediation analysis, indirect effects through depression and ART nonadherence were not significant. Findings suggest that HIV-related stigma is common among African-American women living with HIV, and those who experience higher levels of stigma are less likely to be virally suppressed. However, the mechanisms remain unclear.

PrEP Stigma: Implicit and Explicit Drivers of Disparity

PURPOSE OF REVIEW

Despite its promise as an HIV prevention strategy, PrEP uptake remains slow, especially among highest priority populations. One factor that may be impeding implementation and driving disparities is PrEP-related stigma. This paper reviews the role of PrEP-related stigma in PrEP access, adherence, and persistence and examines its antecedents and consequences.

RECENT FINDINGS

Although PrEP stigma is often experienced at the community level (i.e., by potential and current users), it can be reinforced and even amplified by public health programs, policy, and research. PrEP stigma disproportionately impacts disadvantaged groups and impedes scalability by influencing behavior of both patients and providers. Reducing PrEP stigma and its negative impact on the epidemic requires a significant shift in perspective, language, and programs. Such a shift is necessary to ensure broader reach of PrEP as a prevention strategy and improve its utilization by the individuals who need it most.

[Telemedicine, prison and illness associated with HIV]

OBJECTIVE

Communicate the activity of telemedicine, from its opening, between a hospital consultation of infectious diseases and a penitentiary center.

METHODS

Descriptive study of the tele-consultation of infectious diseases of the Alcorcón Foundation University Hospital with the Navalcarnero penitentiary center from 2013 to 2017, which is carried out by videoconference. The reason and number of consultations, diagnosis of HIV, antiretroviral treatment (ART), immunovirological situation, diagnosis of hepatitis C virus (HCV= and intervention performed by the infectious expert were analyzed.

RESULTS

A total of 75 patients were evaluated in a total of 168 consultations (in the first year 11 consultations and in the fifth year 62). The index of successive / new consultations was 1.24 and 85% of the patients required less than 1 year of follow-up. 84% of patients did not move to the hospital. 99% of patients accepted this modality. 96% were HIV positive, 94% of them took ART and 85% had undetectable viral load with 532 CD4/mL of medium. 90% had positive serology for HCV. 72% of the consultations were for the assessment of HCV treatment, which was sofosbuvir/ledipasvir by 63%. 40% changed their ART (70% to avoid interactions).

CONCLUSIONS

Most of the evaluated patients have HIV infection. This type of consultation has a growing demand, is efficient (avoids transfers and is decisive) and has high acceptance. The most frequent reason for consultation was the treatment of HCV and more than a third of patients required ART change.

Safety of monitoring antiretroviral therapy response in HIV-1 infection using CD4+ T cell count at long-term intervals

The latest Brazilian guideline recommended the reduction of routine CD4+ T cell counts for the monitoring of patients with human immunodeficiency virus type 1 (HIV-1) under combination antiretroviral therapy (cART). The aim of this study was to evaluate the safety of monitoring response to cART in HIV-1 infection using routine viral load at shorter intervals and CD4+ T cell count at longer intervals. CD4+ T cell counts and HIV-1 viral load were evaluated in 1,906 HIV-1-infected patients under cART during a three-year follow-up. Patients were stratified as sustained, non-sustained and non-responders. The proportion of patients who showed a CD4+ T > 350cells/µL at study entry among those with sustained, non-sustained and non-responders to cART and who remained with values above this threshold during follow-up was 94.1%, 81.8% and 71.9%, respectively. HIV-1-infected patients who are sustained virologic responders and have initial CD4+ T cell counts > 350cells/µL showed a higher chance of maintaining the counts of these cells above this threshold during follow-up than those presenting CD4+ T ≤ 350cells/µL (OR = 39.9; 95%CI: 26.5-60.2; p < 0.001). This study showed that HIV-1-infected patients who had sustained virologic response and initial CD4+ T > 350cells/µL were more likely to maintain CD4+ T cell counts above this threshold during the next three-year follow-up. This result underscores that the evaluation of CD4+ T cell counts in longer intervals does not impair the safety of monitoring cART response when routine viral load assessment is performed in HIV-1-infected patients with sustained virologic response.

Chronic Pain Predicting Reciprocity of Support Among Vulnerable, Predominantly African-American Persons Living with HIV/AIDS

Among persons living with HIV/AIDS (PLHIV), approximately two-thirds report moderate to severe pain. Chronic pain can negatively affect PLHIVs' health behaviors and outcomes by interfering with their reciprocity (mutual exchange) of support in their caregiving relationships, which has been found to be associated with PLHIVs' antiretroviral adherence and viral suppression. Data were longitudinal (baseline, 6- and 12-month follow-up) from 383 PLHIV who were formerly or currently using drugs. Utilizing a longitudinal lagged fixed effects structural equation model, we found that never having pain in the past 6 months was predictive of increased reciprocity of support. Sub-analyses by care relationship type revealed never having pain was a significant predictor of greater reciprocity for sexual partner caregiving dyads, but not for kin or friend caregiving dyads. Our study emphasizes the importance of pain management in quality caregiving relationships characterized by reciprocity, which has consistently been found to be associated with stronger, more supportive caregiving relationships and better quality of life. Our findings suggest the importance of pain management intervention for improving reciprocity between vulnerable PLHIVs and their primary caregivers, especially between PLHIVs and caregivers who are current or former sexual partners.

Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX

For time-to-event outcomes, a rich literature exists on the bias introduced by covariate measurement error in regression models, such as the Cox model, and methods of analysis to address this bias. By comparison, less attention has been given to understanding the impact or addressing errors in the failure time outcome. For many diseases, the timing of an event of interest (such as progression-free survival or time to AIDS progression) can be difficult to assess or reliant on self-report and therefore prone to measurement error. For linear models, it is well known that random errors in the outcome variable do not bias regression estimates. With nonlinear models, however, even random error or misclassification can introduce bias into estimated parameters. We compare the performance of 2 common regression models, the Cox and Weibull models, in the setting of measurement error in the failure time outcome. We introduce an extension of the SIMEX method to correct for bias in hazard ratio estimates from the Cox model and discuss other analysis options to address measurement error in the response. A formula to estimate the bias induced into the hazard ratio by classical measurement error in the event time for a log-linear survival model is presented. Detailed numerical studies are presented to examine the performance of the proposed SIMEX method under varying levels and parametric forms of the error in the outcome. We further illustrate the method with observational data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic.

Trends in Racial/Ethnic Disparities Among Patients Living with HIV in Texas, 1996 to 2013

National studies show that Blacks with HIV have higher mortality rates compared to Whites. This study aimed to identify trends in Black racial disparities among Texas residents living with HIV. Using HIV surveillance data from the Texas Department of State Health Services, a cohort of HIV-diagnosed patients (N = 70,996) were identified and grouped according to year of diagnosis, 1996-1997 (T1), 1998-2006 (T2), 2007-2010 (T3), and 2011-2013 (T4). Survival analysis was used to examine racial differences in death rate (analysis 1) and clinical progression to AIDS (analysis 2) for each subcohort, using Blacks as the reference group. In analysis 1, Whites (hazard ratio, HR = 0.80, 95% confidence interval, CI = 0.74-0.87, p < 0.001; HR = 0.82, 95% CI = 0.78-0.87, p < 0.001; respectively) and Hispanics (HR = 0.72, 95% CI = 0.66-0.79, p < 0.001; HR = 0.77, 95% CI = 0.74-0.81, p < 0.001, respectively) had lower death rates in T1 and T2. This remained significant after adjusting for covariates. In T3, death rate was higher for Hispanics after adjustment (HR = 1.13, 95% CI = 1.00-1.28, p < 0.05). In T4, death rate was higher for Whites (HR = 1.66, 95% CI = 1.30-2.13, p < 0.001) and Hispanics (HR = 1.66, 95% CI = 1.34-2.06, p < 0.001). These relationships became non-significant after adjusting for covariates. In analysis 2, the rate of clinical progression to AIDS was higher for Hispanics in all subcohorts. The significance remained after adjusting for covariates. The rate of clinical progression to AIDS was lower for Whites after adjustments in T2 and T3. Additional studies are needed to understand factors that may explain this unexpected finding of improved survival for Blacks over time. Such studies may inform decision-making in HIV care to reduce Black HIV disparities.

Risk factors for delayed antiretroviral therapy initiation among HIV-seropositive patients

Prompt initiation of combination antiretroviral therapy (ART) is important to reduce comorbidity and mortality among people living with HIV, especially for those with a low CD4 cell count. However there is evidence that not everyone receives prompt initiation of ART after enrolling into HIV care. The current study investigated factors associated with failure to initiate ART within two years of entering into care among those with a CD4 count at or below 350 cells/mm³. The sample included 4,907 ART-naive patients with a CD4 count at or below 350 cells/mm³ enrolled between January 1, 2003 and December 31, 2012 at any of eight clinical sites in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). The two-year risk of delayed ART initiation was estimated using a log-binomial regression model with stabilized inverse probability of censoring weights for those lost to follow-up. Adjusting for other factors, an earlier enrollment date was the sole demographic characteristic associated with an increased risk of delayed ART initiation. Higher CD4 count, lower viral load, and a prevalent AIDS diagnosis were clinical characteristics associated with delayed ART initiation. Gender, age, race/ethnicity and HIV risk factors such as reported male-to-male sexual contact and injection drug use were not associated with delayed ART initiation. This study identified characteristics of patients for whom treatment was strongly to moderately recommended but who did not initiate ART within two years of entering care. Despite the known benefits of early antiretroviral therapy initiation, a lower viral load measurement may continue to be an important clinical characteristic in the more recent era with current ART initiation guidelines. These findings provide a target for closer monitoring and intervention to reduce disparities in HIV care.

Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care

BACKGROUND

It is unknown if a survival gap remains between HIV-infected and HIV-uninfected individuals with access to care.

METHODS

We conducted a cohort study within Kaiser Permanente California during 1996-2011, using abridged life tables to estimate the expected years of life remaining ("life expectancy") at age 20.

RESULTS

Among 24,768 HIV-infected and 257,600 HIV-uninfected individuals, there were 2229 and 4970 deaths, with mortality rates of 1827 and 326 per 100,000 person-years, respectively. In 1996-1997, life expectancies at age 20 for HIV-infected and HIV-uninfected individuals were 19.1 and 63.4 years, respectively, corresponding with a gap of 44.3 years (95% confidence interval: 38.4 to 50.2). Life expectancy at age 20 for HIV-infected individuals increased to 47.1 years in 2008 and 53.1 years by 2011, narrowing the gap to 11.8 years (8.9-14.8 years) in 2011. In 2008-2011, life expectancies at age 20 for HIV-infected individuals ranged from a low of 45.8 years for blacks and 46.0 years for those with a history of injection drug use to a high of 52.2 years for Hispanics. HIV-infected individuals who initiated antiretroviral therapy with CD4 ≥500 cells per microliter had a life expectancy at age 20 of 54.5 years in 2008-2011, narrowing the gap relative to HIV-uninfected individuals to 7.9 years (5.1-10.6 years). For these HIV-infected individuals, the gap narrowed further in subgroups with no history of hepatitis B or C infection, smoking, drug/alcohol abuse, or any of these risk factors.

CONCLUSIONS

Even with early treatment and access to care, an 8-year gap in life expectancy remains for HIV-infected compared with HIV-uninfected individuals.

High mortality among male HIV-infected patients after prison release: ART is not enough after incarceration with HIV

Context

French Guiana is a South American French territory, where HIV prevalence consistently exceeds 1% in the adult population. In the only correctional facility, HIV prevalence fluctuates at around 4%.

Aims

After describing the population of HIV-positive inmates, we aimed to evaluate mortality after release from the correctional facility, and to identify its predictive factors.

Rationale

Outside North American settings, data on treatment outcome and vital status of HIV-positive former inmates are scarce. There were no data in French Guiana. Filling this gap represents a basis for potential improvements.

Methods

All HIV-infected adults released from an incarceration of 30 days or more, between 2007 and 2013, were enrolled in a retrospective cohort study. Mortality was described over time, one to seven years following release, using Kaplan-Meier estimates. Factors associated with mortality were identified through a non-parametric survival regression model.

Results

147 former inmates were included. The male to female ratio was 4.4. The median age was 37.3 years. The majority were migrants, 25.8% were homeless, 70.1% suffered from substance abuse, with 34.0% of crack-cocaine users. On admission, 78.1% had an early HIV-stage infection (CDC-stage A), with a median CD4 count of 397.5/mm3, 34.0% had one comorbidity, mainly hypertension. Upon release, 50.3% were on ART. Reasons for not being treated were not fulfilling the criteria for 74.6%, and refusing for 15.1%. Before release, 84.5% of the patients on ART had a viral load≤200cp/ml. After release, 8.2% of the cohort had died, with a crude incidence of 33.8/1000 person-years. All recorded deaths were males, with an incidence of 42.2/1000 person-years. Comparing with the age-specific mortality rates for males in French Guiana, the standardized mortality ratio was 14.8. In multivariate analysis, factors associated with death were age and CD4 count before release.

Conclusion

Despite access to ART while incarcerated, with good virological outcome, the post-release mortality was very high for males, almost 15 times what is observed in the general male population living in French Guiana, after age standardization. Access to ART in correctional facilities may be a necessary, but not sufficient condition to protect male inmates from death after release.

The adherence gap: a longitudinal examination of men's and women's antiretroviral therapy adherence in British Columbia, 2000-2014

OBJECTIVE

The aim of this study was to observe the effect of sex on attaining optimal adherence to combination antiretroviral therapy (cART) longitudinally while controlling for known adherence confounders - IDU and ethnicity.

DESIGN

Using the population-based HAART Observational Medical Evaluation and Research cohort, data were collected from HIV-positive adults, aged at least 19 years, receiving cART in British Columbia, Canada, with data collected between 2000 and 2014. cART adherence was assessed using pharmacy refill data. The proportion of participants reaching optimal (≥95%) adherence by sex was compared per 6-month period from initiation of therapy onward. Generalized linear mixed models with logistic regression examined the effect of sex on cART adherence.

RESULTS

Among 4534 individuals followed for a median of 65.9 months (interquartile range: 37.0-103.2), 904 (19.9%) were women, 589 (13.0%) were Indigenous, and 1603 (35.4%) had a history of IDU. A significantly lower proportion of women relative to men were optimally adherent overall (57.0 vs. 77.1%; P < 0.001) and in covariate analyses. In adjusted analyses, female sex remained independently associated with suboptimal adherence overall (adjusted odds ratio: 0.55; 95% confidence interval: 0.48-0.63).

CONCLUSION

Women living with HIV had significantly lower cART adherence rates then men across a 14-year period overall, and by subgroup. Targeted research is required to identify barriers to adherence among women living with HIV to tailor women-centered HIV care and treatment support services.

Comparing results from multiple imputation and dynamic marginal structural models for estimating when to start antiretroviral therapy

Optimal timing of initiating antiretroviral therapy has been a controversial topic in HIV research. Two highly publicized studies applied different analytical approaches, a dynamic marginal structural model and a multiple imputation method, to different observational databases and came up with different conclusions. Discrepancies between the two studies' results could be due to differences between patient populations, fundamental differences between statistical methods, or differences between implementation details. For example, the two studies adjusted for different covariates, compared different thresholds, and had different criteria for qualifying measurements. If both analytical approaches were applied to the same cohort holding technical details constant, would their results be similar? In this study, we applied both statistical approaches using observational data from 12,708 HIV-infected persons throughout the USA. We held technical details constant between the two methods and then repeated analyses varying technical details to understand what impact they had on findings. We also present results applying both approaches to simulated data. Results were similar, although not identical, when technical details were held constant between the two statistical methods. Confidence intervals for the dynamic marginal structural model tended to be wider than those from the imputation approach, although this may have been due in part to additional external data used in the imputation analysis. We also consider differences in the estimands, required data, and assumptions of the two statistical methods. Our study provides insights into assessing optimal dynamic treatment regimes in the context of starting antiretroviral therapy and in more general settings. Copyright © 2016 John Wiley & Sons, Ltd.

The Association Between HIV Disclosure Status and Perceived Barriers to Care Faced by Women Living with HIV in Latin America, China, Central/Eastern Europe, and Western Europe/Canada

Generally, women are less likely than men to disclose their HIV status. This analysis examined the relationship between HIV disclosure and (1) perceived barriers to care and (2) quality of life (QoL) for women with HIV. The ELLA (EpidemioLogical study to investigate the popuLation and disease characteristics, barriers to care, and quAlity of life for women living with HIV) study enrolled HIV-positive women aged ≥18 years. Women completed the 12-item Barriers to Care Scale (BACS) questionnaire. QoL was assessed using the Health Status Assessment. BACS and QoL were stratified by dichotomized HIV disclosure status (to anyone outside the healthcare system). Multilevel logistic regression analysis was used to identify factors associated with disclosure. Of 1945 patients enrolled from Latin America, China, Central/Eastern Europe, and Western Europe/Canada between July 2012 and September 2013, 1929 were included in the analysis (disclosed, n = 1724; nondisclosed, n = 205). Overall, 55% of patients lived with a husband/partner, 53% were employed, and 88% were receiving antiretroviral therapy. Patients who were with a serodiscordant partner were more likely to disclose (p = 0.0003). China had a disproportionately higher percentage of participants who did not disclose at all (nearly 30% vs. <15% for other regions). Mean BACS severity scores for medical/psychological service barriers and most personal resource barriers were significantly lower for the disclosed group compared with the nondisclosed group (p ≤ 0.02 for all). Compared with the disclosed group, the nondisclosed group reported statistically significantly higher (p ≤ 0.03) BACS item severity scores for 8 of the 12 potential barriers to care. The disclosed group reported better QoL. Overall, HIV nondisclosure was associated with more severe barriers to accessing healthcare by women with HIV.

Sex differences in soluble markers vary before and after the initiation of antiretroviral therapy in chronically HIV-infected individuals

OBJECTIVE

To evaluate differences in soluble inflammatory markers between chronically HIV-infected men and women, with or without cognitive impairment, and in response to treatment.

DESIGN

Soluble biomarkers were measured in cryopreserved plasma and cerebrospinal fluid (CSF) of 60 treatment-naïve individuals (25 men and 35 women) with chronic HIV infection and 18 HIV-uninfected controls (9 men and 9 women) from Thailand. Following enrollment, participants began combination antiretroviral therapy and were evaluated for expression of these markers after 48 weeks.

METHODS

Plasma and CSF levels of 19 soluble biomarkers (IFN-γ, TNFα, TNF-RII, IL-1α, IL-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-15, MCP-1, t-Tau, IP-10, neopterin, IFNα, I-FABP, and sCD14) were measured using either a multiparameter or standard ELISA assay.

RESULTS

Prior to combination antiretroviral therapy, women with impaired cognition had elevated levels of neopterin and TNF-RII compared with women with normal cognition in both the plasma and CSF; however, levels did not differ between cognitively impaired or normal men. In a secondary outcome-hypothesis generating analysis, sex differences were also pronounced in plasma levels of MCP-1, IL-10, I-FABP, and sCD14 in response to treatment. Neopterin, IP-10, TNFα, TNF-RII, IFNα, MCP-1, IL-8, I-FABP, and sCD14 plasma levels remained elevated following 48 weeks of therapy in both sexes compared with uninfected controls.

CONCLUSION

We provide evidence of sustained immune activation after 48 weeks of treatment and identify possible sex differences in biomarkers previously linked to cognitive impairment, chronic inflammation, and gut integrity that may contribute to immunological differences between sexes in relationship to disease progression and response to therapy.

HIV Subspecialty Care in Correctional Facilities Using Telemedicine

In the United States, prisons and jails contain a population at high risk for HIV infection with a relatively large proportion known to be HIV positive. However, many incarcerated persons lack access to subspecialty HIV care due to barriers of geography and travel. Telemedicine clinics can remove these barriers, increasing access to expert, multidisciplinary care. With telemedicine, correctional facilities can provide up-to-date, evidence-based HIV management, which may lead to improved compliance, greater virologic suppression, improved CD4 T-cell counts, fewer adverse drug interactions, and decreased transmission in the community. While HIV care in prisons is an example of harnessing this technology, telemedicine can be used for the diagnosis and management of multiple acute and chronic diseases for underserved populations.

Depression, Abuse, Relationship Power and Condom Use by Pregnant and Postpartum Women with Substance Abuse History

Substance-abusing pregnant and postpartum women are less likely to maintain consistent condom use and drug and alcohol abstinence, which is particularly concerning in high HIV-prevalence areas. Data from 224 pregnant and postpartum women in substance abuse treatment were analyzed to examine effects of history of substance use, child abuse, and mental health problems on current substance use and condom-use barriers. Mediators were depression, relationship power and social support. Most participants (72.9 %) evidenced current depression. Less social support (-0.17, p < 0.05) and relationship power (-0.48, p < 0.001), and greater depression (-0.16, p < 0.05) predicted more condom-use barriers. History of mental health problems predicted condom-use barriers, mediated by recent depression and relationship power (0.15, p < 0.001). These findings suggest depression and diminished relationship power limit highest-risk women's ability to negotiate condom use and abstain from substance use, increasing their risk of acute HIV infection and vertical transmission.

Informal HIV Caregiver Proxy Reports of Care Recipients' Treatment Adherence: Relationship Factors Associated with Concordance with Recipients' Viral Suppression

To explore the role of informal caregivers in adherence, we compared adherence reports by caregivers to those of care recipients. We identified individual-level and relationship factors associated with agreement between caregivers' reports of recipients' adherence and assessed viral suppression. Participants were care recipients, who were on ART and had ever injected drugs, and their caregivers (N = 258 dyads). Nearly three-fourths of caregivers' reports of recipients' ART adherence agreed with recipients' viral suppression status. Agreement was associated with recipient age and expressing affection or gratitude to the caregiver, caregiver's having been close to someone who died of HIV/AIDS, and caregiver's fear of caregiving-related HIV (re)infection, while it was negatively associated with recipient's limited physical functioning. Our findings support the utility of caregiver proxy reports of care recipients' ART adherence and suggest ways to identify and promote HIV caregiver attention to and support of this vulnerable population's ART adherence.

Trends in hospital deaths among human immunodeficiency virus-infected patients during the antiretroviral therapy era, 1995 to 2011

OBJECTIVE

Mortality in hospitalized human immunodeficiency virus (HIV)-infected patients is not well described. We sought to characterize in-hospital deaths among HIV-infected patients in the antiretroviral (ART) era and identify factors associated with mortality.

METHODS

We reviewed the medical records of hospitalized HIV-infected patients who died from January 1, 1995 to December 31, 2011 at an urban teaching hospital. We evaluated trends in early and late ART use and deaths due to acquired immunodeficiency syndrome (AIDS) and non-AIDS, and identified clinical and demographic correlates of non-AIDS deaths.

RESULTS

In-hospital deaths declined significantly from 1995 to 2011 (P < 0.0001); those attributable to non-AIDS increased (43% to 70.5%, P < 0.0001). Non-AIDS deaths were most commonly caused by non-AIDS infection (20.3%), cardiovascular (11.3%) and liver disease (8.5%), and non-AIDS malignancy (7.8%). Patients with non-AIDS compared to AIDS-related deaths were older (median age 48 vs 40 years, P < 0.0001), more likely to be on ART (74.1% vs 55.8%, P = 0.0001), less likely to have a CD4 count of <200 cells/mm(3) (47.2% vs 97.1%, P < 0.0001), and more likely to have an HIV viral load of ≤400 copies/mL (38.1% vs 4.1%, P < 0.0001). Non-AIDS deaths were associated with 4.5 and 4.2 times greater likelihood of comorbid underlying liver and cardiovascular disease, respectively.

CONCLUSIONS

Non-AIDS deaths increased significantly during the ART era and are now the most common cause of in-hospital deaths; non-AIDS infection, cardiovascular and liver disease, and malignancies were major contributors to mortality. Higher CD4 cell count, liver, and cardiovascular comorbidities were most strongly associated with non-AIDS deaths. Interventions targeting non-AIDS-associated conditions are needed to reduce inpatient mortality among HIV-infected patients.

Life expectancy of HIV-positive individuals on combination antiretroviral therapy in Canada

Background

We sought to evaluate life expectancy and mortality of HIV-positive individuals initiating combination antiretroviral therapy (ART) across Canada, and to consider the potential error introduced by participant loss to follow-up (LTFU).

Methods

Our study used data from the Canadian Observational Cohort (CANOC) collaboration, including HIV-positive individuals aged ≥18 years who initiated ART on or after January 1, 2000. The CANOC collaboration collates data from eight sites in British Columbia, Ontario, and Quebec. We computed abridged life-tables and remaining life expectancies at age 20 and compared outcomes by calendar period and patient characteristics at treatment initiation. To correct for potential underreporting of mortality due to participant LTFU, we conservatively estimated 30 % mortality among participants lost to follow-up.

Results

9997 individuals contributed 49,589 person-years and 830 deaths for a crude mortality rate of 16.7 [standard error (SE) 0.6] per 1000 person-years. When assigning death to 30 % of participants lost to follow-up, we estimated 1170 deaths and a mortality rate of 23.6 [SE 0.7] per 1000 person-years. The crude overall life expectancy at age 20 was 45.2 [SE 0.7] and 37.5 [SE 0.6] years after adjusting for LTFU. In the LTFU-adjusted analysis, lower life expectancy at age 20 was observed for women compared to men (32.4 [SE 1.1] vs. 39.2 [SE 0.7] years), for participants with injection drug use (IDU) history compared to those without IDU history (23.9 [SE 1.0] vs. 52.3 [SE 0.8] years), for participants reporting Aboriginal ancestry compared to those with no Aboriginal ancestry (17.7 [SE 1.5] vs. 51.2 [SE 1.0] years), and for participants with CD4 count <350 cells/μL compared to CD4 count ≥350 cells/μL at treatment initiation (36.3 [SE 0.7] vs. 43.5 [SE 1.3] years). Life expectancy at age 20 in the calendar period 2000–2003 was lower than in periods 2004–2007 and 2008–2012 in the LTFU-adjusted analyses (30.8 [SE 0.9] vs. 38.6 [SE 1.0] and 54.2 [SE 1.4]).

Conclusions

Life expectancy and mortality for HIV-positive individuals receiving ART differ by calendar period and patient characteristics at treatment initiation. Failure to consider LTFU may result in underestimation of mortality rates and overestimation of life expectancy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0969-x) contains supplementary material, which is available to authorized users.

Black:White Disparities in HIV Mortality in the United States: 1990-2009

OBJECTIVES

The aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time.

METHODS

Using vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990-2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005-2009.

RESULTS

For the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990-1994) and T4 (2005-2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4.

CONCLUSIONS

Previous research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.

Nevirapine Concentration in Hair Samples Is a Strong Predictor of Virologic Suppression in a Prospective Cohort of HIV-Infected Patients

Effective antiretroviral (ARV) therapy depends on adequate drug exposure, yet methods to assess ARV exposure are limited. Concentrations of ARV in hair are the product of steady-state pharmacokinetics factors and longitudinal adherence. We investigated nevirapine (NVP) concentrations in hair as a predictor of treatment response in women receiving ARVs. In participants of the Women’s Interagency HIV Study, who reported NVP use for >1 month from 2003–2008, NVP concentrations in hair were measured via liquid-chromatography-tandem mass-spectrometry. The outcome was virologic suppression (plasma HIV RNA below assay threshold) at the time of hair sampling and the primary predictor was nevirapine concentration categorized into quartiles. We controlled for age, race/ethnicity, pre-treatment HIV RNA, CD4 cell count, and self-reported adherence over the 6-month visit interval (categorized ≤ 74%, 75%–94% or ≥ 95%). We also assessed the relation of NVP concentration with changes in hepatic transaminase levels via multivariate random intercept logistic regression and linear regression analyses. 271 women contributed 1089 person-visits to the analysis (median 3 of semi-annual visits). Viral suppression was least frequent in concentration quartile 1 (86/178 (48.3%)) and increased in higher quartiles (to 158/204 (77.5%) for quartile 4). The odds of viral suppression in the highest concentration quartile were 9.17 times (95% CI 3.2–26, P < 0.0001) those in the lowest. African-American race was associated with lower rates of virologic suppression independent of NVP hair concentration. NVP concentration was not significantly associated with patterns of serum transaminases. Concentration of NVP in hair was a strong independent predictor of virologic suppression in women taking NVP, stronger than self-reported adherence, but did not appear to be strongly predictive of hepatotoxicity.

Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003-2012

What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3% of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6% in 2003 to 8.1% in 2012, and peaking at 13.7% in 2005 and at 12.0% in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15-19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73% of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66% in 2003 to 53% in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5% in 2003 to 21.3% in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11% in 2003 to 22% in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.

Female and male differences in AIDS diagnosis rates among people who inject drugs in large U.S. metro areas from 1993 to 2007

PURPOSE

We estimated female and male incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess whether declines in IARs varied by sex after combination antiretroviral therapy (cART) dissemination.

METHODS

We compared IARs and 95% confidence intervals for female and male PWID in 95 of the most populous MSAs. To stabilize estimates, we aggregated data across three-year periods, selecting a period immediately preceding cART (1993-1995) and the most recent after the introduction of cART for which data were available (2005-2007). We assessed disparities by comparing IAR 95% confidence intervals for overlap, female-to-male risk ratios, and disparity change scores.

RESULTS

IARs declined an average of 58% for female PWID and 67% for male PWID between the pre-cART and cART periods. Among female PWID, IARs were significantly lower in the later period relative to the pre-cART period in 48% of MSAs. Among male PWID, IARs were significantly lower over time in 86% of MSAs.

CONCLUSIONS

IARs among female PWID in large U.S. MSAs have declined more slowly than among male PWID. This suggests a need for increased targeting of prevention and treatment programs and for research on MSA level conditions that may drive differences in declining AIDS rates among female and male PWID.

Ten-year Survival by Race/Ethnicity and Sex Among Treated, HIV-infected Adults in the United States

BACKGROUND

Ensuring equal access to antiretroviral therapy (henceforth therapy) should alleviate disparities in health outcomes among persons infected with human immunodeficiency virus (HIV). However, evidence supporting the persistence of disparities in survival following therapy initiation is mixed.

METHODS

Patients initiating therapy in eight academic medical centers in the Centers for AIDS Research Network of Integrated Clinical Systems between 1 January 1998 and 30 December 2011. Patients (n = 10 017) were followed from therapy initiation until death from any cause, administrative censoring at 10 years after therapy initiation or the end of follow-up on 31 December 2011. The 10-year risk of all-cause mortality was calculated from standardized Kaplan-Meier survival curves.

RESULTS

Patients were followed for a median of 4.7 years (interquartile range: 2.2, 8.2). During 51 121 person-years of follow-up, 1224 of the 10 017 patients died. The overall 10-year mortality risk was 20.2% (95% confidence interval [CI], 19.2%, 21.3%). Black men and women experienced standardized 10-year all-cause mortality risks that were 7.2% (95% CI, 4.3%, 10.1%) and 7.9% (95% CI, 3.9%, 12.0%) larger (absolute difference) than white men. White women, Hispanic men, and Hispanic women all had lower 10-year mortality than white men.

CONCLUSIONS

These data serve as a call to action to identify modifiable mechanisms leading to these observed mortality disparities among HIV-infected black patients. Effective interventions are needed to ensure that the goal of the National HIV/AIDS Strategy to overcome health disparities becomes a reality.

End-stage renal disease among HIV-infected adults in North America

BACKGROUND

Human immunodeficiency virus (HIV)-infected adults, particularly those of black race, are at high-risk for end-stage renal disease (ESRD), but contributing factors are evolving. We hypothesized that improvements in HIV treatment have led to declines in risk of ESRD, particularly among HIV-infected blacks.

METHODS

Using data from the North American AIDS Cohort Collaboration for Research and Design from January 2000 to December 2009, we validated 286 incident ESRD cases using abstracted medical evidence of dialysis (lasting >6 months) or renal transplant. A total of 38 354 HIV-infected adults aged 18-80 years contributed 159 825 person-years (PYs). Age- and sex-standardized incidence ratios (SIRs) were estimated by race. Poisson regression was used to identify predictors of ESRD.

RESULTS

HIV-infected ESRD cases were more likely to be of black race, have diabetes mellitus or hypertension, inject drugs, and/or have a prior AIDS-defining illness. The overall SIR was 3.2 (95% confidence interval [CI], 2.8-3.6) but was significantly higher among black patients (4.5 [95% CI, 3.9-5.2]). ESRD incidence declined from 532 to 303 per 100 000 PYs and 138 to 34 per 100 000 PYs over the time period for blacks and nonblacks, respectively, coincident with notable increases in both the prevalence of viral suppression and the prevalence of ESRD risk factors including diabetes mellitus, hypertension, and hepatitis C virus coinfection.

CONCLUSIONS

The risk of ESRD remains high among HIV-infected individuals in care but is declining with improvements in virologic suppression. HIV-infected black persons continue to comprise the majority of cases, as a result of higher viral loads, comorbidities, and genetic susceptibility.

HIV Type 1 Disease Progression to AIDS and Death in a Rural Ugandan Cohort Is Primarily Dependent on Viral Load Despite Variable Subtype and T-Cell Immune Activation Levels

BACKGROUND

Untreated human immunodeficiency virus type 1 (HIV) infection is associated with persistent immune activation, which is an independent driver of disease progression in European and United States cohorts. In Uganda, HIV-1 subtypes A and D and recombinant AD viruses predominate and exhibit differential rates of disease progression.

METHODS

HIV-1 seroconverters (n = 156) from rural Uganda were evaluated to assess the effects of T-cell activation, viral load, and viral subtype on disease progression during clinical follow-up.

RESULTS

The frequency of activated T cells was increased in HIV-1-infected Ugandans, compared with community matched uninfected individuals, but did not differ significantly between viral subtypes. Higher HIV-1 load, subtype D, older age, and high T-cell activation levels were associated with faster disease progression to AIDS or death. In a multivariate Cox regression analysis, HIV-1 load was the strongest predictor of progression, with subtype also contributing. T-cell activation did not emerge an independent predictor of disease progression from this particular cohort.

CONCLUSIONS

These findings suggest that the independent contribution of T-cell activation on morbidity and mortality observed in European and North American cohorts may not be directly translated to the HIV epidemic in East Africa. In this setting, HIV-1 load appears to be the primary determinant of disease progression.

Clinical and immunologic predictors of death after an acute opportunistic infection: results from ACTG A5164

BACKGROUND

In the pre-antiretroviral therapy (ART) era, markers of increased disease severity during an acute opportunistic infection (OI) were associated with mortality. Even with ART, mortality remains high during the first year after an OI in persons with advanced HIV infection, but it is unclear whether previous predictors of mortality remain valid in the current era.

OBJECTIVE

To determine clinical and immunological predictors of death after an OI.

METHODS

We used clinical data and stored plasma from ACTG A5164, a multicenter study evaluating the optimal timing of ART during a nontuberculous OI. We developed Cox models evaluating associations between clinical parameters and plasma marker levels at entry and time to death over the first 48 weeks after the diagnosis of OI. We developed multivariable models incorporating only clinical parameters, only plasma marker levels, or both.

RESULTS

The median CD4+ T-cell count in study participants at baseline was 29 cells/µL. Sixty-four percent of subjects had Pneumocystis jirovecii pneumonia (PCP). Twenty-three of 282 (8.2%) subjects died. In univariate analyses, entry mycobacterial infection, OI number, hospitalization, low albumin, low hemoglobin, lower CD4, and higher IL-8 and sTNFrII levels and lower IL-17 levels were associated with mortality. In the combined model using both clinical and immunologic parameters, the presence of an entry mycobacterial infection and higher sTNFrII levels were significantly associated with death.

CONCLUSIONS

In the ART era, clinical risk factors for death previously identified in the pre-ART era remain predictive. Additionally, activation of the innate immune system is associated with an increased risk of death following an acute OI.

The influence of race and comorbidity on the timely initiation of antiretroviral therapy among older persons living with HIV/AIDS

OBJECTIVES

We examined whether the timely initiation of antiretroviral therapy (ART) differed by race and comorbidity among older (≥ 50 years) people living with HIV/AIDS (PLWHA).

METHODS

We conducted frequency and descriptive statistics analysis to characterize our sample, which we drew from 2005-2007 Medicaid claims data from 14 states. We employed univariate and multivariable Cox regression analyses to evaluate the relationship between race, comorbidity, and timely ART initiation (≤ 90 days post-HIV/AIDS diagnosis).

RESULTS

Approximately half of the participants did not commence ART promptly. After we adjusted for covariates, we found that older PLWHA who reported a comorbidity were 40% (95% confidence interval = 0.26, 0.61) as likely to commence ART promptly. We found no racial differences in the timely initiation of ART among older PLWHA.

CONCLUSIONS

Comorbidities affect timely ART initiation in older PLWHA. Older PLWHA may benefit from integrating and coordinating HIV care with care for other comorbidities and the development of ART treatment guidelines specific to older PLWHA. Consistent Medicaid coverage helps ensure consistent access to HIV treatment and care and may eliminate racial disparities in timely ART initiation among older PLWHA.

Disparities in CD4+ T-Lymphocyte Monitoring Among Human Immunodeficiency Virus-Positive Medicaid Beneficiaries: Evidence of Differential Treatment at the Point of Care

BACKGROUND

Monitoring of immune function, measured by CD4 cell count, is an essential service for people with Human Immunodeficiency Virus (HIV). Prescription of antiretroviral (ARV) medications is contingent on CD4 cell count; patients without regular CD4 monitoring are unlikely to receive ARVs when indicated. This study assesses disparities in CD4 monitoring among HIV-positive Medicaid beneficiaries.

METHODS

In this retrospective observational study, we examined 24 months of administrative data on 2,250 HIV-positive, continuously-enrolled fee-for-service Medicaid beneficiaries with at least two outpatient healthcare encounters. We used logistic regression to evaluate the association of patient demographics (age, gender, race/ethnicity, and language) with receipt of at least one CD4 test per year, controlling for other potentially confounding variables.

RESULTS

Having a history of ARV therapy was positively associated with receipt of CD4 tests. We found racial/ethnic, gender, and age disparities in CD4 testing. Among individuals with a history of ARV use, all racial/ethnic groups were significantly less likely to have CD4 tests than White non-Latinos (African Americans, OR = 0.35, p<0.0001; Asian/Pacific Islanders, OR = 0.31, p=0.0047; and, Latinos, OR = 0.42, p<0.0001).

CONCLUSIONS

Disparities in receipt of CD4 tests elucidate one potential pathway for previously reported disparities in ARV treatment. Further qualitative and quantitative research is needed to identify the specific factors that account for these disparities, so that appropriate interventions can be implemented.

Improved virologic suppression with HIV subspecialty care in a large prison system using telemedicine: an observational study with historical controls

Correctional populations have an elevated human immunodeficiency virus (HIV) prevalence, yet many individuals lack access to subspecialty care. Our study showed that HIV-infected inmates had significantly greater virologic suppression and higher CD4 T-lymphocyte counts when managed by a multidisciplinary team of subspecialists conducting clinics via telemedicine. In other studies, these outcomes have been associated with reductions on HIV-related morbidity and mortality, as well as HIV transmission.

Sex differences in overall and cause-specific mortality among HIV-infected adults on antiretroviral therapy in Europe, Canada and the US

BACKGROUND

Here, we aimed to evaluate regional differences in all-cause, AIDS- and non-AIDS-related mortality in HIV-positive men and women started on combination antiretroviral therapy (cART) in Europe, Canada and the US.

METHODS

The ART Cohort Collaboration (ART-CC) combines 19 cohorts of individuals started on cART in Europe and North America (NA). We analysed patients infected via injecting drug use (IDU) or heterosexual sex using Cox proportional hazards models.

RESULTS

A total of 32,443 European (45.9% women), 1,162 (32.5% women) Canadian and 2,721 (15.5% women) US patients were included. In Europe and NA, women were younger, more likely to have acquired HIV heterosexually, be AIDS-free and have higher CD4(+) T-cell counts and lower HIV-1 RNA at baseline. European women had lower rates of all-cause (adjusted hazard ratio: 0.76; 95% CI 0.68, 0.84) and non-AIDS mortality (0.67; 0.57, 0.78) than men, but AIDS-mortality rates were similar (0.90; 0.75, 1.09). Women had lower mortality due to non-AIDS infections (0.6 versus 1.3 per 1,000 person-years), liver diseases (0.4 versus 1.7), non-AIDS malignancies (0.6 versus 2.0) and cardiovascular diseases (0.6 versus 1.0). Between-sex differences in all-cause mortality were larger in heterosexuals (0.70; 0.61, 0.80) than in IDU (0.88; 0.73, 1.05; interaction P-value =0.043). No sex differences in all-cause mortality were found in Canada (hazard ratio women 1.13; 0.82, 1.56) or US (hazard ratio women 1.12; 0.79, 1.58).

CONCLUSIONS

The increasing importance of non-AIDS mortality is leading to emergent sex differences among HIV-positive patients in Europe, as in the general population. Despite the better clinical characteristics at cART initiation, women in NA had similar mortality to men.

Race/ethnicity and HAART initiation in a military HIV infected cohort

Background

Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity.

Methods

Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm³. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR).

Results

1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk.

Conclusions

No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.

Gender differences in clinical outcomes among HIV-positive individuals on antiretroviral therapy in Canada: a multisite cohort study

BACKGROUND

Cohort data examining differences by gender in clinical responses to combination antiretroviral therapy (ART) remain inconsistent and have yet to be explored in a multi-province Canadian setting. This study investigates gender differences by injection drug use (IDU) history in virologic responses to ART and mortality.

METHODS

Data from the Canadian Observational Cohort (CANOC) collaboration, a multisite cohort study of HIV-positive individuals initiating ART after January 1, 2000, were included. This analysis was restricted to participants with a follow-up HIV-RNA plasma viral load measure and known IDU history. Weibull hazard regression evaluated time to virologic suppression (2 consecutive measures <50 copies/mL), rebound (>1000 copies/mL after suppression), and all-cause mortality. Sensitivity analyses explored the impact of presumed ART use in pregnancy on virologic outcomes.

RESULTS

At baseline, women (1120 of 5442 participants) were younger (median 36 vs. 41 years) and more frequently reported IDU history (43.5% vs. 28.8%) (both p<0.001). Irrespective of IDU history, in adjusted multivariable analyses women were significantly less likely to virologically suppress after ART initiation and were at increased risk of viral load rebound. In adjusted time to death analysis, no differences by gender were noted. After adjusting for presumed ART use in pregnancy, observed gender differences in time to virologic suppression for non-IDU, and time to virologic rebound for IDU, became insignificant.

CONCLUSIONS

HIV-positive women in CANOC are at heightened risk for poor clinical outcomes. Further understanding of the intersections between gender and other factors augmenting risk is needed to maximize the benefits of ART.

Understanding the disparity: predictors of virologic failure in women using highly active antiretroviral therapy vary by race and/or ethnicity

BACKGROUND

Stark racial/ethnic disparities in health outcomes exist among those living with HIV in the United States. One of 3 primary goals of the National HIV/AIDS Strategy is to reduce HIV-related disparities and health inequities.

METHODS

Using data from HIV-infected women participating in the Women's Interagency HIV Study from April 2006 to March 2011, we measured virologic failure (HIV RNA >200 copies/mL) after suppression (HIV RNA < 80 copies/mL) on highly active antiretroviral therapy. We identified predictors of virologic failure using discrete time survival analysis and calculated racial/ethnic-specific population-attributable fractions (PAFs).

RESULTS

Of 887 eligible women, 408 (46%) experienced virologic failure during the study period. Hispanic and white women had significantly lower hazards of virologic failure than African American women [Hispanic hazard ratio, (HR) = 0.8, 95% confidence interval: (0.6 to 0.9); white HR = 0.7 (0.5 to 0.9)]. The PAF of virologic failure associated with low income was higher in Hispanic [adjusted hazard ratios (aHR) = 2.2 (0.7 to 6.5), PAF = 49%] and African American women [aHR = 1.8 (1.1 to 3.2), PAF = 38%] than among white women [aHR = 1.4 (0.6 to 3.4), PAF = 16%]. Lack of health insurance compared with public health insurance was associated with virologic failure only among Hispanic [aHR = 2.0 (0.9 to 4.6), PAF = 22%] and white women [aHR = 1.9 (0.7 to 5.1), PAF = 13%]. By contrast, depressive symptoms were associated with virologic failure only among African-American women [aHR = 1.6 (1.2 to 2.2), PAF = 17%].

CONCLUSIONS

In this population of treated HIV-infected women, virologic failure was common, and correlates of virologic failure varied by race/ethnicity. Strategies to reduce disparities in HIV treatment outcomes by race/ethnicity should address racial/ethnic-specific barriers including depression and low income to sustain virologic suppression.