By Liz Highleyman

Three decades into the HIV/AIDS epidemic, evidence continues to accumulate showing that people of different racial/groups and socioeconomic status have disparate experiences with HIV and its treatment -- even though antiretroviral therapy works similarly regardless of race (though some side effects appear to vary).

African-Americans and Hispanics/Latinos are overrepresented in the total number of people living with HIV/AIDS and blacks have the highest rate of new infections. These groups also tend to access care later, and thus may have poorer outcomes.

Two presentations at the 48th International Conference on Antimicrobial Agents and Chemotherapy (ICAAC) last week in Washington, DC, looked at differences in HIV treatment outcomes by race/ethnicity.

Risk Factors for Hospital Outcomes

Researchers from the University of Texas at Austin sought to understand factors associated with poor health outcomes in HIV positive people of different racial/ethnic groups. As background, they noted that some groups are believed to have higher rates of comorbidities such as hepatitis C virus (HCV) coinfection, opportunistic infections (OIs), and substance abuse. However, it is unclear if race/ethnicity is an independent predictor of length of hospital stays or death while hospitalized after accounting for these other factors.

The investigators extracted data from the 1996-2005 National Hospital Discharge Survey -- annual national surveys conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) -- and used ICD-9-CM codes to identify individuals with HIV/AIDS, HCV, OIs, and substance abuse. People younger than 18 years and those who left the hospital against medical advice were excluded. Data included patient age, sex, race/ethnicity, insurance status, source of admission, length of stay, and discharge status.

Results

• 14,153 cases, representing 1.3 million national discharges, met the inclusion criteria (51% black and 27% white).

• Black and white patients were similar with respect to median age (41 years), but whites were more likely to be male (82% vs 62%; P < 0.0001).

• Black patients were more likely than whites to have diagnosed substance abuse (25% vs 20%; P < 0.0001) and OIs (39% vs 37%; P = 0.0463).

• Whites, however, were more to have HIV-HCV coinfection (10% vs 8%; P = 0.0022).

• More black patients than whites used cocaine (43% vs 20%; P = 0.0001), but fewer blacks used alcohol (28% vs 33%; P = 0.0326) or tobacco (18% vs 24%; P < 0.0001).

• Black race (about 4 times greater likelihood), OIs (about 14 times greater), cocaine use (about 45 times greater), and older age (> 49 years) (about 20 times greater) independently predicted a higher risk of in-hospital death, although HCV coinfection did not.

• Black race remained an independent predictor of in-hospital mortality (P = 0.0391) and length of hospital stay (P = 0.0496) after controlling for age, OIs, HCV coinfection, and cocaine use.

Based on these findings, the researchers concluded, "Black HIV/AIDS patients admitted to U.S. hospitals have higher rates of opportunistic infection, cocaine use, stay longer, and are more likely to die during hospitalization."

"Our study demonstrates that blacks have higher rates of associated illnesses and hospital admissions, longer hospital stays, and more deaths compared to white patients," said lead investigator Christine Oramasionwu in a press release issued by ICAAC. "Alarmingly, these disparities persist even after years of experience with effective medications to reduce HIV complications. Black patients often don't seek care until they are sick with all these illness -- and by then it is too late."

The researchers were not able to explain the lower rate of HCV coinfection among blacks in this study, given that some prior research suggests they may have a higher coinfection rate.

Univ. of Texas, Austin, TX.

Treatment Outcomes in WIHS

In a related study, investigators with the large Women's Interagency HIV Study (WIHS) looked at disparities in the likelihood of receiving HAART and whether these are influenced by substance abuse and health insurance status.

The analysis included a subset of WIHS participants for whom HAART was clinically indicated (CD4 count < 350 cellls/mm3 or HIV viral load > 50,000 copies/mL) in 2002 (n = 1463) and in 2005 (n = 1345), controlling for measures of substance abuse, health insurance, and other potential confounding factors.

Results

• About 30% of treatment-eligible women were not receiving antiretroviral therapy in both 2002 and 2005.

• In 2002 and in 2005, African-American women were about twice as likely as white women to not be receiving HAART.

• After adjusting for potential confounders, the likelihood of not receiving HAART remained greater for African-American women -- but not for Latina women -- compared with white women.

• Disparities in HAART use according to race/ethnicity improved -- but did not disappear -- by 2005.

• The effects of substance use changed during the study period:

• Alcohol use -- including moderate or light use -- was related to lack of HAART in both years;

• Illicit/recreational drug use was not significantly associated with lack of HAART.

• Having health insurance was associated with a significantly greater likelihood of receiving HAART in both years, as was enrolled in an AIDS Drug Assistance Program (ADAP).

• Uninsured or privately insured women were about 4 times as likely as women on Medicaid to not be receiving HAART in 2002, and about twice as likely in 2005.

• Women enrolled in ADAP had a lower likelihood of not receiving HAART than non-participants (OR 0.53 in 2005).

The researchers concluded that, "Substantial disparities in receipt of HAART persist by race/ethnicity among women with HIV/AIDS."

"Disparities exist even after controlling for health insurance and substance abuse," they continued. "However, having Medicaid and/or ADAP appears to improve access to HAART."

"Some narrowing of disparities was seen over the 2002-2005 period," they noted, but recommend that efforts to address remaining disparities are warranted.

George Washington Univ, Washington, DC; Harvard Med. School, Boston, MA; Wake Forest Univ School of Med., Winston-Salem, NC.

11/07/08

References

CU Oramasionwu, l Ryan, and CR Frei. Disparities in Comorbid Conditions among White and Black HIV/AIDS Patients in the United States National Hospital Discharge Survey (NHDS). 48th International Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2008). Washington, DC. October 25-28, 2008. Abstract H-445.

M Lillie-Blanton, VE Stone, and A Snow Jones. Race, Drug Use & Insurance Coverage in Use of HAART among HIV Positive Women, 2002-2005. 48th International Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2008). Washington, DC. October 25-28, 2008. Abstract H-444.

Other source
ICAAC. HIV/AIDS-Related Ethnic Health Disparities in the United States. Press release. October 25, 2008.