Gender, Race, and Geographic Disparities in HIV/AIDS Outcomes

	SUMMARY: Women, blacks, and people living in the southern U.S. had poorer HIV treatment outcomes than other groups, according to a study of more than 2000 seroconverters described in the February 15, 2011 Journal of Infectious Diseases. People from these disadvantaged populations were less likely to start antiretroviral therapy (ART) and more likely to experience HIV/AIDS-related events over 8 years of follow-up; those who started treatment, however, responded equally well after the first 6 months.

By Liz Highleyman

Research over the past 3 decades looking at the effects of demographic factors such as sex, race/ethnicity, and socioeconomic status on HIV and its treatment has produced conflicting results. Some studies have suggested that women and people of color respond less well to ART, for example, but others have shown that such differences are attributable to poorer access to care.

In the present study, Amie Meditz from the University of Colorado and colleagues sought to determine whether sex and race/ethnicity influence clinical outcomes following primary HIV infection. This analysis followed people who were identified as HIV positive within 1 year after infection, so it was not affected by the issue of early vs late diagnosis -- a confounding factor in many studies.

The analysis included 2277 participants in the Acute Infection and Early Disease Research Program, a multi-center observational cohort of individuals (mostly from North America and Australia) diagnosed with acute or recent HIV infection during the ART era. A limitation of the study was that only 5.4% of participants were women. The researchers classified participants as "white" or "non-white," with most of the "non-whites" being black. The majority (77%) of men were white, while the majority of women (55%) were non-white. Participants were followed for up to 8 years (average about 4.5 years).

Results

	At the time of enrollment, women had a lower HIV viral load (average .40 log copies/mL less) and higher CD4 T-cell count (66 cells/mm3 more) than men, after controlling for age and race/ethnicity.
	Women were less likely than men to report symptoms of early HIV infection, or acute retroviral syndrome.
	68.5% of men and 63.7% of women started ART during the study.
	Non-white women and men were significantly less likely to start ART at any time point compared with white men.
	White women, however, were somewhat more likely to start ART than white men.
	People from the southern U.S. were less likely to start treatment compared with those from other regions.
	Sex and race/ethnicity were not associated with significant differences in virological or immunological response to ART after 6 months.
	During follow-up, women were more than twice as likely as men (2.17-fold) to experience at least 1 HIV-related event.
	Non-white women were more likely than any other group to experience HIV or AIDS events, after adjusting for ART use and injection drug use:
	HIV-related events, non-white women: 64%; HIV-related events, other groups combined 21%; AIDS-defining events, non-white women: 22%; AIDS-defining events, other groups combined: 6%.
	Non-white women were also significantly more likely than other groups to have their CD4 count fall below 200 cells/mm3 during follow-up.
	By 8 years after diagnosis, there were significant differences in proportions of people who experienced at least 1 HIV/AIDS event:
	78% of non-white participants in the southern U.S.; 37% of white participants in the southern U.S.; 24% of white participants in other regions; 17% of non-white participants in other regions.
	Mortality was low overall, and did not differ significantly between women and men (0.8% vs 0.7%, respectively).

"Despite more favorable clinical parameters initially, female HIV-1-seroconverters had worse outcomes than did male seroconverters," the study authors concluded. "Elevated morbidity was associated with being non-white and residing in the southern United States."

While women, non-whites, and southerners were less likely to start ART, this did not fully account for differences in outcomes, they elaborated in their discussion, suggesting that these disparities could be attributable in part to socioeconomic factors including "access to health care, health behaviors, lifestyle, and environmental exposures." Given that differences in HIV outcomes between men and women are typically not observed in studies outside the U.S., they added that "sex differences in HIV-related morbidity observed in this study are not biologically based but are the result of socioeconomic conditions speci?c to the United States."

In an accompanying editorial, Carlos del Rio and Wendy Armstrong from Emory University cautioned that socioeconomic factors play an important role in determining HIV disease outcomes -- at both the individual and population levels -- and "although theoretically modifiable, they represent complex challenges that are beyond the traditional influence of public health."

Investigator affiliations: Departments of Medicine and Biostatistics & Informatics, University of Colorado Denver, Aurora, CO; Aaron Diamond AIDS Research Center, Rockefeller University, New York, NY; Department of Family and Preventive Medicine, University of California, San Diego, CA; Department of Medicine, University of California, San Francisco, CA; Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles Medical Center, Torrance, CA; Department of Medicine, University of Washington, Seattle, WA; Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD; Department of Medicine and Microbiology/Immunology, University of Alabama, Birmingham, AL; Department of Medicine, McGill University Health Centre, Montreal, Canada; Department of Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada; National Centre for HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia; Partners AIDS Research Center, Boston, MA; Veterans Affairs San Diego Healthcare System, San Diego, CA.

1/25/11

References

AL Meditz, S MaWhinney, A Allshouse, and others. Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection. Journal of Infectious Diseases 203(4): 442-451 (Free full text). February 15, 2011.

WS Armstrong and C del Rio. Gender, Race, and Geography: Do They Matter in Primary Human Immunodeficiency Virus Infection? Journal of Infectious Diseases 203(4): 437-438 (Free full text). February 15, 2011.

Other Source

Infectious Diseases Society of America. Sex, Race, and Geography Influence Health Outcomes of Those Identified Within a Year of HIV Infection. Press release. January 18, 2010.