Mortality among people with HIV has continued to decline over time as antiretroviral treatment and access to care has improved, but gender and racial disparities still persist, according to recent research published in Open Forum Infectious Diseases. However, another study found that racial/ethnic gaps in antiretroviral prescription appear to have closed.
Rachael Pellegrino, MD, MPH, of Vanderbilt University Medical Center in Nashville, and colleagues analyzed all-cause mortality and premature death among more than 6,500 people with HIV who received care at the Vanderbilt Comprehensive Care Clinic between January 1998 and December 2018.
Nearly 80% of the participants were men, about half were white and 40% were Black. A total of 956 people (15%) died during the study period. Premature death was calculated using U.S. life expectancy data.
The researchers compared outcomes during two eras: 1998 to 2003, after protease inhibitors (first approved in 1995) and effective combination therapy became available; and 2014 to 2018, when advances in antiretroviral therapy had made treatment more effective, better tolerated and easier to take.
After adjusting for age and other factors, people who received care during the later era had a 78% lower risk of death than those in care during the earliest period. Overall, women had an increased risk of death compared with men. Among those who died, Black women had the highest premature mortality—the largest number of years of potential life lost—followed by Black men, white women and white men.
“Despite marked improvement over time, sex disparities in mortality as well as sex and race disparities in years of potential life lost remained among people with HIV in this cohort,” the study authors concluded.
One factor that affects outcomes is whether people have access to the latest HIV treatment.
Lauren Zalla, PhD, of the University of North Carolina at Chapel Hill, and colleagues looked at differences in initial antiretroviral therapy prescription for people entering HIV care in the United States.
This retrospective observational study included nearly 43,000 individuals who started care at more than 200 clinical sites participating in the NA-ACCORD collaboration between October 2007—when the first integrase inhibitor, Isentress (raltegravir), was approved—and April 2019. Of the 41,263 people with available information on race/ethnicity, 47% were Black, 33% were white and 16% were Latino. Most (85%) were men, and the median age was 42 years.
Here, too, the researchers compared two time periods: 2007 to 2015 and 2016 to 2019. During most of the earlier period, guidelines still recommended starting treatment based on CD4 count. In 2012, national guidelines were revised to recommend treatment for everyone diagnosed with HIV regardless of CD4 count. In 2015, the START trial provided definitive evidence that early treatment initiation, before immune function substantially declines, leads to better outcomes.
As reported in JAMA, the overall probability of receiving a prescription for antiretroviral therapy did not differ significantly according to race/ethnicity. During the earlier time period, 45% of Black people, 45% of white people and 51% of Latino people were prescribed treatment within one month after entering care. During the later period, the likelihood of receiving a prescription rose to 68%, 66% and 71%, respectively.
Black and Latino people were significantly less likely than white people to receive a prescription for an integrase inhibitor during the earlier period, but the gap closed over time.
Between 2009 and 2014, when integrase inhibitors were approved but not yet recommended in national guidelines, 22% of white people received these drugs, compared with 17% of Black people and 17% of Latino people. Between 2014 and 2017, after guidelines added integrase inhibitors as a recommended option, Black people were still less likely to receive them than white people, but Latinos caught up. Between 2017 and 2019, after guidelines made integrase inhibitors the single preferred option for first-line therapy, these racial and ethnic disparities disappeared.
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