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Male-Female and White-Black ART Disparities Persist in US
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18th Conference on Retroviruses and Opportunistic Infections, February 27-March 2, 2011, Boston
Mark Mascolini
Antiretroviral treatment disparities between women and men, blacks and whites, and injection drug users and gay men in care persist--and in some cases have grown worse--according to results of a 13-center survey in the United States [1].
This study by HIV Research Network (HIVRN) investigators examined trends in antiretroviral therapy among adults eligible for treatment from January 2002 through December 2008. The analysis involved 14,527 adults seen at 13 centers that provide HIV care across the United States. Patients could be included only if they entered care in 2002 or later and if they had not taken antiretrovirals in 2000 or 2001. HIVRN investigators limited analysis to years in which a person received care, defined as having at least one outpatient visit and at least one CD4 count. The researchers grouped people according to four CD4 thresholds: (1) no CD4 counts below 500, (2) one or more counts between 350 and 500, (3) one count below 350, and (4) two or more counts below 350.
Across the 7 study years, racial/ethnic proportions held steady at about 50% blacks, 28% whites, and 22% Hispanics. Men made up about 73% of the study group across the 7 years. Proportions of gay men held steady over the years at about 42%, as did proportions of injection drug users (IDUs) at about 10%. Proportions of people under 40 years old declined gradually over the study period, while proportions of those 40 or older rose:
-- 18-30 years old, from 19% in 2002 to 14% in 2008
-- 31-39 years old, from 37% in 2002 to 22% in 2008
-- 40-50 years old, from 31% in 2002 to 38% in 2008
-- Over 50 years old, from 13% in 2002 to 26% in 2008
For all four CD4 threshold groups, the proportion of people taking antiretrovirals rose steadily. Even among people with a CD4 count always above 500, the proportion on treatment climbed from about 30% in 2002 to over 50% in 2008. For people with one of more counts between 350 and 500, the proportion taking antiretrovirals jumped from 40% in 2002 to almost 60% in 2008. For people with one CD4 count below 350, the proportion on treatment rose from under 60% in 2002 to over 70% in 2008. And for people with two or more counts under 350, the proportion treated billowed from 80% in 2002 to just over 90% in 2008.
Analyses of antiretroviral treatment by race, gender, age, and HIV transmission group involved people who should have been offered treatment because they had two or more CD4 counts under 350. Compared with whites, blacks had nearly an equivalent likelihood of treatment in 2002 (risk ratio 1.02), but that likelihood slipped gradually and consistently over the years: RR 0.99 in 2003, 0.98 in 2004, 0.97 in 2005, 0.96 in 2006, 0.96 in 2007, and 0.95 in 2008. Hispanics were more likely than whites to be taking antiretrovirals in 2002 (RR 1.08). By 2008, their likelihood of getting treated was equivalent to that of whites (RR 1.01).
Women were less likely than men to be treated in 2002 (RR 0.93). That chance improved slowly over the years, but women still remained less likely to be taking antiretrovirals than men in 2008 (RR 0.97). Compared with gay men, IDUs remained slightly less likely to be treated over the year (RR 0.96 in 2002, RR 0.99 in 2008). Over the years, likelihood of receiving treatment was equivalent between gay men and people infected heterosexually.
People 30 or younger were less likely to be treated than older people. In analyses adjusted for year, disparities in antiretroviral treatment by age group (younger versus older) were more pronounced for people with higher CD4 counts. The opposite held true for IDUs: they were less likely to get treated than gay men at lower CD4 counts.
While this kind of analysis offers a broad overview of demographic treatment trends, it cannot explain why one group may start antiretrovirals less often than another. For example, to be considered for analysis in any given year, a person had to make one office visit. But if more people in certain groupsÑyoung, female, black, or IDU--made only one visit in a year, they would be much less likely to start treatment. If more people in comparison groups--older, male, white, or gay--made more clinic visits in a year, they would be much more likely to begin therapy if they needed it.
Reference
1. Yehia B, Fleishman J, Gebo K, Agwu A, HIV Research Network. Disparities in HAART receipt for HIV-infected adults in care. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 1069.
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