The Role of Demographics in HIV Clinical Outcomes

According to 2006 estimates from the CDC, about 56,300 people were newly infected with HIV and 1,106,400 Americans were living with HIV infection, 21% of whom were undiagnosed. “It’s critical that quality of care for HIV-infected people be optimized, particularly among newly infected individuals, so that disparities in HIV-related outcomes are minimized,” says Amie L. Meditz, MD. The United States government has identified HIV/AIDS-related healthcare as a top priority and has set three major goals for providers: the first is to reduce the number of new infections; the second is to increase access to care and optimize outcomes among those infected; and the third is to reduce health-related disparities.

A study by Dr. Meditz and colleagues published in the February 2011Journal of Infectious Diseases sought to determine whether sex and race influenced clinical presentation, use of antiretroviral therapy (ART), and morbidity following primary HIV infection. The study was part of the Acute Infection and Early Disease Research Program (AIEDRP), a multicenter study network funded by the National Institute of Allergy and Infectious Diseases. Over 2,000 North American subjects who enrolled in AIEDRP between 1997 and 2007 were evaluated and followed for an average of 4 years. “Previous research has shown that women have lower viral loads and higher CD4 cell counts,” says Dr. Meditz. “However, few studies have examined the role of sex and race on clinical outcomes in people with early-stage HIV infection.”

Important New Data on HIV Morbidity

Dr. Meditz’s study found that, compared with Caucasian men, Caucasian women were more likely to initiate ART. Non-Caucasian men and women were less likely to start ART at any time point (Table 1). Individuals from the South were less likely to start ART than those from other regions. Dr. Meditz says the reasons for differential use of ART within the cohort are unknown and require further investigation. She adds that “ART should be offered to all patients because it helps reduce overall HIV morbidity. The findings from our analysis demonstrated that disparities exist in ART initiation. It behooves clinicians to target patients for HIV treatment—particularly non-Caucasians and women—and to make resources accessible to all HIV-infected patients.”

The Journal of Infectious Diseases study also revealed that sex, race, and geography affected the rate of HIV- and AIDS-related events in individuals recently infected with HIV. Women had 2.17 times more combined HIV-related and AIDS-defining diseases per person than men after adjusting for follow-up time; this difference remained after removing female-specific events and controlling for intravenous drug use (Table 2). Non-Caucasian women appeared to be at greatest risk; 22% of non-Caucasian women experienced an AIDS-defining event compared with a 6% rate in all other race and sex groups.

Region of residence and race were also associated with morbidity in the study. Specifically, 78% of Non-Caucasians and 37% of Caucasians from the southern part of the U.S. experienced one or more HIV/AIDS-related events, compared with 24% of Caucasians and 17% of Non-Caucasians from other regions. “The current literature does not suggest that women are biologically predisposed to worse outcomes from HIV/AIDS,” Dr. Meditz explains. “Our findings may be related to socioeconomic factors such as access to healthcare, health behaviors, lifestyle, and environmental exposures. In the long run, it’s important to consider both biological and socioeconomic factors when developing strategies of care.”

Improving HIV Management

The findings from Dr. Meditz’s study suggest that sex, race, and geographic region profoundly influence clinical outcomes after primary HIV infection. “The health disparities uncovered in our investigation emphasize the importance of optimizing care for all patients,” says Dr. Meditz. “Clinicians should take extra efforts to target non-Caucasians, women, and people living in the South for intensive HIV screening, therapy, and long-term care. Importantly, government resources should be allocated for these interventions.”

In future analyses, Dr. Meditz recommends that investigators gather and analyze data on other factors that could be associated with clinical outcomes relating to HIV, including co-infection with hepatitis B or C, mental illness, insurance coverage, income, and education. “These factors may be important considerations and should be evaluated and addressed in the clinical practice setting. It’s critical to develop research aimed at a better understanding of the causes of poor health outcomes among HIV-infected women, non-Caucasians, and people from the South so that we can develop strategies to reduce barriers to quality care.”