Racial and Sex Disparities in Life Expectancy Losses among HIV‐Infected Persons in the United States: Impact of Risk Behavior, Late Initiation, and Early Discontinuation of Antiretroviral Therapy

Abstract

Background Most HIV-infected persons in the US present to care with advanced disease and many discontinue therapy prematurely. We sought to evaluate gender and racial/ethnic disparities in life-years lost due to risk behavior, late presentation and early discontinuation of HIV care, and to compare these survival losses in HIV-infected persons with losses from high-risk behavior and HIV disease itself. Methods Using a state-transition model of HIV disease, we simulated cohorts of HIV-infected persons and compared them to non-infected individuals with similar demographic characteristics. We estimated non-HIV-related mortality using risk-adjusted standardized mortality ratios as well as years of life lost due to late presentation and early discontinuation of antiretroviral therapy (ART) for HIV infection. Data from the national HIV Research Network, stratified by gender and race/ethnicity, were used for estimating CD4 counts at ART initiation. Results In HIV-uninfected persons in the US with risk profiles similar to those with HIV, the projected life expectancy starting at age 33 was 34.58 years, compared to 42.91 years for the general US population. Those with HIV lost an additional 11.92 years if they received HIV care concordant with guidelines; late treatment initiation resulted in 2.60 additional years of life lost, while premature ART discontinuation led to 0.70 more years of life lost. Losses from late initiation and early discontinuation were greatest for Hispanics (3.90 years). Conclusions The high-risk profile of HIV-infected persons, HIV infection itself, as well as late initiation and early discontinuation of care, all lead to substantial decreases in life expectancy. Survival disparities from late initiation and early discontinuation are most pronounced for Hispanic HIV-infected men and women. Interventions focused on risk behaviors as well as earlier linkage and better retention in care will lead to improved survival of HIV-infected persons in the US.

Food Insecurity Is Associated with Greater Acute Care Utilization among HIV-Infected Homeless and Marginally Housed Individuals in San Francisco

“…[3][4][5] Gains in health, longevity, and reductions in acute care usage, however, have not been uniform across all population groups in the US. Among HIV-infected individuals, women, 6-9 injection drug users, 7,8,10 and racial/ethnic minorities 8,11,12 account disproportionately for morbidity and suboptimal health-care utilization patterns. Socioeconomic marginalization, in the form of unmet subsistence needs, may drive the acute care usage seen in these subpopulations.…”

Barriers to HIV Care for Women of Color Living in the Southeastern US Are Associated with Physical Symptoms, Social Environment, and Self-Determination

“…1 Of women diagnosed with HIV, African-American (AA) women were the largest proportion of those infected and accounted for two-thirds of new AIDS diagnoses in 2010, 2 while Hispanic women were 4.2 times more likely to be infected than White women from 2007 to 2010. 3 HIV-infected women belonging to racial and ethnic minorities (women of color, WOC) are more likely to report infrequent antiretroviral therapy (ART) use, 4 to be socioeconomically disadvantaged, miss medical appointments, 5 and have late access to, and more frequent discontinuations of ART [6][7][8] than other women. Related work suggests unique trajectories for the process of engaging and remaining in HIV care among WOC compared with other populations.…”

Cost-effectiveness of Adding an Agent That Improves Immune Responses to Initial Antiretroviral Therapy (ART) in HIV-Infected Patients: Guidance for Drug Development

“…27–34 All patients also face a risk of non-HIV-related mortality that depends on age and sex, 35 adjusted for race/ethnicity and other risk factors as has been previously described. 35–37 Cost of HIV treatment and care is from the health system perspective and is derived from HIV Research Network data and Medicare fee schedules. 10,38–41 …”