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Disparities in Survival Attributable to Suboptimal HIV Care in the US: Influence of Gender and Race/Ethnicity
Elena Losina*1,2, Elena Losina*1,2, B Schackman3, S Sadownik1, K Gebo4, R Walensky1,5,6, R Walensky1,5,6, R Walensky1,5,6, M Weinstein7, P Lawrence4, W Aaronson1, R Moore4, and D Paltiel8
1Massachusetts Gen Hosp, Boston, US; 2Boston Univ Sch of Publ Hlth, MA, US; 3Weill Med Coll of Cornell Univ, New York, NY, US; 4Johns Hopkins Univ Sch of Med, Baltimore, MD, US; 5Harvard Med Sch, Boston, MA, US; 6Brigham and Women's Hosp, Boston, MA, US; 7Harvard Sch of Publ Hlth, Boston, MA, US; and 8Yale Univ Sch of Publ Hlth, New Haven, CT, US
Background: HIV-infected
patients from underserved populations in the United States are more likely to
present to care late and discontinue therapy prematurely. Our objective was to
quantify gender and racial disparities in years of life lost due to suboptimal
HIV care.
Methods: We used the cost-effectiveness
of preventing AIDS complications model, a state-transition model of HIV
disease, to estimate survival losses due to late initiation and premature
discontinuation of ART. Data from the National HIV Research Network provided
US-based estimates of race/ethnicity- and gender-specific distributions of CD4
cell counts at the time of ART initiation. From these data, 25% of black men
presented to care with CD4 cell counts <50/mL compared to only 10% of white women. ART efficacy and
subgroup-specific rates of premature discontinuation were from published
studies. Rates of premature discontinuation were 14% for Hispanic women
compared with 5% for white men and women. CD4 cell count and treatment
discontinuation rates were varied in sensitivity analyses to assess their
impact on the results.
Results: Full adherence with
current US HIV treatment guidelines leads to 9.6 years of life lost from HIV
compared to survival in persons without HIV.
An additional 5.1 years of life are lost because of late ART initiation
and premature ART discontinuation in the United States. Survival losses are
higher for Hispanics and blacks than for whites (5.8, 5.3, and 4.3 years, see
the figure). Compared with men, Hispanic and black women show greater survival
losses, due to higher rates of premature treatment discontinuation. Mean
per-person decreases in survival were 6.4 years for Hispanic women compared with
3.9 years for white women.
Conclusions: Late initiation and
premature discontinuation of HIV therapy result in substantial loss of life-expectancy
in HIV-infected persons in the United
States.
Racial/ethnic minorities lose on average 1.5 years of life more than
whites. These disparities are more pronounced for black and Hispanic women,
with losses of as much as 2.5 years compared to white women. Outreach efforts
should focus on earlier treatment and retention in HIV care, especially for
women from racial/ethnic minorities.
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