Back HIV/AIDS HIV/AIDS Topics HIV Treatment Cascade of Care Studies Reveal Age, Race, and Sex Disparities in HIV Care and Outcomes

Studies Reveal Age, Race, and Sex Disparities in HIV Care and Outcomes


Women, African-Americans, and people who inject drugs are on average less likely to remain in care,start antiretroviral therapy (ART), or achieve viral load suppression, while young people are more likely to seek HIV care later in the course of their disease, according to 2 recently published studies.

The first study, published in the January 23 advance edition of Clinical Infectious Diseases, looked at outcomes among demographic subgroups in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

Keri Althoff from Johns Hopkins and colleagues estimated indicators used by the U.S. Department of Health and Human Services to monitor HIV care. NA-ACCORD maintains a large database of participants in several clinical cohorts, representing an estimated 3% of all adults living with HIV in the U.S.

A total of 35,324 participants who had at least 1 HIV care visit between January and June 2008 were included in the retention-in-care metric, while 38,331 participants who had at least 1 visit in 2009 were included in the ART use and viral suppression estimates. Most (83%) were men, 45% were black, about half were age 50 or older, and 19% were current or former injection drug users.


  • Overall, 71% of participants were retained in care, 82% were prescribed antiretroviral treatment, and 78% achieved HIV RNA <200 copies/mL.
  • Younger adults, women, black people, and injection drug users had poorer outcomes than other subgroups.
  • All 3 indicators were statistically higher in older age groups after adjusting for sex, race/ethnicity, HIV risk group, and cohort.
  • Women were 7% more likely to be retained in care and 6% less likely to be prescribed ART compared with men, but there was no significant difference in rates of viral suppression.
  • Black patients were significantly less likely to be retained in care (3%), to be prescribed ART (3%), and to achieve viral suppression (9%), while Hispanic participants were 9% more likely to be retained in care compared with whites.
  • People who inject drugs were 11% less likely and heterosexuals were 4% less likely to be retained in care compared with gay men.
  • Injection drug users were also 6% less likely to be prescribed ART and 7% less likely to achieve viral suppression.

Based on these findings, the study authors concluded, "Interventions are needed to reduce retention- and treatment-related disparities."

Adults in HIV care "should be the most easily-accessible group in which 100% viral load suppression could potentially be achieved," they elaborated in their discussion. "Our study, nested in the largest U.S. collaboration of HIV-infected adults, showed 29% of HIV-infected adults in care fail to meet the definition for retention in care, 18% were not prescribed ART, and 22% of adults did not achieve viral load suppression; and these proportions were higher for young adults, females, non-whites, and those with [injection drug use] and heterosexual risk."

Looking at implications for treatment-as-prevention, they noted that, "[d]ifferences in viral suppression are likely to play a role in disparities of HIV incidence; for example a higher prevalence of detectable viral load among black [men who have sex with men] likely contributes to the increase in odds of HIV infection if one has a black partner."

"Our estimate of 71% retained in care is higher than the regularly used meta-analysis estimate of 59%, which is similar to that employed in the cascade of care," they wrote. "Consistent with previous studies, disparities in retention existed, with lower retention in younger adults, males, and those with [injection drug use] or heterosexual HIV risk, suggesting the need for programs specifically targeting these groups."

Youth Delay Treatment


In a related study published in the February 3 advance edition of JAMA Pediatrics, Allison Agwu, also from Johns Hopkins, and fellow investigators with the HIV Research Network assessed when HIV positive youth present for care.

This analysis included nearly 1500 HIV positive teenagers and young adults, age 12-24, seen at 13 U.S. clinics between 2002 and 2010. They were not infected via perinatal transmission.

Between 30% and 45% sought HIV treatment only after they had sustained substantial immune system damage, with CD4 T-cell counts below 350 cells/mm3. U.S. treatment guidelines now recommend that everyone with HIV should consider ART regardless of CD4 count, and prior to this the treatment threshold was 500 cells/mm3. Participants with lower CD4 cell counts also tended to have higher viral load, making them more likely to transmit HIV to others.

Young men and people of color more often sought care at advanced stages of disease. Black youth, in particular, were more than twice as likely as white youth to present for care at more advanced stages. Young men also had lower CD4 counts than young women. The researchers suggested that young men may be more likely to delay treatment because they tend to receive less regular care than young women, who often received annual OB/GYN exams. Young men infected through heterosexual sex also tended to access care later than gay and bisexual men.

"These are decidedly disappointing findings that underscore the need to develop better ways to diagnose teens sooner and, just as importantly, to get them into care and on therapy sooner," Agwu said in a Johns Hopkins press release. "Clinicians need to get away from their own preconceived notions about who gets infected, stop risk-profiling patients, and test across the board."

"In our study, heterosexual males emerged as this fall-through-the-cracks group," Agwu added. "We’ve put a lot of emphasis on men who have sex with men in our screening and outreach, but one side effect of this may be that straight males perceive themselves as low risk."



KN Althoff, P Rebeiro, JT Brooks, et al. Disparities in the quality of HIV care when using US Department of Health and Human Services Indicators. Clinical Infectious Diseases. January 23, 2014 (Epub ahead of print).

AL Agwu, A Neptune, C Voss, et al (HIV Research Network). CD4 Counts of Nonperinatally HIV-Infected Youth and Young Adults Presenting for HIV Care Between 2002 and 2010. JAMA Pediatrics. February 3, 2014 (Epub ahead of print).

Other Source

Johns Hopkins Medicine. HIV-Infected Teens Delaying Treatment Until Advanced Disease, Johns Hopkins Study Shows. Press release. February 3, 2014.