Hispanic
Men and Women with HIV Are More Likely to Have Decreased
Survival Due to Late Initiation of Antiretroviral Therapy
By
Liz Highleyman
An
estimated 25% of people with HIV
do not get diagnosed and start treatment for HIV until
after they have already developed advanced immune
suppression. In addition, a significant proportion
of patients interrupt ART or drop out of medical care
entirely.
Elena
Losina from Massachusetts General Hospital in Boston
and colleagues evaluated sex and racial/ethnic disparities
in life-years lost due to risk behavior, late presentation,
and early discontinuation of HIV care.
Using
a mathematical model, the researchers devised simulated
cohorts of HIV positive people and compared them against
HIV negative individuals with similar demographic
characteristics.
They
estimated non-HIV-related mortality using risk-adjusted
standardized mortality ratios, and estimated years
of life lost due to late initiation and early discontinuation
of ART. Data from the national HIV Research Network,
stratified by sex and race/ethnicity, were used to
estimate CD4 cell counts at the time of ART initiation.
Results
 |
For
the HIV negative U.S. general population overall,
the projected life expectancy starting at age
33 was 42.9 years. |
|
For
HIV negative individuals with risk profiles comparable
to those of HIV positive people (e.g., similar
rates of poverty and injection drug use), the
projected life expectancy was 34.6 years -- or
a loss of 8.3 years. |
|
HIV
positive people who received HIV care according
to treatment guidelines (based on earlier guidelines
with an initiation threshold of 350 cells/mm3)
lost an additional 11.9 years of life. |
|
HIV
positive people who initiated ART late lost 2.60
additional years of life. |
|
Those
who discontinued ART prematurely lost 0.70 more
years of life. |
|
Life
expectancy losses due to late initiation and early
discontinuation of ART were greatest for Hispanic
individuals, at 3.90 years. |
|
Black
and white people with HIV had statistically similar
life expectancies. |
|
Overall,
women had shorter expected survival than men. |
Based
on these findings, the study authors concluded, "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 resulting from late initiation and early
discontinuation of therapy are most pronounced for
Hispanic HIV-infected men and women," they continued.
"Interventions focused on risk behaviors, as
well as on earlier linkage to and better retention
in care, will lead to improved survival for HIV-infected
persons in the United States."
"Our
challenge as clinicians and researchers is to design
and implement better strategies to identify HIV-infected
individuals at earlier stages of disease and to provide
the necessary support to enter and retain them in
care," Kimberly Smith of Rush University Medical
Center in Chicago wrote in an accompanying editorial.
"Improving the care for those with the most challenges
raises the level of care for all, and that should
be our goal."
Divisions
of General Medicine and Infectious Disease, Department
of Medicine, Massachusetts General Hospital, Boston,
MA; Harvard University Center for AIDS Research, Harvard
Medical School, Boston, MA; Department of Orthopedic
Surgery and Division of Infectious Disease, Brigham
and Women's Hospital, Boston, MA: Department of Health
Policy and Management, Harvard School of Public Health,
Boston, MA; Departments of Biostatistics and Epidemiology,
Boston University School of Public Health, Boston,
MA; Department of Public Health, Weill Cornell Medical
College, New York, NY; Department of Medicine, Johns
Hopkins University School of Medicine, Baltimore,
MD; Department of Epidemiology and Public Health,
Yale School of Medicine, New Haven, CT.
12/15/09
References
E
Losina, BR Schackman, SN Sadownik, and others. 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. Clinical Infectious
Diseases 49(10): 1570-1578 (Abstract).
November 15, 2009.
KY Smith. Paying the price for late starts and early
stops: racial and sex disparities in HIV-related mortality
(editorial commentary). Clinical Infectious Diseases
49(10): 1579-1581. November 15, 2009.
