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Disparities in HIV Care
Slides prepared by Kirk Fergus, Intern
National Quality Center
At a glance…
At a glance…
• “MSM accounted for 61% of all new HIV infections in the
U.S. in 2009, as well as nearly half (49%) of people living with
HIV in 2008.” [1]
• “While blacks represent approximately 14% of the U.S.
population, they accounted for almost half (46%) of people
living with HIV in the U.S. in 2008, as well as an estimated
44% of new infections in 2009.” [1]
[1] http://aids.gov/hiv-aids-basics/hiv-aids-101/statistics/
At a glance…
• “In 2009, the rate of new HIV infections among Hispanic/Latino
men was two and a half times that of white men and the rate
among Hispanic/Latino women was four and a half times that of
white women.”[1]
• “In 2009, young persons accounted for 39% of all new HIV
infections in the US. For comparison's sake, persons aged 15–29
comprised 21% of the US population in 2010.”[2]
• “At some point in their lifetimes, an estimated 1 in 32
black/African American women will be diagnosed with HIV
infection, compared with 1 in 106 Hispanic/Latino women and 1
in 526 white women.”[3]
[1] http://aids.gov/hiv-aids-basics/hiv-aids-101/statistics/
[2] http://www.cdc.gov/hiv/youth/index.htm
[3] http://www.cdc.gov/hiv/topics/women/
H. I. Hall et. al., “Continuum of HIV care: differences in care and treatment by sex and race/ethnicity in the United States,” AIDS 2012 International AIDS
Conference Abstract, <http://pag.aids2012.org/Abstracts.aspx?AID=21098>
National HIV/AIDS Strategy
What are health disparity populations?
“…includes populations for which there is a
significant disparity in the quality, outcomes, cost,
or use of healthcare services or access to or
satisfaction with such services as compared to the
general population.” [1]
– Affordable Care Act
– National HIV/AIDS Strategy
http://www.whitehouse.gov/administration/eop/onap/nhas
National HIV/AIDS Strategy
• “Data indicate that HIV disproportionately affects the most vulnerable in
our society—those Americans who have less access to prevention and
treatment services and, as a result, often have poorer health out-comes.”[1]
• “Therefore, to successfully address HIV, we need more and better
community-level approaches that integrate HIV prevention and care with
more comprehensive responses to social service needs.”[2]
[1]/[2] http://www.whitehouse.gov/administration/eop/onap/nhas
National HIV/AIDS Strategy
•
•
Key steps for the public and private sector to take to reduce HIV-related
health disparities are:
– “Reduce HIV-related mortality in communities at high risk for HIV
infection.”
– “Adopt community-level approaches to reduce HIV infection in high-risk
communities.”
– “Reduce stigma and discrimination against people living with HIV.”
Anticipated Results By 2015…
– “Increase the proportion of HIV diagnosed gay and bisexual men with
undetectable viral load by 20 percent.”
– “Increase the proportion of HIV diagnosed Blacks with undetectable viral
load by 20 percent.”
– “Increase the proportion of HIV diagnosed Latinos with undetectable viral
load by 20 percent.”
http://www.whitehouse.gov/administration/eop/onap/nhas
Disparity Research
Engagement Continuum
[1] Health Resources and Services Administration, HAB. August 2006. Outreach: Engaging People in HIV Care Summary of a HRSA/HAB 2005
Consultation on Linking PLWH Into Care.
[2] Eldred L, Malitz F. Introduction [to the supplemental issue on the HRSA SPNS Outreach Initiative]. AIDS Patient Care STDS 2007; 21(Suppl 1):S1–S2.
The CDC Cascade for HIV in the United States
Disparity Research
• Data are organized by demographic group
• Studies:
– Most are from 2012 and 2013
– Rigorous studies; Peer-reviewed academic journals
– Some studies found no disparities
– Include multivariate analysis
– Focus on Viral Load Suppression, ART
Prescription, Retention in care
Who is affected?
There are disparities in care
among racial/ethnic groups.
There are disparities in care
among racial/ethnic groups.
• A large clinic in Chicago found that non-Hispanic black race was
independently associated with viral nonsuppression.[1]
• The findings of an HIV Research Network 2002-2008 study
indicate black patients were less likely to be prescribed ART
[AOR=0.79; 95% CI= 0.72, 0.86][2]
[1] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
[2] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419427.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center
[1] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care
among gender groups.
There are disparities in care
among gender groups.
• The HIV Research Network study 2002-2008 found that women
were less likely to be prescribed ART [AOR=0.83; 95% CI= 0.76,
0.91][1]
• Chicago CORE clinic found that being female was independently
associated with viral nonsuppression.[2]
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
[2] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center
[1] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care
among age groups.
There are disparities in care
among age groups.
• Longitudinal study in North America 2001-2009 found increasing
age was associated with virologic suppression.[1]
• Among patients engaged in care in a Chicago clinic, younger-aged
patients were independently associated with viral nonsuppression.[2]
• The HIV Research Network found that youth aged 18-29 were less
likely to be prescribed ART than all other age groups.[3]
[1] David B. Hanna et. al., “Trends and Disparities in Antiretroviral Therapy Initiation and Virologic Suppression Among Newly Treatment-Eligible HIV-Infected
Individuals in North America, 2001-2009,” Clinical Infectious Diseases 56, no. 8 (2013): 1174-1182.
[2] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
[3] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
There are disparities in care
among age groups.
• The San Francisco Department of Health found that those less
than age 40 at diagnosis had lower viral suppression rates
compared to persons aged 40 or above [OR=1.92; 95% CI=1.4,
2.7][3]
[1] Dharushana Muthulingam et. al., “Disparities in Engagement in Care and Viral Suppression among Persons with HIV,” Journal of Acquired Immune
Deficiency Syndromes published ahead of print (2013).
[1] David B. Hanna et. al., “Trends and Disparities in Antiretroviral Therapy Initiation and Virologic Suppression Among Newly Treatment-Eligible HIV-Infected
Individuals in North America, 2001-2009,” Clinical Infectious Diseases 56, no. 8 (2013): 1174-1182.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network
[1] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center
[1] Oluwatoyin M. Adeyemi et. al., “Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic,” Clinical Infectious
Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care
among subsets of demographic populations.
There are disparities in care
among subsets of demographic populations.
• In Miami-Dade County, Florida, researchers studied viral load
suppression among racial/ethnic subpopulations naïve to HAART
that had received treatment for at least 96 weeks.[1] After 96 weeks:
– 58.5% of Haitian patients were viral load suppressed
– 74.1% of African American patients were viral load suppressed
– 82.8% of Hispanic patients were viral load suppressed
– (p-value = 0.011)
• The HIV Research network found MSM IDUs were less likely to
be prescribed ART than were MSM that were not IDUs
[AOR=0.81; 95% CI= 0.67, 0.97]
[1] Jonathan Colasanti et. al., “Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County,
Florida,” Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
[2] John Fleishman et. al., “Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008),” Medical Care 50, no. 5 (2012): 419-427.
[3]
The Data: Miami-Dade County
[1] Jonathan Colasanti et. al., “Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County,
Florida,” Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
The Data: Miami-Dade County
[1] Jonathan Colasanti et. al., “Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County,
Florida,” Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
There are disparities in care
among socioeconomic groups
There are disparities in care
among socioeconomic groups
• The San Francisco Department of Health found that homeless
[OR=2.13; 95% CI=1.3, 3.5] or people with unknown housing
status [OR=2.67; 95% CI=1.4, 5.0] were less likely to be viral
suppressed compared to persons who were housed at diagnosis.[1]
• CDC Data published in American Journal of Public Health found
homeless patients less likely to be viral suppressed than housed
patients [OR=0.69; 95% CI=0.48,0.99][2]
[1] Dharushana Muthulingam et. al., “Disparities in Engagement in Care and Viral Suppression among Persons with HIV,” Journal of Acquired Immune
Deficiency Syndromes published ahead of print (2013).
[2] Danial Kidder et. al., “Health Status, Health Care Use, Medication Use, and Medication Adherence Among Homeless and Housed People Living with
HIV/AIDS,” American Journal of Public Health 97, no. 12 (2007):2238-2245.
The Data: HIV Surveillance Study
[1] Jonathan Colasanti et. al., “Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County,
Florida,” Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
HIVQUAL Organizational Assessment
HIVQUAL Organizational Assessment
HIVQUAL Organizational Assessment Prompt:
To what extent does the HIV program measure disparities in care and
patient outcomes, and use performance data to improve care to
eliminate or mitigate discernible disparities?
HIVQUAL Organizational Assessment
Discussion
• What improvement strategies in the field are you aware
of that address disparities?
• What are we missing to describe disparities in HIV Care?
• What geographic level is most appropriate for examining
disparities (e.g., clinic, community, county, state,
Regional Group, nation etc.)?
• What actions do you suggest to address disparities as a
national priority?
• What measures could we use for a potential campaign?