November 27, 2012
Table of Contents
Richard D. Moore et al. Clinical Infectious Diseases 2012;55(9):1242-51. Read the abstract.
Disparities in health outcomes are pervasive in the U.S., with some in our big pot melting better than others. Racial and ethnic minorities, and those living close to or in poverty, typically get burned. When it comes to HIV care, there have been data pointing to significant disparities, including racial differences, in the rates at which antiretroviral therapy (ART) is prescribed, viral suppression is achieved and mortality is averted.
In an important and provocative paper from the Johns Hopkins University School of Medicine, differences in HIV outcomes, including receipt of combination ART, HIV RNA levels, CD4+ cell counts, opportunistic infections and mortality, were examined and stratified by HIV risk group, sex and race. At their Baltimore, Md.-based clinic, 6,366 patients were followed from 1995 to 2010; about two thirds were men, three quarters were African American, 45% were injection drug users (IDU), 30% were men who have sex with men (MSM) and 60% had either Medicaid or private insurance.
Over the course of the period studied, there was an increasing trend for receipt of ART across all demographic and behavioral risk groups, with uptake occurring earlier and more briskly among MSM, all men and white patients. However, by 2010, 87% of the clinic cohort was prescribed ART, and there was no significant difference (after multivariable adjustment) seen in receipt of ART among the groups.
Looking at HIV RNA levels, by 2010 the median viral load was less than 200 copies/mL for all demographic and risk groups. In multivariate analysis, the log10 HIV RNA level was slightly but significantly higher -- by 0.28 log in the IDU group compared to the MSM group in 2010 (P < .001), although there was no significant difference between the MSM and heterosexual groups. The log10 HIV RNA level was also 0.24 log higher in blacks compared to whites in 2010 (P < .001). There was no difference by sex.
Similarly, median CD4+ cell counts were high, at almost 500 cells/mm3 by 2010. Slightly lower counts were seen among IDU compared to MSM, as well as among men compared to women. Opportunistic infections became virtually extinct by 1998 and there were no differences between groups seen in more recent years.
Lastly, there was no significant difference in mortality among the groups. Life expectancy computed for the entire sample found that, for a 28-year-old HIV-infected patient in their care in 2009, remaining life expectancy was calculated to be 45.4 years (95% confidence interval, 39.6-51.3 years). That is, a 28-year-old patient -- regardless of race, gender or risk category -- could be expected to live to 73 years of age.
Other studies have detected differences that were not seen in the analyses of this cohort; however, the Hopkins study includes more current data. There was a striking "catch-up" effect among minorities, women and IDU over time: By 2010, the benefits of ART and advances in care appeared to be universal regardless of race, gender and risk category.
These results fly in the face of overall health disparity trends in the U.S., wherein African Americans and those with lower socioeconomic status have higher rates of morbidity and mortality. Although HIV disproportionately affects those same populations that are at risk for worse outcomes and could be expected to compound these disparities, this study finds the opposite.
So, why do populations vulnerable to disparities in health care outcomes fare better when it comes to HIV care? Two words: big government. While that term may often find itself slung like an insult in a political scrap, in the case of HIV, it is public funding through the Ryan White Care Act that provides the primary care, supportive care and medication assistance that are critical to achieving the very outcomes studied by the Hopkins investigators.
HIV is a complex and expensive disease to manage, yet the results coming from Baltimore are mirrored in clinics across the nation precisely because we have a national safety net that sets up those with HIV for success rather than failure.
While the investigators stress their finding of little to no difference in HIV outcomes across populations, what they also discovered is how different HIV is from other serious conditions in achieving this degree of parity. This lesson should be Exhibit A when the Ryan White Care Act comes up for reauthorization, and as we look to ways in which the Affordable Care Act will be implemented.
Ank E. Nijhawan et al. J Acquir Immune Defic Syndr 2012;61:349-358. Read the abstract.
It is sad that the house staff at my hospital -- those who admit patients with HIV infection -- see a side of the disease that is completely warped compared to the reality of widespread suppression of HIV RNA levels, boosted CD4+ cell counts and jolly, round faces that characterize my clinic population. While these interns and residents have heard of the fruits of advances in HIV care, they might as well be in a third-world nation as they take histories from patients gasping with Pneumocystis pneumonia or battling an aggressive lymphoma.
Few medical residents spend time in our outpatient clinics, and thus they experience HIV through the lens of "difficult cases" -- the non-adherent, the out-of-care and the very unlucky. It is no wonder that few young physicians are gunning to become HIV docs.
Further disheartening to these clinicians are the "frequent flyers": patients who are admitted, treated and released, but "bounce back" soon after discharge with the same -- or a new -- set of problems and issues.
To get a better sense for which patients with HIV infection tend to return after a hospital stay, a team from the Dallas Parkland Hospital system examined hospital records of HIV-infected inpatients from 2005 to 2008 in an attempt to develop a predictive model of 30-day risk of readmission or death.
Looking at 1,500 cases (three quarters African American, 16% Latino, 60% male, less than half with outpatient medical insurance), one quarter were readmitted. We should let that settle in: One in four patients with HIV in this medical system were readmitted within 30 days of discharge. Dallas, we have a problem.
Delving into the details, a range of clinical factors were associated with risk of readmission, including AIDS-defining illness, CD4+ cell count less than 92 cells/mm3 within 12 weeks of the first admission, creatinine greater than 1.77 mg/dL, HCO3 less than 19 mmol/L, ALT or AST greater than 35 U/L, HCT less than 28.4 or greater than 48.8%, anion gap greater than 12 mmol/L, and an ALC less than 0.34x109/L (probably reflecting low CD4+ cell count).
In addition, and tellingly, patients were more likely to be readmitted within 30 days of release if they were homeless, lived more than a dozen or so miles from the hospital, were insured by Medicaid (i.e., were disadvantaged or sick enough to qualify) or had higher rates of utilization of inpatient and emergency department services.
Three percent (74 patients) of those examined were known to have died within 30 days of hospital discharge. Factors associated with mortality were basically the same laboratory abnormalities I listed above, including immunosuppression.
This study is interesting in that the elements included in its models for readmission are readily available to clinicians. Recognizing these red flags for readmission during hospitalization should prompt discharge planning that addresses this risk. Careful coordination of post-release services -- including immediate, community-based medical care appointments and check-ins by care coordinators -- could go a long way toward reducing bounce backs. Of course, not releasing patients until they are really ready to be discharged, while difficult, will also help.