A review of:
Richard D. Moore, et al. Improvement in the Health of HIV-Infected Persons in Care: Reducing Disparities. Clin Infect Dis 2012;55(9):1242-51.
This was a year of percentages. We had "The 99% " and, infamously, "The 47%." In HIV, HPTN 052's findings of the level of protection afforded by treatment of the HIV-infected half of a serodiscordant couple led to the bandying about of "The 96%" at our conferences. I would like to add a new pithy, numeric stand-in to the lexicon, and that is "The Hopkins 87%."
This is the proportion of patients at Johns Hopkins' Baltimore-based HIV clinic that was receiving HIV therapy in 2010. That same year, the median plasma HIV RNA level across the 6,366 patients cared for at the clinic was less than 200 copies. Likewise, median CD4 cell counts were high -- at almost 500/mm3 by 2010, with slightly lower counts seen among injection drug users compared to MSM and among men compared to women.
Importantly, by the last year of the study, there were no differences by race or risk group in receipt of antiretrovirals or suppression of viremia. 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.
That 87% of individuals in this clinic -- patients with a generous share of challenges -- are receiving HIV therapy is remarkable. That the vast majority has an undetectable viral load is extraordinary; it is a testament to the potency and convenience of our antiretrovirals, but also to the strong system of support that has been created to assist people with HIV.
These results fly in the face of health disparity trends in the U.S., wherein African Americans and those with lower socioeconomic status having 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 be slung 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 medications assistance that is 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 U.S. precisely because we have a national safety net that sets up those with HIV for success rather than failure.
While the investigators tout 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 at the ways in which the Affordable Care Act will be implemented.