Health Outcomes Worse for HIV-Positive Black Men Even Despite Equal Access

A new study finds significant health disparities between black and white men with HIV, even though these men had equal access to health care through the Veterans Administration (VA). These disparities still existed after researchers accounted for differences in health conditions and neighborhood characteristics, according to research coauthored by Kelly Richardson, Ph.D., an adjunct assistant professor at the University of Iowa.

"Even in an equal access health care system, blacks have worse outcomes," Richardson said, speaking at IDWeek 2015 in San Diego, California. Richardson and her colleagues evaluated health outcomes for 24,088 HIV-positive men treated through the VA in 2013. Of these men, approximately half were black and half were white.

Richardson and her team not only looked for poor HIV outcomes (defined as "uncontrolled" viral load or an HIV RNA serum of greater than 200 copies/mL), but also evaluated common comorbidities, including uncontrolled blood pressure and uncontrolled diabetes.

The researchers also collected certain information about each patient that could potentially impact his likelihood of achieving good health. Richardson gathered information about "patient-level characteristics," which included age, race, amount of time on combination antiretroviral therapy, lowest CD4+ count on record, retention in care and other comorbid conditions (such as drug abuse, stroke or coronary artery disease).

The researchers also theorized that racial disparity in health outcomes could be the result of socio-economic status, or neighborhood characteristics. To account for this, Richardson collected information about poverty level, employment status, female-headed households and median household income. Collectively, she called these factors "neighborhood social disadvantage."

At the end of the year-long study, Richardson found that white men were healthier than black men with respect to their HIV, blood pressure and diabetes. Almost 15% of black men had uncontrolled viral load compared to almost 8% of white men. A greater percentage of black men also had uncontrolled blood pressure (34% compared to 28%) and uncontrolled diabetes (15% compared to 11%).

The odds of uncontrolled disease were worse for black men relative to white men, even after accounting for potentially confounding factors. Overall, the black men were 1.89 times as likely to have uncontrolled viral load. Also, black men were 1.33 times as likely to have uncontrolled blood pressure and 1.42 times as likely to have uncontrolled diabetes.

After controlling for patient-level characteristics, the disparities shrank by a small amount. Black men were 1.67 times as likely to have uncontrolled viral load, 1.30 times as likely to have uncontrolled blood pressure and 1.32 times as likely to have uncontrolled diabetes. And, after controlling for neighborhood social disadvantage, black men were 1.56 times as likely to have uncontrolled viral load, 1.31 times as likely to have uncontrolled blood pressure and 1.28 times as likely to have uncontrolled diabetes.

Despite the narrowing gap, the racial disparities were still statistically significant, Richardson noted. From the start, black men had worse outcomes than their white counterparts treated at the VA. But patient-level characteristics and neighborhood factors "only partially explained this difference," she said.

When trying to understand the well-established racial disparities in health outcomes among HIV positive men, three main explanations have been proposed: insurance type, patient-level characteristics/comorbidities and socio-economic/neighborhood factors.

However, this study controlled for all three of those potential explanations, and still found significant disparities. Therefore, the study suggests that there are additional, less obvious factors contributing to inferior health outcomes among HIV-positive African Americans.