This Week in HIV Research: Existing Solutions Won't Close the Race Gap

By utilizing existing evidence-based HIV interventions, large drops in overall U.S. HIV incidence are realistic over the next 10 years—but even if they are successful, racial and ethnic disparities will remain unless unequal access to health care is also addressed, a modeling study published in Clinical Infectious Diseases showed.

The study estimated the development of seroconversion rates in six U.S. cities between 2020 and 2030. Researchers found that, even if localized combination interventions are implemented at ideal levels, HIV incidence will remain considerably higher among Black people than white people in each city by 2030 if social determinants of health are not resolved. These projected Black-white racial differences ranged from a roughly 1.7 HIV incidence rate ratio (IRR) in Miami, Florida, to nearly 3.5 in Baltimore, Maryland.

Across the board, Latinx people were found to fare better than Black people in the model: By 2030 using optimally executed evidence-based interventions, Latinx people and whites will reach HIV incidence parity in Miami (IRR = 0.95) and near-parity in Baltimore (IRR = 1.10) and Los Angeles, California (IRR = 1.12), researchers found. But significant disparities would remain in New York City, where the IRR would only drop to about 3.

Among men who have sex with men (MSM) specifically, the proportion of Blacks and Latinos who newly acquire HIV will drop in Los Angeles and Miami by 2030, the model suggested—but it would increase in all other cities by as much as 7.8% (as was the case for Baltimore).

To combat these trends, access to pre-exposure prophylaxis (PrEP) needs to be increased in Black and Brown communities and service delivery must go beyond medical settings, study authors recommended. They also called for explicitly including zero-discrimination targets in the U.S. government’s current “Ending the HIV Epidemic” strategy.

Transgender women living with HIV were retained in care and/or virally suppressed at lower rates than cisgender women or men, an analysis of the 2016 Ryan White HIV/AIDS Program report found.

The analysis, published in PLOS Medicine, included data on 6,534 transgender women, 143,173 cisgender women and 382,591 cisgender men. Among trans women, HIV care retention and viral suppression rates were 80% and 79%, respectively, compared to cisgender women at 84% each and cisgender men at 81% and 85%, respectively.

Race exacerbated these differences. The gap was especially great among Blacks, where the adjusted prevalence ratio for viral suppression was 0.55 when transgender women were compared to cisgender women or men.

These findings are consistent with smaller observational studies and point to the intersectionality of stigma and discrimination based on race, gender identity, and HIV status that Black trans women experience, study authors noted. They called for reducing barriers to care for this population, as well as conducting similar research among transgender men and gender-diverse people.

Interventions targeted at the Black and Brown transgender community, such as peer navigation, also need to be developed, they added.

People living with HIV (PLWH) returning to the community after spending time in a jail or prison need adherence support beyond the immediate post-release period, researchers concluded in PLOS One.

They interviewed 20 PLWH in New York City who had been in jail or prison for an average of 4.5 years. A common barrier to antirtetroviral adherence was the number of pills to track and take daily—a challenge often exacerbated by the need to take additional medications for comorbidities. Better provider-patient communication and efforts to simplify regimens, as well as text message reminders, may help alleviate adherence issues, study authors suggested.

In addition, in follow-ups conducted an average of 1.5 years after release, 75% of participants were still homeless, with most living in single-room occupancy units. In this population, the lack of stable housing was compounded by fear of renewed police encounters, which participants cited as reason for not carrying their medications with them.

Forgetfulness, which is common among people with chronic illnesses, was another problem frequently cited by study participants, as were substance use and mental illness—interviewees often felt there was a conflict between using substances and taking HIV medications.

Study authors advocated integrating mental health and behavioral interventions with HIV services, noting that many of the barriers to adherence identified by formerly incarcerated PLWH also occur in the general PLWH population. Adherence support programs must ensure access for people with limited resources, such as those returning to the community from jail or prison, study authors wrote.

Acute respiratory illnesses do not occur more frequently among PLWH than among HIV-negative people, but when they do happen, symptoms are more severe, a small British observational study published in PLOS One found. It was conducted prior to the current COVID-19 pandemic.

Over the course of 12 months, researchers interviewed 136 PLWH and 73 HIV-negative controls in London weekly about respiratory symptoms. The difference in reported severity of any acute respiratory illness persisted even after adjusting for demographic factors, such as current smoking (29% of the PLWH group compared to 16% among the controls) and chronic respiratory symptoms at baseline (which were more common among PLWH).

Possible explanations for the observed difference include impaired lung function and greater immune activation among those living with HIV, or PLWH’s greater awareness of symptoms because of concerns about higher risk, study authors hypothesized. They called for further research into the cause for greater severity of symptoms among PLWH, as well as for including respiratory risk assessments in routine HIV care and providing interventions, such as referrals for smoking cessation, as needed.