This Week in HIV Research: Our Racial Biases Persist

Existing screening methods for HIV-associated neurological disorders (HAND)—in particular, dementia—may overestimate HAND risk for Black PLWH, a study published in AIDS Care suggests.

The findings derive from an examination of 123 study volunteers (39 of whom were Black ) recruited in the San Diego, California, metropolitan area. Volunteers were assessed for dementia using the HIV Dementia Scale; received an oral word-reading test; and received an array of neuropsychological tests, after which HAND diagnoses were made based on Frascati criteria.

HAND was diagnosed among 41% of the Black participants, versus 18% of the white participants. Raw HIV Dementia Scale scores for Black participants were significantly lower than scores for white participants in nearly every measurement, including total raw score, attention, psychomotor speed, and memory recall.

Notably, baseline education levels were significantly lower among Black participants (12.8 years, on average) than white participants (14.2 years). The study authors pointed out that oral word reading was a key driver of the difference in HIV Dementia Scale performance between Black and white participants. “Race is a social construct and thus it does not directly lead to lower literacy/quality of education for Black PLWH,” they wrote. “Rather, Black PLWH are more likely to experience inequity within the education system such as structural racism, social stigmatization, and scarcity of financial resources, which impact academic experience.”

The authors also concluded with a cautionary note regarding the viability of established measuring tools for neurocognitive performance: “Neurocognitive measures themselves are typically developed with predominantly White samples and in a largely colonized scientific infrastructure,” they wrote, “thus it is possible that key elements of both constructs that are uniquely relevant to Black Americans are either missing, mis-represented, or mismeasured.”

Experiences of discrimination within the U.S. health care system remain common among Black PLWH, with nearly one in four reporting such an incident within the past 12 months in an HIV care setting, researchers report in AIDS Care.

The analysis is based on data collected by the Medical Monitoring Project between June 2018 and May 2019. A total of 1,631 individuals were included in the examination of self-reported discrimination; demographics included 34% cisgender female; 64% heterosexual; 56% on public insurance; 49% living at or below the poverty level; and 94% having a regular HIV care provider. Half the cohort was age 50 or older.

Among the study participants, 22% reported experiencing discrimination in the course of receiving HIV care within the prior 12 months. Individuals who experienced discrimination were significantly less likely than those who did not to be taking antiretroviral therapy (ART); to be adherent to ART if they were taking it; and to have missed at least one HIV care visit. They were also significantly more likely than those who did not experience discrimination to have recently experienced anxiety or depression; to have visited an emergency room in the past 12 months; or to have been hospitalized within the past 12 months.

Within a subset of 362 participants who specified what they perceived to be the reason for their discriminatory treatment, the most common reason cited was HIV status (29% of respondents), followed by race/ethnicity (25%), income or social class (18%), sexual orientation/practices (17%), and gender (9%). In addition, among respondents who reported ever injecting drugs, 19% felt that their presumed drug use history was a reason for their experience of discrimination. “It is concerning that 40 years into the epidemic, [PLWH] continue to report experiences of discrimination due to their HIV status,” the study authors wrote.

“Results confirm the need for strategies to reduce HIV-related stigma among providers. These efforts include continued educational messages and campaigns,” such as the federal Let’s Stop HIV Together campaign.

Among PLWH who experience chronic pain and depressive symptoms, men who use cannabis or cigarettes tend to have greater levels of physical activity than women, according to research published in AIDS Care.

The authors conducted a cross-sectional analysis of 187 PLWH surveyed between 2017 and 2020 in one of three U.S. cities: Boston, Massachusetts; Minneapolis, Minnesota; and Providence, Rhode Island. Participants’ median age was 51; 43% of volunteers were female; 33% were Black, and 13% were Latinx. Most participants reported joint or back/neck pain at baseline, and 48% were on antidepressants.

Researchers asked participants about their recent or lifetime use of three categories of substances: alcohol, cannabis, and cigarettes. Rates of usage within the past 30 days were high: 45% for alcohol use, 45% for cannabis use, and 58% for cigarette use.

Physical activity (including walking, moderate exercise, and vigorous exercise) was assessed using an established international questionnaire, with results calculated in a measurement known as Metabolic Equivalent of Task Units (METs), which estimates a person’s total calories burned.

Overall, there was heterogeneity of findings across gender, type of substance used, and type/intensity of physical activity. A particularly stark difference was observed among cannabis users, where men reported a significantly greater amount of vigorous activity than women; by contrast, there was no difference in vigorous activity by gender among people who never used cannabis. The study authors hypothesized that this difference may be due to a greater pain relief effect of cannabis among men than women, or to a propensity for women to experience worse side effects from cannabis use than men.

In a somewhat similar vein, among people who reported alcohol use, significant gender-based differences were seen in levels of walking activity—differences that did not exist among people who reported no alcohol use. On the flip side, among cigarette users, no difference in vigorous activity was seen by gender—but that observation existed in stark contrast to people who reported no cigarette use, among whom men reported far more vigorous activity than women.

These findings, though disparate, still speak to the potential value of increased physical activity in PLWH experiencing pain and depressive symptoms, the study authors concluded. Noting the high overall substance use rates among the study population, the authors also urged clinicians to work with their patients to explore issues of substance use and barriers to physical activity.

Vaping is relatively common among adult PLWH in the U.S., and is associated with both depression and panic disorder, according to a study published in JAIDS.

The seven-site study involved data obtained from 7,431 PLWH between 2017 and 2021 regarding their use of e-cigarettes (i.e., vaporized nicotine or vaping). Participants’ mean age was 49; 38% were Black; 13% were Latinx; and 18% identified as female.

Overall, 11% of the cohort reported ever vaping, with 5% saying they did so at least a few times each week. People reporting a history of vaping were significantly more likely to be white than Black or Latinx; they were also more likely to report injection drug use than other activities as their likely transmission vector for HIV. Younger age was also associated with a greater likelihood of vaping: the average age of people who reported vaping was 42, compared to 50 among those who reported never vaping.

After adjusting for age, gender, HIV transmission factor, and race, people who reported ever vaping were more likely to report symptoms of depression (risk ratio 1.20; 95% CI 1.02-1.42), panic disorder (RR 1.71; 1.43-2.05), and panic symptoms (RR 1.38; 1.15-1.65) than people who reported never vaping.

Researchers also asked participants about their usage of combustible cigarettes (i.e., smoking); 51% of the cohort with a history of vaping reported current smoking, and an additional 38% reported that they were former smokers. Similar relationships were seen between smokers and depression/panic risk as between vapers and depression/panic risk. “Interestingly, those reporting former [combustible cigarette] use reported greater frequency (days/month) of [vaporized nicotine] use compared to [people with HIV] reporting current [combustible cigarette] use,” the study authors noted. “The possibility of a substitution effect, whether intentional or not, is an important point.”