This Week in HIV Research: Disclosing Our Disparities

HIV prevalence rates are higher among Latinx residents than non-Latinx whites—not only as an overarching racial group, but also within nearly every individual U.S. county in which they live, a study published in PLOS One found.

The study analyzed 775 counties with sufficient available race-specific data; in 94% of them, Latinx HIV prevalence was higher than non-Latinx white HIV prevalence. Median prevalence rates were 284/100,000 people for Latinx and 112/100,000 for whites, resulting in a median disparity of 2.4.

Researchers identified 11 factors that significantly affected these differences, including how rural a county is (which appeared to heighten disparities) and the proportion of residents that are Latinx (the fewer Latinx residents, the greater the HIV prevalence disparity). Other factors included poverty levels, English proficiency, and the number of HIV diagnoses related to injection drug use.

Study authors suggested several measures to address disparities:

• Culturally appropriate Spanish-language HIV services, both in person and delivered via telemedicine (especially to rural areas).
• Targeted substance use programs.
• Community health workers to help retain people in care.

They also noted the impact of the U.S.’s current immigration situation on the mental health of Latinx residents, and the consequences that may have on substance use rates.

“Research and large-scale implementation of macro-level, structural interventions, including education; universal healthcare; policies designed to reduce income inequality and increase income of the poor such as progressive income tax and increases in minimum wage; and immigration policies, are needed to address some of the underlying root causes of health disparities,” the study authors concluded.

Mental health, substance use, and transportation difficulties are the top three barriers to HIV care access for U.S. patients, according to the results of a survey of HIV clinicians published in Open Forum Infectious Diseases.

The brief survey, which was completed by 211 HIV clinicians who work at an academic medical center that offers an accredited fellowship program in infectious diseases, focused on their understanding of the Affordable Care Act (ACA) and its impact on HIV care.

Overall, the vast majority of respondents viewed the ACA favorably or very favorably, with similar rates among those in states that had expanded Medicaid (93%) as those in states that did not expand it (91%). That said, 52% percent of practitioners in Medicaid expansion states reported that their ability to render high-quality HIV care had improved since the ACA took effect, compared to 34% of clinicians in non-expansion states.

Not all clinicians exhibited a thorough understanding of the ACA’s applicability and guidelines within their locality, however. For instance, only 80% of the 211 participants knew whether the state in which they practice had expanded Medicaid eligibility. The implications of this are significant: For example, Medicaid covers the costs of transportation to and from medical appointments, which is one of the significant barriers to care identified by survey respondents. If clinicians are able to fully inform patients about their insurance options, it might help overcome this barrier.

Integrating mental health and substance use services with HIV care, as Ryan White-funded clinics often do, could address the other two key issues identified by survey participants. However, such programs will need additional support, particularly as outreach in the context of the national Ending the HIV Epidemic plan increases the number of people who are diagnosed with HIV, study authors wrote.

“To be successful, the ‘Ending the HIV Epidemic’ initiative should address these identified barriers,” study authors commented—although they cautioned that people living with HIV (PLWH) may identify different barriers than their providers.

Widespread pain was more commonly reported by PLWH than HIV-negative people in a study conducted in the U.K. and Ireland that was published in AIDS.

The 1,207 study participants included 263 HIV-negative controls who were at least 50 years old, 614 PLWH aged 50 years or older, and 330 PLWH who were younger than 50 years old. “Widespread pain” was defined as self-identified pain in at least 4 of 5 body regions and at least 7 of 15 sites on the body.

Overall, widespread pain was most likely to be reported within the older group of PLWH (19%), followed by the younger group of PLWH (13%) and the HIV-negative control group (10%).

Longer HIV treatment exposure was determined to be a risk factor for pain, though the study authors hypothesized this may be caused by 1) older HIV drugs that are no longer prescribed; and 2) a longer time living with HIV itself. (The study was conducted between 2013 and 2016, and more recent antiretrovirals may be different in this respect, study authors noted.)

Lower educational attainment, which may serve as a proxy for socio-economic status and lifestyle, was also associated with more extensive pain—a finding that could help providers identify PLWH who may be at increased risk of pain in the future, the authors suggested.

Clinicians should be alert to pain in PLWH, especially when their patients have been on suppressive antiretroviral therapy for a long time, study authors concluded.

Among PLWH, cancer mortality has declined significantly through the early part of this century, but deaths due to non-AIDS-defining cancers have not dropped as much as those from non-Hodgkin’s lymphoma (NHL) or Kaposi’s sarcoma (KS), researchers reported in Clinical Infectious Diseases.

The study, which examined population-based U.S. HIV and cancer registries, found that overall cancer mortality dropped by 35% when comparing the 2001-2005 time period to the 2011-2015 time period. In 2001-2005, cancer mortality among PLWH was 484/100,000 person-years; By 2011-2015, that number had dropped to 314/100,000 PY.

However, the population-attributable fraction for non-AIDS cancers is on the rise, especially among PLWH aged 60 years or older, the researchers found. Further, even among younger PLWH—i.e., those between ages 20 and 39—the cancer mortality rate was 12 times that of the general population.

During the 2011-2015 time period, the most common non-AIDS-defining cancers among PLWH were lung, liver, and anal cancer, probably because of higher smoking rates, coinfection with HCV, and greater HPV prevalence among MSM, the authors suggested.

Study authors recommended several public health interventions to further reduce cancer mortality among PLWH:

• Early ART initiation to prevent the onset of AIDS-defining cancers.
• HCV screenings.
• Smoking cessation programs.

“Although NHL and KS are among the leading causes of cancer deaths in the HIV population, the spectrum of cancer deaths is shifting toward non–AIDS-defining sites, and mortality due to non–AIDS-defining cancers will likely rise as the HIV population ages,” they concluded.