This Week in HIV Research: The Long Road to Racial Health Justice

Do participants in HIV treatment adherence trials properly reflect the diversity of people living with HIV (PLWH) in the U.S.? According to a meta-analysis published in AIDS Care, the answer is a resounding “No.”

The authors analyzed 80 studies conducted in Organisation for Economic Co-operation and Development (OECD) countries over the course of 17 years and assigned each a cultural competence score based on whether the demographic characteristics of the study population reflected those of PLWH in that country. While various industrialized nations were represented, the majority of studies included in the meta-analysis were conducted in the U.S.

The median cultural competence score among the 80 studies examined was 2.5 out of a possible 20. The highest score any single study achieved was 12.

In general, clinical trials enrolled fewer women, ethnic minorities and heterosexual men than their corresponding proportions among PLWH in the countries where the studies were conducted.

Caution should be exercised when translating trial data to real-world implementation, study authors warned. They also noted an overall lack of data on some characteristics, such as migrant status, sexual orientation or mode of HIV acquisition.

Nonetheless, "guidelines for carrying out research need to recognize that research methods must be adapted to support the wide range of people with differing needs that make up the diversity of people with a specific disease,” said lead researcher Debi Bhattacharya, from the University of East Anglia in the United Kingdom, in a press release.

Neighborhood deprivation—i.e., low levels of education, employment, housing quality, and income—is negatively associated with HIV viral suppression in a given area, independent of that neighborhood’s racial/ethnic makeup, a single-center retrospective cohort study published in Clinical Infectious Diseases showed.

The results testify to the predominance of structural racism, rather than race per se, as a risk factor for lack of HIV viral suppression in the U.S., the study authors concluded.

The study included data on 947 PLWH attending the University of Nebraska clinic in Omaha, Nebraska, between 2012 and 2018. The city has a history of redlining and housing segregation, which helps to explain the race-independent disparities seen when applying per-neighborhood values from the Area Deprivation Index, which quantifies highly localized inequalities by assessing 17 different U.S. Census-derived measurements.

While various sociodemographic factors were considered, data did not allow for deep analyses by race, such as a distinction between African immigrants and U.S.-born African Americans. Reliance on ZIP codes to delineate neighborhoods also meant that unhoused people were excluded from the study. (Housing status has been previously associated with viral suppression rates.)

The study was conducted prior to COVID-19, but the respiratory virus also highlights the impact of structural determinants of health, a related commentary authored by Rupali K. Doshi, M.D., of George Washington University, and colleagues noted. They added that, beyond viral infections, neighborhood deprivation is also associated with the prevalence of non-infectious chronic diseases such as diabetes, as well as overall mortality and other health issues.

Healthcare providers need to be trained to identify system-level issues and should advocate for the elimination of such problems, in addition to examining how medical practice itself can perpetuate these inequities, Doshi et al urged.

Given sufficient resources, rapidly starting antiretroviral treatment during acute and early HIV is feasible even when people are experiencing challenges that have traditionally been considered barriers to treatment, a small study published in Clinical Infectious Diseases found.

Forty-six percent of the study’s 84 participants were using substances, 6% were unstably housed and 24% reported a median household income under $1,000 per month. Rapid antiretroviral treatment was defined as beginning treatment seven or fewer days after receiving an HIV diagnosis; 69% of participants started during that time and 96% began treatment within 60 days. By week 24, 80% of all participants—and 91% of participants who received rapid treatment—were virally suppressed.

Beyond improving individual health, early HIV treatment initiation and subsequent viral suppression also help to prevent onward transmission of the virus, study authors noted.

In a related commentary, a group of noted HIV clinician-researchers offered additional components of successful rapid antiretroviral treatment start, including: established relationships between testing and treatment sites; warm hand-offs from one site to another; patient navigation services; and medical education about prescribing antiretrovirals before all lab results are available. The commentary authors called for clinics to reduce the complex enrollment paperwork often required for publicly funded programs.

Rapid antiretroviral treatment also reduces the number of required in-person visits, an important benefit in the COVID-19 era, the commentary authors added.

Long-term clinical outcomes are similar for integrase strand transfer inhibitor (INSTI)-based and efavirenz (EFV)-based initial regimens—including their respective risk rates for key adverse events, an analysis of a large cohort published in Clinical Infectious Diseases found.

Researchers followed 15,993 participants (36% INSTI, 64% EFV) in the massive, ongoing NA-ACCORD trial for six years. A composite outcome of AIDS, acute myocardial infarction, stroke, end-stage renal or liver disease, or death occurred among 440 in the INSTI arm and 1,097 in the EFV group. The intention-to-treat analysis found a 15% risk of the composite outcome in the INSTI group compared to a 14% risk in the EFV arm.

Earlier clinical trials have suggested more favorable outcomes on INSTIs compared to EFV, but some adverse effects may not have appeared until after the trials’ shorter follow-up periods, study authors suggested. Due to a lack of data, other adverse outcomes—such as cancers or metabolic disorders—could not be ascertained, nor could differences between specific INSTIs be determined.