Low income consistently associated with virologic failure among women using HAART in the US - other predictors differ by race/ethnicity

Understanding the Disparity: Predictors of Virologic Failure in Women Using Highly Active Antiretroviral Therapy Vary by Race and/or Ethnicity.  

McFall AM, Dowdy DW, Zelaya CE, Murphy K, Wilson TE, Young MA, Gandhi M, Cohen MH, Golub ET, Althoff KN. J Acquir Immune Defic Syndr. 2013 Nov 1;64(3):289-98. doi: 10.1097/QAI.0b013e3182a095e9.

Background: Stark racial/ethnic disparities in health outcomes exist among those living with HIV in the United States. One of 3 primary goals of the National HIV/AIDS Strategy is to reduce HIV-related disparities and health inequities.

Methods: Using data from HIV-infected women participating in the Women's Interagency HIV Study from April 2006 to March 2011, we measured virologic failure (HIV RNA >200 copies/mL) after suppression (HIV RNA < 80 copies/mL) on highly active antiretroviral therapy. We identified predictors of virologic failure using discrete time survival analysis and calculated racial/ethnic-specific population-attributable fractions (PAFs).

Results: Of 887 eligible women, 408 (46%) experienced virologic failure during the study period. Hispanic and white women had significantly lower hazards of virologic failure than African American women [Hispanic hazard ratio, (HR) = 0.8, 95% confidence interval: (0.6 to 0.9); white HR = 0.7 (0.5 to 0.9)]. The PAF of virologic failure associated with low income was higher in Hispanic [adjusted hazard ratios (aHR) = 2.2 (0.7 to 6.5), PAF = 49%] and African American women [aHR = 1.8 (1.1 to 3.2), PAF = 38%] than among white women [aHR = 1.4 (0.6 to 3.4), PAF = 16%]. Lack of health insurance compared with public health insurance was associated with virologic failure only among Hispanic [aHR = 2.0 (0.9 to 4.6), PAF = 22%] and white women [aHR = 1.9 (0.7 to 5.1), PAF = 13%]. By contrast, depressive symptoms were associated with virologic failure only among African-American women [aHR = 1.6 (1.2 to 2.2), PAF = 17%].

Conclusions: In this population of treated HIV-infected women, virologic failure was common, and correlates of virologic failure varied by race/ethnicity. Strategies to reduce disparities in HIV treatment outcomes by race/ethnicity should address racial/ethnic-specific barriers including depression and low income to sustain virologic suppression.

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Editor’s notes: There has been a dramatic decrease in HIV/AIDS related mortality following the widespread introduction of HAART in the US. However, these improvements have been unequally distributed, with substantial variation by race/ethnicity. This study explored the levels and causes of virologic failure among 3 racial/ethnic groups of HIV positive women accessing treatment.  Virologic failure was common, with an annual failure rate of 23% - 27%. Low income was a large and consistent barrier to sustained virologic suppression across all groups, although there was a greater burden of poverty in Hispanic and African American women. Depressive symptoms were significantly associated with virologic failure only among African American women, whilst current smoking was significantly associated with an increased hazard of virologic failure among American women. The findings illustrate the challenges of sustaining virologic suppression, and the need for a greater understanding of the social, economic and cultural factors that may impact on consistent ART use.   

Northern America
United States of America
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