Racial/Ethnic Disparities in the HIV Care Continuum: Better Targets and Better Measures
Embargo until
2022-08-01
Date
2018-05-30
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Johns Hopkins University
Abstract
Background: The United States (US) National HIV/AIDS Strategy (NHAS) prioritized reductions in disparities in HIV care and improvements in HIV care retention, antiretroviral therapy (ART) use, and viral suppression particularly in key populations of persons with HIV (PWH) in the US. The goals of this dissertation are to describe the progress made in achieving NHAS goals and identify which subgroups of PWH experience the largest burdens of racial/ethnic disparities in HIV care.
Methods: We nested studies in the North American AIDS Cohort Collaboration on Research and Design. We estimated trends in racial/ethnic differences in retention in care, ART use, and viral suppression between 2004-2014 using log binomial regression models with generalized estimating equations accounting for repeated measures. Standard measures of retention in care were scrutinized in their ability to correlate with HIV care engagement (as measured by viral suppression) over time using Spearman correlations, sensitivity, specificity, c-statistic, and prevalence ratio (PR) for viral suppression. Racial/ethnic differences in the 5-year restricted mean person-time spent in care, on ART, and virally suppressed were assessed using nonparametric cumulative incidence curves of seven HIV care continuum stages.
Results: Among 19,006 participants, the proportion retained in care remained relatively stable at 65% over time. Between 2004-2014, ART use and viral suppression increased from 55.7% to 83.7% and 33.9% to 77.8%, respectively. Black men who have sex with men (MSM) had consistently lower percentages of ART use and viral suppression than white MSM over time. Standard measures of HIV care retention showed a poor or worsening correlation with HIV care engagement over time (Spearman correlation <0.40; c-statistic <0.675; PRs approached 1.0). Sex, age, and sexual HIV acquisition risk (i.e., MSM vs. men who have sex with women) modified the magnitude of racial/ethnic differences in mean person-time spent in HIV care continuum stages. The magnitude of the Black-white disparity increased in older ages among MSM.
Conclusions: Racial/ethnic disparities in the HIV care continuum persist and suggest the need for clinical and public health interventions targeted towards specific subgroups of PWH to achieve NHAS goals to reduce disparities in HIV care. Novel measures of retention are needed to better quantify HIV care engagement.
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Keywords
HIV care continuum, racial/ethnic disparities, key populations