Disparities in HIV Care Slides prepared by Kirk Fergus, Intern National Quality Center
At a glance
At a glance MSM accounted for 61% of all new HIV infections in the U.S. in 2009, as well as nearly half (49%) of people living with HIV in 2008. [1] While blacks represent approximately 14% of the U.S. population, they accounted for almost half (46%) of people living with HIV in the U.S. in 2008, as well as an estimated 44% of new infections in 2009. [1] [1] http://aids.gov/hiv-aids-basics/hiv-aids-101/statistics/
At a glance In 2009, the rate of new HIV infections among Hispanic/Latino men was two and a half times that of white men and the rate among Hispanic/Latino women was four and a half times that of white women. [1] In 2009, young persons accounted for 39% of all new HIV infections in the US. For comparison's sake, persons aged 15 29 comprised 21% of the US population in 2010. [2] At some point in their lifetimes, an estimated 1 in 32 black/african American women will be diagnosed with HIV infection, compared with 1 in 106 Hispanic/Latino women and 1 in 526 white women. [3] [1] http://aids.gov/hiv-aids-basics/hiv-aids-101/statistics/ [2] http://www.cdc.gov/hiv/youth/index.htm [3] http://www.cdc.gov/hiv/topics/women/
H. I. Hall et. al., Continuum of HIV care: differences in care and treatment by sex and race/ethnicity in the United States, AIDS 2012 International AIDS Conference Abstract, <http://pag.aids2012.org/abstracts.aspx?aid=21098>
National HIV/AIDS Strategy
What are health disparity populations? includes populations for which there is a significant disparity in the quality, outcomes, cost, or use of healthcare services or access to or satisfaction with such services as compared to the general population. [1] Affordable Care Act National HIV/AIDS Strategy http://www.whitehouse.gov/administration/eop/onap/nhas
National HIV/AIDS Strategy Data indicate that HIV disproportionately affects the most vulnerable in our society those Americans who have less access to prevention and treatment services and, as a result, often have poorer health out-comes. [1] Therefore, to successfully address HIV, we need more and better community-level approaches that integrate HIV prevention and care with more comprehensive responses to social service needs. [2] [1]/[2] http://www.whitehouse.gov/administration/eop/onap/nhas
National HIV/AIDS Strategy Key steps for the public and private sector to take to reduce HIV-related health disparities are: Reduce HIV-related mortality in communities at high risk for HIV infection. Adopt community-level approaches to reduce HIV infection in high-risk communities. Reduce stigma and discrimination against people living with HIV. Anticipated Results By 2015 Increase the proportion of HIV diagnosed gay and bisexual men with undetectable viral load by 20 percent. Increase the proportion of HIV diagnosed Blacks with undetectable viral load by 20 percent. Increase the proportion of HIV diagnosed Latinos with undetectable viral load by 20 percent. http://www.whitehouse.gov/administration/eop/onap/nhas
Disparity Research
Engagement Continuum [1] Health Resources and Services Administration, HAB. August 2006. Outreach: Engaging People in HIV Care Summary of a HRSA/HAB 2005 Consultation on Linking PLWH Into Care. [2] Eldred L, Malitz F. Introduction [to the supplemental issue on the HRSA SPNS Outreach Initiative]. AIDS Patient Care STDS 2007; 21(Suppl 1):S1 S2.
The CDC Cascade for HIV in the United States
Data are organized by demographic group Studies: Disparity Research Most are from 2012 and 2013 Rigorous studies; Peer-reviewed academic journals Some studies found no disparities Include multivariate analysis Focus on Viral Load Suppression, ART Prescription, Retention in care
Who is affected?
There are disparities in care among racial/ethnic groups.
There are disparities in care among racial/ethnic groups. A large clinic in Chicago found that non-hispanic black race was independently associated with viral nonsuppression. [1] The findings of an HIV Research Network 2002-2008 study indicate black patients were less likely to be prescribed ART [AOR=0.79; 95% CI= 0.72, 0.86] [2] [1] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063. [2] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center [1] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care among gender groups.
There are disparities in care among gender groups. The HIV Research Network study 2002-2008 found that women were less likely to be prescribed ART [AOR=0.83; 95% CI= 0.76, 0.91] [1] Chicago CORE clinic found that being female was independently associated with viral nonsuppression. [2] [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427. [2] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center [1] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care among age groups.
There are disparities in care among age groups. Longitudinal study in North America 2001-2009 found increasing age was associated with virologic suppression. [1] Among patients engaged in care in a Chicago clinic, younger-aged patients were independently associated with viral nonsuppression. [2] The HIV Research Network found that youth aged 18-29 were less likely to be prescribed ART than all other age groups. [3] [1] David B. Hanna et. al., Trends and Disparities in Antiretroviral Therapy Initiation and Virologic Suppression Among Newly Treatment-Eligible HIV-Infected Individuals in North America, 2001-2009, Clinical Infectious Diseases 56, no. 8 (2013): 1174-1182. [2] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063. [3] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
There are disparities in care among age groups. The San Francisco Department of Health found that those less than age 40 at diagnosis had lower viral suppression rates compared to persons aged 40 or above [OR=1.92; 95% CI=1.4, 2.7] [3] [1] Dharushana Muthulingam et. al., Disparities in Engagement in Care and Viral Suppression among Persons with HIV, Journal of Acquired Immune Deficiency Syndromes published ahead of print (2013).
[1] David B. Hanna et. al., Trends and Disparities in Antiretroviral Therapy Initiation and Virologic Suppression Among Newly Treatment-Eligible HIV-Infected Individuals in North America, 2001-2009, Clinical Infectious Diseases 56, no. 8 (2013): 1174-1182.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: HIV Research Network [1] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427.
The Data: Chicago CORE Center [1] Oluwatoyin M. Adeyemi et. al., Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic, Clinical Infectious Diseases, first published online February 5, 2013 doi:10.1093/cid/cit063.
There are disparities in care among subsets of demographic populations.
There are disparities in care among subsets of demographic populations. In Miami-Dade County, Florida, researchers studied viral load suppression among racial/ethnic subpopulations naïve to HAART that had received treatment for at least 96 weeks. [1] After 96 weeks: 58.5% of Haitian patients were viral load suppressed 74.1% of African American patients were viral load suppressed 82.8% of Hispanic patients were viral load suppressed (p-value = 0.011) The HIV Research network found MSM IDUs were less likely to be prescribed ART than were MSM that were not IDUs [AOR=0.81; 95% CI= 0.67, 0.97] [1] Jonathan Colasanti et. al., Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County, Florida, Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190. [2] John Fleishman et. al., Disparities in Receipt of Antiretroviral Therapy Among HIV-infected Adults (2002-2008), Medical Care 50, no. 5 (2012): 419-427. [3]
The Data: Miami-Dade County [1] Jonathan Colasanti et. al., Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County, Florida, Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
The Data: Miami-Dade County [1] Jonathan Colasanti et. al., Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County, Florida, Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
There are disparities in care among socioeconomic groups
There are disparities in care among socioeconomic groups The San Francisco Department of Health found that homeless [OR=2.13; 95% CI=1.3, 3.5] or people with unknown housing status [OR=2.67; 95% CI=1.4, 5.0] were less likely to be viral suppressed compared to persons who were housed at diagnosis. [1] CDC Data published in American Journal of Public Health found homeless patients less likely to be viral suppressed than housed patients [OR=0.69; 95% CI=0.48,0.99] [2] [1] Dharushana Muthulingam et. al., Disparities in Engagement in Care and Viral Suppression among Persons with HIV, Journal of Acquired Immune Deficiency Syndromes published ahead of print (2013). [2] Danial Kidder et. al., Health Status, Health Care Use, Medication Use, and Medication Adherence Among Homeless and Housed People Living with HIV/AIDS, American Journal of Public Health 97, no. 12 (2007):2238-2245.
The Data: HIV Surveillance Study [1] Jonathan Colasanti et. al., Disparities in HIV-treatment Responses between Haitians, African Americans, and Hispanics Living in Miami-Dade County, Florida, Journal of Health Care for the Poor and Underserved 23, no. 1 (2012): 179-190.
HIVQUAL Organizational Assessment
HIVQUAL Organizational Assessment HIVQUAL Organizational Assessment Prompt: To what extent does the HIV program measure disparities in care and patient outcomes, and use performance data to improve care to eliminate or mitigate discernible disparities?
HIVQUAL Organizational Assessment
Discussion What improvement strategies in the field are you aware of that address disparities? What are we missing to describe disparities in HIV Care? What geographic level is most appropriate for examining disparities (e.g., clinic, community, county, state, Regional Group, nation etc.)? What actions do you suggest to address disparities as a national priority? What measures could we use for a potential campaign?