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HIV News: Risk for HIV Depends on Who You Are
January 2009 to December 2018, and included 262 patients for analysis.
Of the patients, 30% were receiving ART at the time of KS diagnosis and one-fourth were first diagnosed with HIV and KS at the same time. Regarding disease stage, 46% of patients had T1, 75% had I1 and 54% had S1 stage disease.
Of the included patients with KS, 30.9% died, with a median survival duration of 11 months from KS diagnosis. Black patients had the highest mortality of all race/ethnic groups, including white and Hispanic patients.
According to Dr. Knights, U.S. Surveillance, Epidemiology, and End Results program data indicate an expected five-year survival rate of about 77% in KS, but in the current study, that rate for Black patients was 69%. The five-year survival rate was 78% for white patients and 81% for Hispanic patients. A multivariable analysis showed Black patients had a mortality risk twice that of white or Hispanic patients (hazard ratio, 2.07; 95% CI, 1.12-3.82). Black race was found to be independently associated with mortality.
“Although white and Hispanic patients had slightly better mortality than expected in our study, Black patients had worse mortality than expected,” Dr. Knights said.
Implications
Dr. Knights and her colleagues found Black patients had more advanced KS disease at diagnosis, and often were younger than other ethnicities, which could explain the mortality difference.
“What’s not clear from our study is why these patients are presenting with more advanced disease,” Dr. Knights said. “Could these patients be infected with a specific genotype of KS-associated herpesvirus that may be associated with more advanced disease? Could there be a complex combination of socioeconomic factors involved that are difficult to measure?”
She said they were unable to answer this question in this study, but hope to do so in future studies.
Dr. Knights said according to the CDC’s HIV Surveillance program, Black people in the southern United States have the highest death rates from HIV, too.
“I suspect that whatever the underlying etiology of the mortality disparity in KS is, it is most likely related to the same factors that contribute to higher mortality in HIV deaths in the southern United States,” Dr. Knights said. “We as HIV providers still have a lot of work to do to help identify and alleviate healthcare disparities.” ■
Dr. Dittmer reported a position as an investigator with the AIDS Malignancy Consortium. Dr. Knights reported grant funding from the UT Southwestern Simmons Comprehensive Cancer Center Pilot Award.
Risk for HIV Depends On Who You Are
BY MARIE ROSENTHAL, MS
Despite the tremendous progress made in reducing new HIV transmissions in the United States, the disease continues to affect some groups more than others, according to Sonia Singh, PhD, an epidemiologist with the CDC’s Division of HIV Prevention, who calculated the lifetime risk for HIV among various groups.
“Overall, the lifetime risk for an HIV diagnosis in the United States was one in 120,” Dr. Singh said, an 11% decrease from the last analysis in 2014 (CROI 2022).
One in 76 males and one in 309 females will receive a diagnosis of HIV in their lifetime, but the probable risk sharply increases based on sex and race with Black and Hispanic males having a greater risk than white or Asian males.
The analysis used data from the National HIV Surveillance System, the National Center for Health Statistics and census data to calculate the probability of a diagnosis of HIV at a given age, assuming 2017-2019 diagnosis rates continue. These probabilities were applied to a hypothetical cohort to obtain risk estimates. The lifetime risk is the probability of being diagnosed with HIV from birth.
The lifetime risk for Black males was one in 27, whereas the lifetime risk for Hispanic males was one in 50—both higher than the overall lifetime risk for males. Asian males experienced the lowest lifetime risk at one in 187. The risk for white males was one in 171. For American Indian/Alaskan Native men, the lifetime risk was one in 116, and one in 89 for Native Hawaiian and other Pacific Islander men.
Females fared better across the board. The risk for an HIV diagnosis was one in 75 for Black females; one in 287 for Hispanic females; one in 435 for American Indian/Alaskan Native females; one in 611 for Native Hawaiian and other Pacific Islander females; one in 874 for white females; and one in 1,298 for Asian females.
The states with the highest lifetime risk for being diagnosed with HIV were Georgia, Florida, Louisiana, Nevada and Maryland. “Nine of the 10 areas of residence with the highest possibility of a lifetime HIV diagnosis were located in the South,” she said.
The lifetime risk for a disease is used to compare the burden of disease across populations, she explained, and is frequently used to describe cancer risk but not necessarily the risk for HIV. Lifetime risk could be a “useful tool for clinicians, outreach workers and policymakers when describing a burden of HIV,” she said. ■
Engaging HIV Patients
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case managers. The latter are health department staff, who help with things like getting patients bus passes and food vouchers, providing psychosocial support, and coordinating the overall clinic.”
They also provide financial incentives. “It’s not enough to lower the barriers; you have to give something to draw people in,” she said. “We give cash for having a visit with blood draw and cash for remaining virally suppressed.
The Max Clinic also coordinates with housing agencies, providers of substance use treatment, and other agencies that work with this population. The clinic also works with the local jail to ensure inmates being released will have immediate access to medications on the outside.
Many patients achieved their first successful treatment at the Max Clinic. They described a “family-like environment” in a report in AIDS and Behavioral and Psychosocial Research (2020;34[6]:267-274).
Good relationships with clinic staff and the ability to receive care on a walkin basis were the strongest influences on maintaining engagement. “Walk-in visits lowered the barrier to accessing care,” according to the report. They also eliminated the shame associated with missing appointments.
Participants felt that Max Clinic staff attended to their social circumstances whereas others had not. That attention resulted in patients feeling that their healthcare providers treated “me, the person—not me, the disease.”
Across the country, from San Francisco to Mississippi, to Boston’s Brigham and Women’s Hospital, clinics are taking similar approaches, trying to reach the “10% to 15% who are not virologically suppressed, and who, across the board, are struggling with social stressors such as [lack of] housing and food insecurity and/or mental health issues,” Dr. Solomon said. “It requires a multidisciplinary effort to keep them coming back.”
Who Slipped Through the Cracks?
The first step is identifying patients who have fallen out of the healthcare system. A registry enables tracking patients. When a patient misses an appointment, the physician works with a social worker to determine the major barrier to keeping the patient engaged, Dr. Solomon explained.
The clinic also has an embedded psychiatry team “who help tremendously in addressing mental health,” and providers with expertise treating addictions, who can prescribe buprenorphine-naloxone or buprenorphine for SUDs. “Treating substance use disorders proactively is essential to keeping these patients in care,” Dr. Solomon said. Patients whose addictions go beyond what the Infectious Disease/HIV clinic can treat are sent to the Brigham Health Bridge To Recovery Clinic. That clinic provides immediate care for SUDs, offering medications that help treat addiction and providing connections to the longer-term care and support services critical to their recovery, including help finding housing if that’s an issue. So far, few data exist comparing the multidisciplinary approach with more conventional treatments for HIV. But in a comparison of outcomes of the first 50 patients enrolled in the Max Clinic and 100 randomly selected, matched control patients at the nearby Madison Clinic, viral supThe pression improved in the former group from 20% to 82% (P<0.001) and from 51% to 65%
Goal for in the latter group (P=0.04). “Adjusted for differences in unstable housing, substance
Ending HIV: use and psychiatric diagnoses, Max Clinic patients were [more than] three Reduce new U.S. times as likely to achieve viral suppression,” Dr. Dombrowski and her infections by co-authors wrote (2019;6[7]:ofz294). There are caveats to these find90% by ings: lack of randomization and the Max 2030. Clinic’s enrollment depending on clinician and case manager decisions to refer patients in the treatment arm and also the lower levels of instability in the control group. This kind of individualized, hands-on care is less costeffective and may not be something that other clinics can do, but those negatives need to be viewed with the necessity to end HIV/AIDS in the United States. There were an estimated 34,800 new HIV infections in 2019, bringing the total of people living with HIV to 1.2 million, according to the CDC. Although this was an 8% fall in new infections, since 2015, more is needed to end HIV as we know it, according to the National HIV/AIDS Strategy: 2022-2025 (https://hivgov-prodv3.s3.amazonaws.com/s3fs-public/NHAS-2022-2025.pdf). The strategy calls for engaging people at risk for HIV in “traditional public health and health care delivery systems, as well as in nontraditional community settings.” Everyone caring for people with HIV really needs to evaluate how the HIV healthcare system can be modified to meet the needs of these difficult-to-reach patients, rather than expecting the patient to meet the requirements of these systems. ■ Drs. Dombrowski and Solomon reported no relevant financial disclosures.
