Our clinic-wide analysis shows that substantial improvements have occurred in the health of those infected with HIV irrespective of HIV transmission risk group, race, and sex. As of calendar year 2010, there is no difference by demographic or behavioral risk groups in ART prescription, OI rates, or mortality rates. This likely reflects the remarkable advances in the development of ART, coupled with continual improvements in the management of HIV-infected individuals based on evidence-based guidelines [1
]. In a previous study, we found that the HIV-1 RNA level had declined markedly over time but we did not analyze individual demographic and HIV transmission risk groups [14
]. Our group previously published results showing disparities in comorbidity and mortality rates by race, sex, and risk group using data through 2005 [15
]. Others have also shown higher mortality rates in blacks vs whites, women vs men, and IDUs vs other HIV transmission risk groups in HIV care through 2005 [17
]. A recent study with more recent data from HOPS, a consortium of HIV care sites in the United States, did not show differences in mortality rates by race for patients with a CD4 T-cell count >200 cells/mm3
Though markedly improved, there remained some differences in 2010 in both the HIV-1 RNA and the CD4 T-cell levels between the IDU risk group and the other HIV transmission risk groups. Approximately half of our patients who have IDU as a risk factor for HIV transmission continue to episodically use illicit drugs, primarily opiates [19
]. This behavior may have an impact on adherence to prescribed ART and on subsequent HIV-1 RNA and CD4 response. It is also possible that use of opiates may have a direct effect on the immune system [20
]. However, these differences did not appear to translate into differences in OI or mortality rates. This would not appear to be confounding related to retention in care since there were no significant differences between IDUs and other risk groups in retention after 2005. It is possible that receipt of ART and associated general medical management led to improved clinical outcomes, but this is speculative. Studies have shown that management of HIV-infected opioid-dependent patients will have better HIV outcomes associated with opioid substitution therapy [21
]. Our clinic has had programs for treatment of opioid and other addictions for much of its history, which may have influenced the clinical outcomes in our patients.
Health disparities/inequalities has been defined as “potentially avoidable differences in health (or in health risks that policy can influence) between groups of people who are more and less advantaged socially; these differences systematically place socially disadvantaged groups at further disadvantage on health” [25
]. An analysis of HIV in the United States by age, sex, and race for the post–highly active antiretroviral therapy era to 2005 showed the death rate was 7.92-fold higher for blacks compared with whites and 2.72-fold higher for low compared with high socioeconomic status [26
]. Numerous reports have documented inequalities in healthcare receipt based on income, race, and, to a lesser extent, sex [27
]. These differences are dramatized and more challenging by the demographics and cost of HIV infection. In the United States the prevalence of HIV is reported at 6-fold greater levels in blacks compared with whites [7
], and the infection rate in persons below the poverty line is substantially higher [32
]. There are probably few major medical conditions that have so selected minorities and “have nots.” The advances in HIV care since 1996 are also remarkably unique, but the cost for contemporary medications averaged about $12 000/year [33
These disparities in the population at risk and challenges in healthcare delivery are further exaggerated in Baltimore, where 86% of reported HIV cases are in blacks and 32% are IDUs. The Centers for Disease Control and Prevention released its 2011 report outlining the continuing disparities in both the access to care and health outcomes based on a number of comorbidities including race/ethnicity, sex, and behaviors [36
]. An important public health goal for Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups in the United States [34
]. Optimizing health outcomes among people living with HIV and reducing HIV-related disparities is a major goal of the National HIV/AIDS Strategy for the United States [35
]. Specifically in regard to HIV/AIDS, disparities are based not only upon race and sex, but also non-MSM transmission risk groups, particularly IDUs, with concern about adherence to treatment and retention in care.
One reason for our ability to deliver HIV care to patients who might otherwise have financial and other barriers to care is the Ryan White HIV/AIDS program. Since 1990, this program, administered by the Health Resources and Services Administration of the US Department of Health and Human Services, has provided federal financial assistance to the clinic to deliver HIV care using a care model that combines primary, specialty (substance abuse and mental health), and supportive care (case management, nutrition, treatment adherence, emergency assistance, transportation) into an integrated multidisciplinary program of care [36
]. The Ryan White HIV/AIDS Program is designed to provide financial support for HIV care for the economically disadvantaged, and among the patients who received Ryan White support in fiscal year 2010 in our clinic, 73% had verified incomes less than the federal poverty guidelines and another 19% had incomes between 101%–200% of the federal poverty guidelines (personal communication, J. C. Keruly, August 2011). A recent policy paper describes the components of effective HIV care, with an emphasis on the contributions that the Ryan White HIV/AIDS Program has made in making medical and supportive services accessible [37
An important caveat in our analysis is that these are data from patients who have engaged in care sufficiently to have laboratory testing and clinical follow-up. We did not assess patients who come to the clinic and then subsequently disengage from care. A recent estimate suggests that 36% of HIV-infected adults aged 18–64 who are linked to HIV care in the US are retained in care over 18–48 months [38
], approximately the same as seen in our clinic. We do not know how many of the patients who were not retained in care transferred their care to another facility or did not receive any further HIV care. We also do not know whether our results would generalize to other HIV care settings in the United States, and they certainly do not generalize to HIV-infected people in the United States who have not engaged in HIV care. Nevertheless, we believe that our results are an important demonstration of what can be achieved by contemporary HIV care in patients who are retained in care.
In summary, we have shown a dramatic improvement in receipt of ART and in HIV outcomes in every demographic and HIV transmission risk groups in our Baltimore clinic, with relatively small remaining disparities in HIV-1 RNA and CD4 T-cell levels as of calendar year 2010. We believe that our results reflect what is possible when HIV care is delivered based on state-of-the-art care guidelines with support from the Ryan White HIV/AIDS Program to address the challenge to deliver treatment that is highly effective, but also expensive, complex, and requires continuous patient engagement by populations that are often underserved by healthcare disparities. These results may not reflect the care received by HIV-infected individuals across the entire United States, and particularly in patients with an IDU history, further improvement is needed. Nevertheless, we believe that our results reflect an effective model of care, and should continue in the United States if individuals with HIV infection are to have the maximal benefit possible from modern HIV care.