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Black Women in US Have Doubled Risk of AIDS Death, Regardless of Adherence
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19th Conference on Retroviruses and Opportunistic Infections, March 5-8, 2012, Seattle
Mark Mascolini
Black women in the US Women's Interagency HIV Study (WIHS) run a twice higher risk of AIDS death than nonblack women, according to results to two multivariate analyses involving women on continuous antiretroviral therapy (ART) [1]. Adherence to ART was worse among black women than others, but that did not explain the higher AIDS death risk.
A large proportion of WIHS members--and many HIV-positive women in the US--are poor minority women in whom sociocultural disadvantages can complicate HIV care and antiretroviral therapy. HIV-positive blacks may also be genetically predisposed to worse antiretroviral responses because they are more likely to have genetic polymorphisms that unbalance drug metabolism.
An earlier WIHS analysis identified a nonsignificant trend toward a lower risk of AIDS death in white women than in blacks (adjusted hazard ratio [aHR] 0.49, P = 0.19). But WIHS investigators observed that such a trend, if real, could have a meaningful clinical impact. To examine AIDS death risk further in WIHS, researchers planned this analysis of 1471 HIV-positive women on continuous ART. An analysis that factored in time-updated adherence involved 1255 women with self-reported antiretroviral adherence data.
Cumulative incidence of AIDS death after 10 years of follow-up was 16% for black women and 8.2% for white women. Black women reported significantly lower antiretroviral adherence (P < 0.0001), as did women with depression, defined as a Center for Epidemiologic Studies Depression (CESD) score at or above 16 (P = 0.0015).
Multivariate analysis determined that black women had a twice higher risk of dying from AIDS than nonblack women (aHR 2.03, P = 0.004). Black women were 68% more likely than others to have a new AIDS illness during follow-up (aHR 1.68, P = 0.005). Compared with white women, blacks were 35% less likely to self-report good antiretroviral adherence (aHR 0.65, P = 0.0001).
In the 1255-woman time-updated analysis that accounted for adherence, black women still had a doubled risk of AIDS death compared with other women (aHR 2.35, P = 0.04). Adherence of 95% or better cut the risk of AIDS death 70% (aHR 0.30, P < 0.0001). In this same analysis, depression almost tripled the risk of AIDS death (aHR 2.82, P < 0.0001), higher peak viral load almost doubled the risk (aHR 1.87, P= 0.0008), and a positive HCV RNA test tripled the risk (aHR 2.99, P = 0.0002). In the analysis not accounting for adherence, illicit drug use raised the risk of an AIDS death 64% (aHR 1.64, P = 0.02).
Besides black race, five other factors made good adherence less likely: depression (aHR 0.81, P = 0.02), illicit drug use (aHR 0.66, P = 0.003), injection drug use (aHR 0.80, P= 0.04), lower education (aHR 0.82, P = 0.03), and smoking (aHR 0.79, P = 0.013). As in other studies, older age improved chances of good adherence (aHR 1.13, P = 0.0003).
Besides black race, higher peak viral load (aHR 1.57, P < 0.0001), smoking (aHR 1.64, P = 0.007), and a prior AIDS illness (aHR 2.10, P < 0.0001) independently boosted the risk of a new AIDS illness.
The WIHS team speculated that "genetic polymorphisms in drug metabolism and transport that differ by ancestry may be playing a role in lower adherence and higher AIDS deaths in black women."
References
1. Murphy K, Hoover D, Shi Q, et al. The association of race with death from AIDS in continuous HAART users: WIHS. 19th Conference on Retroviruses and Opportunistic Infections. March 5-8, 2012. Seattle. Abstract 1045.
2. Anastos K, Schneider MF, Gange SJ, et al; for the Women's Interagency HIV Study Collaborative Group. The association of race, sociodemographic, and behavioral characteristics with response to highly active antiretroviral therapy in women. J Acquir Immune Defic Syndr. 2005;39:537-544.
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