| |
Gender & Racial Aging/HIV Disparities
|
| |
| |
Specifically, women experience higher rates of falls, disability, frailty, and functional disability than men. So not only do we need to work to lessen gender disparities in terms of life expectancy, we also need to work with our patients to determine how best to optimize QoL and to be sure that QoL for WLWH is on par with that of men..... fewer Black PWH had sustained virologic suppression, which can adversely affect their health outcomes....Among non-HIV-infected Black and Latino individuals, higher rates of functional decline and disability with aging have been documented.109,110 Among Black and Latino PWH, aging is further complicated by HIV-related stigma resulting in limited social engagement, social isolation, and depressive symptoms.111,112 These factors, in addition to well-described demographic and structural challenges faced by aging Black and Latino PWH (e.g., poverty, unstable housing, and suboptimal neighborhood resources), lend themselves to a patient-centered, community-engaged understanding of aging.
"Older women with HIV had significantly worse physical function and quality of life than older men, according to analysis of 1126 people in the Modena HIV cohort [1]. Women's worse physical function contrasted with their better CD4 recovery and lower cardiovascular disease rates and risk than men"
AGE: Physical function worse in older women than men with HIV, despite better CD4 recovery 55% of men & women with poor physical functioning, exhaustion, pain - Mark Mascolini (09/19/18)
AGE: Considerations for The HIV Positive Woman during menopause - (09/19/18)
Gender disparities
One of the key areas of research in the context of HIV and aging needs to be women aging with HIV. Obviously, this includes gynecologically-focused concerns such as the management of human papillomavirus (HPV) and when to stop screening for breast and cervical cancer. However, there are other areas that are of equal importance that are considered less often when discussing women's health.
Since 2006, highly effective ART in once-daily formulations has led to improved survival among PWH. Life expectancy, however, has not improved equally in men and women: a growing body of research suggests that HIV+ men live longer. This is in marked contrast to the general population where women live longer than men. In a 2017 study of HIV+ and uninfected men and women in British Columbia, at age 20 years, the life expectancy of women living with HIV (WLWH) was 5 years less than men living with HIV (29 vs. 34 years; p < .001). The uninfected women in the study, however, lived for almost 5 years longer than the uninfected men.114 While this is the most dramatic evidence of how WLWH are disadvantaged in terms of life expectancy relative to men, it is not a unique finding. This finding suggests that there are a number of important research gaps that need to be addressed. First, we need to understand what the most common causes of mortality among WLWH are. In particular, we need to explore the role that domestic violence plays in early death among women. In the WIHS, French et al. found that between 1995 and 2004, the most common cause of non-AIDS-related death among study participants (all women) was trauma and self-harm. Contributing factors included the high prevalence of depressive symptoms, physical abuse, and the ongoing vulnerability associated with poverty and substance abuse.115 In contrast, the ART Cohort Collaboration (ARTCC), in a study that was primarily (73%) men, found that violent death (7.8%) was the fourth most common cause of death behind non-AIDS malignancies (11.8%), non-AIDS infections (8.2%), and CVD (7.9%).116
We also need to understand whether this difference in survival is the result of disparities in access to care between men and women? Research out of Kaiser suggests that men have significantly greater linkage to HIV care, ART prescription, and viral suppression than women in 2010–2011, but these differences in linkage to care did not persist.117
Substance use may also be an important contributor to earlier death in WLWH relative to men. We know that an equivalent amount of alcohol has a more negative impact on women than on men.118 We also know that alcohol has a more negative impact on PWH than on uninfected comparators.119 A key question is whether there is an interaction between alcohol use and HIV that makes alcohol particularly dangerous for WLWH. Similar questions need to be asked about smoking. As trends in injection drug use change with the increase in opioid use will we note higher increases in new HIV infection among men and women? We know that women who use drugs are faced with multiple issues, which enhance their vulnerability to HIV, including sex work, stigma, discrimination, and violence.
Multimorbidity and polypharmacy may also have differential impacts on women versus men. Research from the ALIVE cohort suggests that WLWH have higher rates of multimorbidity than men.120 There is ample evidence to suggest that pharmacokinetics are different in women than in men. We need to understand whether these differences contribute to an increased risk of adverse events and thus to a shorter life expectance in WLWH compared with men. Comparisons need
to be made both in non-antiretroviral (ARV) medications and in ART.
In addition to issues related to life expectancy, women in the general population do less well than men on issues of health-related QoL. Specifically, women experience higher rates of falls, disability, frailty, and functional disability than men. So not only do we need to work to lessen gender disparities in terms of life expectancy, we also need to work with our patients to determine how best to optimize QoL and to be sure that QoL for WLWH is on par with that of men.
Racial and ethnic disparities
In the United States, ∼47% of PWH are 50 years and older, the majority of whom are Black/African American or Latino.108 Black and Latino individuals living with HIV have higher rates of HIV-related morbidity and mortality than older adults of other racial and ethnic groups.108 Among non-HIV-infected Black and Latino individuals, higher rates of functional decline and disability with aging have been documented.109,110 Among Black and Latino PWH, aging is further complicated by HIV-related stigma resulting in limited social engagement, social isolation, and depressive symptoms.111,112 These factors, in addition to well-described demographic and structural challenges faced by aging Black and Latino PWH (e.g., poverty, unstable housing, and suboptimal neighborhood resources), lend themselves to a patient-centered, community-engaged understanding of aging. Future research directions identified through the panel discussion regarding racial/ethnic disparities include:
(1) According to the CDC, fewer Black PWH had sustained virologic suppression, which can adversely affect their health outcomes and pose a risk for HIV transmission to others. The racial/ethnic differences in sustained virologic suppression were present across all sex, age, and transmission categories.108 What more needs to be done to promote racial and ethnically targeted retention in care, adherence, reduce structural barriers etc., among older individuals living with HIV to overcome these persistent findings?
(2) Black and Latino individuals over 50 years old are, respectively, 13 and 5 times more likely to receive an HIV diagnosis than are White Americans. What is driving this disparity? Underestimation of personal risk, increased biologic vulnerability (among women increased risk for HIV during penetration potentially due to differential rates in vaginal and cervical thinning that occurs during menopause), greater availability of sexual partners through the internet, or less focus on older populations in prevention efforts?
(3) Has the gender disparity in life expectancy (described below) differentially impacted women by race or ethnicity? In an analysis of data from the Women's Interagency HIV Study (WIHS), Murphy et al.113 noted that Black women were twice as likely as white women to experience adverse HIV clinical outcomes, specifically death from AIDS even after adjusting for multiple potential confounding characteristics, including illicit drug use, depressive symptoms, and adherence. Additional studies confirming these findings and examining structural factors and behavioral and potentially biologic factors that were not explored in this analysis should be undertaken.
|
|
| |
| |
|
|
|
