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Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015
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July 1 2021- AIDS - Thibaut Davy-Mendeza,b, Sonia Napravnika,b, Joseph J. Erona,b Stephen R. Colea, David Van Duinb, David A. Wohla,b,
Kelly A. Geboc,d, Richard D. Moorec,d, Keri N. Althoffc,d, Tonia Poteatb,
M. John Gille, Michael A. Horbergf, Michael J. Silverbergg, Ni Gusti Ayu Nandithah, Jennifer E. Thorned, Stephen A. Berryd, for the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA
Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.....cancers, depression, COPD
Among United States and Canadian PWH in care 2005-2015, unadjusted all-cause hospitalization rates decreased for most racial, ethnic, and gender groups and were highest among Black cisgender women. After adjusting for CD4+, viral load, and age, we did not detect a significant change in rates for any group. In adjusted analyses, Black and Indigenous cisgender men were approximately 1.5 times likelier to be hospitalized than White cisgender men, and transgender patients 1.4 times likelier than cisgender men. Indigenous cisgender women had 1.8 times the adjusted rate of White cisgender women. Adjusted rates were lower for Asian than White cisgender men. In cause-specific analyses, unadjusted hospitalization rates for ADI were higher for Black, Hispanic, and Indigenous versus White cisgender men, and for transgender patients versus cisgender men. Black cisgender men and women also experienced higher adjusted rates than White counterparts for cardiovascular and renal/genitourinary conditions.
Non-HIV clinical characteristics might also have affected hospitalization disparities. End-stage renal disease rates among PWH decreased after 2000, but women and Black PWH have substantially higher rates than men and White PWH, respectively [15]. Black PWH are at higher risk of developing hypertension and type 2 diabetes mellitus, risk factors for more severe morbidity [16]. Women are at higher risk of developing type 2 diabetes mellitus compared with men with HIV [16]. In contrast, PWH who develop end-stage liver disease are likelier to be men and White [17].
In addition to differences in HIV care outcomes and chronic conditions, unmet social needs might contribute to hospitalization disparities. Out-of-pocket health expenses, difficulty finding transportation to clinic, and insurance coverage gaps can prevent PWH from accessing HIV and non-HIV care [37,38]. Caregivers, frequently women, might be unable to seek outpatient care for themselves because of their responsibilities [39]. Vulnerable populations, including people who use drugs and Indigenous, transgender, and immigrant PWH, might delay accessing care because of discrimination or stigma [40-44]. Other barriers, including mental illness, homelessness, and food insecurity, have been associated with poorer health outcomes among PWH and could lead to more frequent hospitalizations [45,46]. Some PWH might also lack a support network to assist with outpatient illness management, requiring inpatient admission. Efforts should continue to be made to provide safe environments and culturally competent care, and resources to mitigate structural factors leading to poorer health outcomes. For example, interventions providing medication-assisted treatment for opioid use disorder in HIV clinics and culturally competent care to Hispanic PWH can improve visit attendance [47,48].
Differences in HIV treatment outcomes likely contributed to the hospitalization disparities we observed. Prior studies have shown that women and transgender patients versus men, and Black and Indigenous versus White PWH, are likelier to experience unsuppressed viral loads or viral rebound [8,12,31]. HIV care interruptions occur more frequently among Black and Indigenous than White PWH [13,14]. Although earlier ART initiation can prevent AIDS and non-AIDS morbidity, Black, Hispanic, and Indigenous PWH continue to experience delayed HIV diagnosis or care compared with White PWH, with low CD4+ cell counts or an ADI diagnosis [7,9-11,32]. Ongoing viral replication and severe immunodeficiency also contribute to end-organ damage, immune dysregulation, and inflammation, which can lead to further non-AIDS morbidity, including myocardial infarction and HIV-associated nephropathy [33,34].
We aimed to describe hospitalization rates stratified by racial, ethnic, and gender groups among PWH in clinical care between 2005 and 2015 in the United States and Canada.This study was based in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), a collaboration of over 20 cohorts including more than 180 000 PWH [21,22]. Patients aged at least 18 years contributed person-time at risk from cohort entry or 1 January 2005, whichever occurred later, until death or 31 December 2015, whichever occurred first.
During follow-up, the overall mortality rate was 1.4 deaths per 100 person-years [95% confidence interval (CI) 1.3-1.5]. The highest mortality rates per 100 person-years were observed for Black patients among cisgender men (1.8, 95% CI 1.7-2.0), and for Indigenous patients among cisgender women (3.0, 95% CI 1.7-5.4), respectively (Table, Supplemental Digital Content 1, http://links.lww.com/QAD/C59).
Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015
Abstract
Objective:
To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada.
Design:
HIV clinical cohort consortium.
Methods:
We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load.
Results:
Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05).
Conclusion:
Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.
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