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Association of Race and Ethnicity With Initial Prescription of
Antiretroviral Therapy Among People With HIV in the US
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January 3, 2023
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Among individuals entering HIV care within a large research consortium in the US from 2007-2019, the 1-month probability of ART prescription was not significantly different across most race and ethnicity comparisons.
However, Black and Hispanic individuals were significantly less likely than White individuals to be prescribed INSTI-containing ART for several years after the initial FDA approval of INSTIs but not after national guidelines recommended INSTIs as the single preferred initial treatment regimen for most people with HIV.
Results
Of 41 263 patients with information on race and ethnicity, 19 378 (47%) as non-Hispanic Black, 6798 (16%) identified as Hispanic, and 13 539 (33%) as non-Hispanic White; 36 394 patients (85%) were male, and the median age was 42 years (IQR, 30 to 51).
From 2007-2015, when guidelines recommended treatment initiation based on CD4+ cell count, the probability of ART initiation within 1 month of care entry was 45% among White patients, 45% among Black patients (difference, 0% [95% CI, -1% to 1%]), and 51% among Hispanic patients (difference, 5% [95% CI, 4% to 7%]).
From 2016-2019, when guidelines strongly recommended treating all patients regardless of CD4+ cell count, this probability increased to 66% among White patients, 68% among Black patients (difference, 2% [95% CI, -1% to 5%]), and 71% among Hispanic patients (difference, 5% [95% CI, 1% to 9%]). INSTIs were prescribed to 22% of White patients and only 17% of Black patients (difference, -5% [95% CI, -7% to -4%]) and 17% of Hispanic patients (difference, -5% [95% CI, -7% to -3%]) from 2009-2014, when INSTIs were approved as initial therapy but were not yet guideline recommended.
Significant differences persisted for Black patients (difference, -6% [95% CI, -8% to -4%]) but not for Hispanic patients (difference, -1% [95% CI, -4% to 2%]) compared with White patients from 2014-2017, when INSTI-containing ART was a guideline-recommended option for initial therapy; differences by race and ethnicity were not statistically significant from 2017-2019, when INSTI-containing ART was the single recommended initial therapy for most people with HIV.
Probability of Being Prescribed INSTI-Containing ART by Time Period at Treatment Initiation
Among patients starting ART, the probability of being prescribed INSTI-containing ART increased from 2007-2019. In 2008, the first full year after the FDA approved raltegravir (the first available INSTI) for treatment-experienced patients, 3% of patients were prescribed INSTI-containing initial ART. By 2018, the first full year after INSTI-containing ART was recommended as the single preferred initial therapy for most people with HIV, 89.9% of Black patients (95% CI, 87.5% to 92.3%), 93.2% of Hispanic patients (95% CI, 89.4% to 96.9%), and 90.8% of White patients (95% CI, 87.4% to 94.2%) starting ART were prescribed an INSTI.
While there were no significant racial or ethnic differences in INSTI prescription among patients starting ART in 2018 or 2019, significant differences were observed in earlier periods (Figure 3; eTable 2 and eFigure 4 in Supplement 1). From October 12, 2007 to July 7, 2009, when INSTIs were FDA approved as salvage therapy, 5.0% of White patients, 3.5% of Black patients (difference, -1.6% [95% CI, -2.9% to -0.2%]), and 3.1% of Hispanic patients (difference, -2% [95% CI, -3.6% to -0.3%]) were prescribed INSTIs (Figure 1). From July 8, 2009 to April 30, 2014, when INSTIs were FDA-approved as initial therapy but not yet guideline recommended, 22.1% of White patients, 3.5% of Black patients (difference, -1.6% [95% CI, -2.9% to -0.2%]), and 17.3% of Hispanic patients (difference, -4.8% [95% CI, -6.5% to -3.2%]) were prescribed INSTIs. From May 1, 2014 to October 16, 2017, when the DHHS Panel recommended INSTI-containing ART as an option for initial therapy, there was no significant difference in the probability of being prescribed INSTIs between Hispanic patients (71.8%) and White patients (72.4%), but Black patients (66.1%) were still significantly less likely than White patients to be prescribed INSTIs (difference, -6.3% [95% CI, -8.4% to -4.2%]).
Racial and ethnic differences in the prescription of INSTI-containing initial ART were similar by sex except from May 1, 2014 to October 16, 2017, when other regimens were gradually being removed from the DHHS Panel's list of recommended first-line regimens in favor of INSTIs. During that period, while INSTI prescriptions were 5.1% less common (95% CI, -7.4% to -2.9%) among Black male patients compared with White male patients starting ART, they were 12.2% less common (95% CI, -18.7% to -5.7%) among Black female patients compared with White female patients starting ART. During the same period, the probability of INSTI prescription was not significantly different among Hispanic female patients compared with White female patients (Figure 1).
Variation in Racial and Ethnic Differences in INSTI Prescription
Exploratory analyses of factors that may contribute to the observed differences by race and ethnicity suggested that the magnitude of the observed differences may be modified by cohort, geographic region, and residence in a state that had expanded Medicaid, although the observed differences followed a similar pattern across most levels of each of these contextual factors (eTable 2 and eFigures 5, 6, 7, 8, 9, 10, 11, 12, and 13 in Supplement 1). Larger racial and ethnic differences were observed among patients with private health insurance and among uninsured patients than among patients with public health insurance (Figure 4; eTables 3 and 4, eFigures 8 and 9 in Supplement 1). The differences were most pronounced from 2014-2016, when INSTIs were recommended as an option for initial therapy but were not yet the preferred initial treatment regimen for most people living with HIV. For example, in 2014, 68.9% of privately insured White patients, 49.2% of privately insured Black patients (difference, -19.8% [95% CI -26.8% to -12.7%]), and 51.7% of privately insured Hispanic patients (difference, -17.2% [95% CI, -26.9% to -7.6%]) were prescribed INSTI-containing initial ART. During the same year, 44.9% of publicly insured White patients, 41.5% of publicly insured Black patients (difference, -3.4% [95% CI, -8.4% to 1.7%]), and 45.3% of publicly insured Hispanic patients (difference, 0.4% [95% CI, -6.5% to 7.3%]) were prescribed INSTI-containing initial ART.
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