From 2009 to 2013, the percentage of blacks and whites ages 50 and over increased significantly, the percentage of blacks who had been diagnosed with HIV for 10 or more years increased significantly, the percentage of blacks and whites with depression decreased significantly, and the proportion of all 3 racial/ethnic groups reporting 100% ART adherence increased significantly (Table S1, Supplemental Digital Content, http://links.lww.com/QAI/A860). There was no significant change among any of the racial/ethnic groups in gender, insurance type, household poverty, education, homelessness, recent incarceration, binge drinking, or drug use (data not shown). Patterns were similar among MSM (data not shown).
For viral suppression, the 15.4 percentage point black–white disparity in viral suppression observed in 2009 decreased to 10.4 in 2013, a 32% reduction. However, this change was not significant and disparities remained at the end of the period. The Hispanic–white disparity in viral suppression remained virtually unchanged over the time period (from 4.9 to 4.8 percentage points), and a significant disparity persisted in 2013. After adjusting for the confounding factors of age and time since HIV diagnosis, the magnitude of the observed disparities was somewhat reduced, but significant racial/ethnic disparities remained for both blacks and Hispanics compared with whites.
Further adjustment for mediation via ART use, adherence, and depression reduced the magnitude of the racial/ethnic disparity, but significant black–white and Hispanic–white differences remained. This suggests that racial/ethnic disparities in viral suppression would persist in 2013 even after attainment of equal levels of depression, ART use and adherence and consideration of the effects of group differences in age and time since diagnosis.
As in the overall population, the black–white disparity in ART prescription among MSM significantly declined from 9.5 to 4.1 percentage points over the time period and, after adjusting for differences in age and time since HIV diagnosis, there was no significant black–white disparity in ART prescription by 2013. Among MSM, there was no significant Hispanic–white disparity in ART prescription during 2009–2013. Although the black–white disparity in viral suppression declined from 16.5% to 13.2%, this change was not significant and the disparity remained in 2013, even after adjustment for confounding and mediating factors. By 2013, there was no significant Hispanic–white disparity in viral suppression among MSM.
We found significant increases in ART prescription and viral suppression among persons in HIV medical care in all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, the Hispanic–white disparity in ART prescription was nonexistent, and the black–white disparity was explained by differences between blacks and whites in age and time since HIV diagnosis. Despite reductions in the magnitude of racial/ethnic disparities in viral suppression over the time period, significant disparities remained, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic–white disparity in viral suppression among MSM by 2013.
Our findings of declining but persisting national racial/ethnic disparities are generally supported by the available literature. Although many studies have found significant black–white disparities in ART use,2,4,6,21–23 some have found no racial disparities when examining specific populations, such as clinic attendees or those newly eligible for ART.3,5,24 Regarding Hispanic–white disparities, many,2,3,6,21,22,25 though not all,4,23,24 found no significant Hispanic–white difference in ART use. Across varying populations, most studies find black–white disparities in viral suppression.4–7,21,25–28 Only one recent analysis found no black–white differences in time to viral suppression among a large cohort of persons newly eligible for ART.3 Among recent studies, all but one4 found no differences between Hispanics and whites in viral suppression.3,6,7,21,25,26 Adjudicating between these disparate findings can be challenging because of different study populations, measurement of outcomes, and adjustment factors. The MMP data presented here provide annual information on national trends in racial/ethnic disparities among HIV-positive persons in care in the United States and, because of the richness of behavioral and clinical data collected, can help identify areas for intervention that may decrease these disparities.
This analysis adds to the limited body of knowledge about trends in racial/ethnic disparities in ART prescription and viral suppression among MSM. Hoots and colleagues documented increased ART use between 2008 and 2011 among black, Hispanic, and white MSM living in 20 US cities with high AIDS burden and found significant black–white disparities in ART use for both time periods.29 We found encouraging reductions in Hispanic–white disparities in this highly affected population although black–white disparities persisted. It is important to note that Hispanic–white disparities in viral load were smaller than black–white disparities at the start of the time period examined; therefore, a smaller decline was needed to render the disparity nonsignificant. With a longer observation period, we may see further reductions in the black–white disparity in viral suppression among MSM. However, black MSM face the same barriers to optimal health as those faced by all black persons, and higher prevalence of HIV stigma and homonegativity that may add to these challenges,30–32 so enhanced efforts to reduce disparities for this population may be warranted.
The observed improvements in ART prescription may be due in part to changing clinical guidelines for ART initiation, which steadily moved toward universal prescription over the time period.33 In addition, the development of simpler, more tolerable regimens may have lessened providers' concerns about prescribing ART for persons for whom they have adherence concerns. Interventions addressing the contributors to the persisting black–white disparity in ART prescription—differences between the groups in age and time since diagnosis—could contribute to further reductions in black–white disparities in ART prescription. Expanding provider adoption of universal ART immediately upon diagnosis could increase ART prescription among black persons, a higher proportion of whom are more recently diagnosed. Understanding and addressing provider barriers to prescribing ART to younger adults, who are disproportionately black, may also inform efforts to further reduce black–white disparities.
The significant increases in viral suppression observed among all racial/ethnic groups are cause for optimism because higher levels of viral suppression can be expected to reduce HIV transmission and improve life expectancy.11,12 By 2013, levels of viral suppression for Hispanics and whites were over 80%, but the persistence of significant black–white disparities in suppression is troubling and not fully understood. More time may be needed to see reductions in black–white disparities in viral suppression because they were the largest disparities observed in 2009. MMP as an ongoing surveillance system can be used to monitor such future trends.
In addition to increasing ART prescription among blacks, efforts to reduce the prevalence of factors associated with lack of viral suppression that are more common among blacks may have the potential to reduce black–white disparities in viral suppression. Evidence-based programs that address social determinants of health, such as poverty, education, incarceration, and homelessness, have been recommended.1,34,35 Although addressing social determinants of health is notoriously difficult, these efforts are crucial to achieve the goals of the NHAS. Patient-provider factors such as lack of trust and poor communication may also contribute to ongoing black–white disparities in viral suppression because of lack of engagement in care or because patients might not fully understand their treatment regimens and providers may be operating with incomplete understanding of the patient's behaviors and environment.36,37 Saha et al38 found racial disparities in receipt of ART and viral suppression among patients of providers with low cultural competency, but no racial disparities were observed among patients of providers with moderate-to-high cultural competency. Finally, factors related to the influence of care setting on racial disparities in viral suppression could be explored. Weiser and colleagues found that poor HIV patients were more likely to achieve viral suppression if they received care at facilities funded by the Ryan White HIV/AIDS program, which have greater availability of ancillary services to address lack of resources.39
This analysis is subject to several limitations. First, unmeasured confounders and mediators, and thus some residual bias, may exist. Second, racial/ethnic disparities in our outcomes in the overall sample may differ according to gender.23,26 However, our sample sizes for Hispanic and white women in each data collection year do not allow for adequate gender-stratified assessment of trends in our outcomes. Because the MMP surveillance system is ongoing, in the future we may be able to examine these trends by gender and race/ethnicity by grouping data from multiple years. Additionally, our patient response rate was lower than optimal, though our use of population-based sampling methods and weighting adjustments for nonresponse should reduce bias40 and the MMP population has been found to be demographically similar to all HIV-diagnosed persons in the United States.41
Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the NHAS goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.
We thank participating MMP patients, facilities, project areas, and Provider and Community Advisory Board members. We also acknowledge the contributions of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC and the MMP Study Group Members (http://www.cdc.gov/hiv/statistics/systems/mmp/resources.html#StudyGroupMembers).
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