Racial Disparities in HIV Care and Mortality in the Modern Treatment Era

Survival among people with HIV has improved dramatically since the first U.S. cases were reported in 1981. However, racial disparities in mortality remain entrenched, and have worsened over time as more effective treatments have become available.Currently, adults are recommended to start integrase inhibitor (INSTI)-containing antiretroviral therapy (ART) as soon as possible after a diagnosis of HIV. INSTIs are associated with more rapid viral suppression, fewer adverse events, and decreased risk of drug resistance compared with other forms of ART. Yet, possible racial differences in INSTI prescription have been inadequately examined since INSTIs were first FDA-approved in 2007. Furthermore, few studies have evaluated whether interventions to ensure timely treatment initiation, improve retention in care, or expand access to INSTI-containing ART might reduce racial inequities in mortality among people with HIV.In this work, we examined racial disparities in the timely initiation of INSTI-containing ART among people entering HIV care in the United States. We also evaluated the effects of several hypothetical clinical interventions on Black-White disparities in mortality among people with HIV. Our study population consisted of people newly entering HIV care in the United States from 1996-2019 at one of >200 clinical sites participating in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).We found that racially minoritized patients were less likely to be prescribed INSTI-containing ART for nearly a decade after INSTIs were approved by the FDA, and that reductions in prescribing disparities corresponded with updates to national treatment guidelines. We also found that universal immediate treatment would not have reduced the Black-White disparity in 5-year mortality among people entering HIV care from 1996-2019. However, the disparity would likely have been reduced under an intervention to ensure both immediate treatment and routine follow-up for all people with HIV, from a difference of 1.5 percentage points (95% CI: 0.9, 2.0) to 0.3 percentage points (95% CI: -3.3, 3.9), and would likely have been reversed under an intervention to ensure immediate treatment and routine follow-up for all Black patients, while White patients continued to receive the observed pattern of care (RD: -2.2; 95% CI: -5.2, 0.8).