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Lower rate of undetectable viral load in black than white gay/bisexual men in US study.

Compared with white HIV-positive gay or bisexual men in a large US study, black gay or bisexual men were less likely to take antiretroviral therapy * and less likely to have an undetectable viral load. (1)

Reaching and keeping an undetectable viral load are the main goals of antiretroviral therapy. HIV-positive people with an undetectable viral load are less likely to get AIDS diseases and some serious non-AIDS diseases, and they are unlikely to pass HIV to partners during sex. Previous research found black gay or bisexual men with HIV less likely than white men to start antiretroviral therapy and less likely to reach an undetectable viral load. (2-5)

Health experts in the United States and across the world now recommend that people start antiretroviral therapy as soon as they test positive for HIV. At the same time, safer one-pill-once-daily antiretroviral combinations now make it easier for people to take their antiretroviral drugs on time with a lower risk of side effects. For these reasons, US researchers aimed to see whether rates of antiretroviral use and its impact on viral load have changed in black, white, and Hispanic gay or bisexual men with HIV.

How the study worked. Study participants came from the CDC-funded+ HIV Outpatient Study (HOPS). The HOPS has been collecting and analyzing data from HIV-positive patients in the United States since 1993. For this analysis researchers used data from HIV-positive men who agreed to participate in this study at 9 clinics in 6 cities across the United States. HOPS patients make regular clinic visits for routine HIV and primary care (physical exams, testing, and treatment). Every year participants are offered a brief HOPS survey with health-related questions. With patient consent, researchers can use information collected as part of HOPS participants' medical care for studies like this analysis of gay or bisexual men.

This study focused on men who reported that they had sex with other men and that they were black, white, or Hispanic. All men made at least two HOPS clinic visits, including one in 2014 or later, and all men had their viral load measured sometime between January 1, 2014 and December 31, 2015. A subgroup of men who had sex with men in the past 6 months completed a computer-assisted interview about antiretroviral pill-taking and sex behavior.

The main aim of the study was to see how many men reached an undetectable viral load (defined as a load below 50 copies). The study also determined who took antiretroviral therapy for at least 6 months. The researchers used an accepted statistical method to pinpoint factors that predicted who reached an undetectable viral load. They did this for all men and for men who took antiretrovirals for at least 6 months. This kind of analysis identifies individual factors that predict an undetectable viral load, regardless of whatever other risk factors a man may have.

What the study found. The study involved 1303 gay or bisexual men with HIV, 856 (66%) of them white, 308 (24%) black, and 139 (11%) Hispanic. Median (midpoint) age of the group stood at 50 years, and the group had taken antiretroviral therapy for a median of 10.1 years. These men had a median CD4 count of 607, most men (91%) were taking antiretroviral therapy at the time their viral load was measured, and about 60% had private insurance.

Compared with white men, blacks and Hispanics were younger (medians 52 white, 43 black, and 45 Hispanic) and took antiretrovirals for a shorter time (medians 11.9, 6.4, and 8.0 years). In this group of HOPS participants, blacks and Hispanics were more likely than whites to use public insurance (like Medicaid or Medicare) rather than private insurance, and more often received care at a public clinic rather than a private clinic (Table 1). All of these differences were statistically significant, meaning chance probably did not explain the difference.

A significantly higher proportion of black men and Hispanic men than white men were not taking antiretroviral drugs when viral load was measured for this study (Figure 1). A significantly lower proportion of blacks and Hispanics than whites had an undetectable viral load at the measurement closest to January 1, 2015 (Figure 1). And a significantly lower proportion of blacks and Hispanics than whites had all viral loads below 50 copies in the study year (Figure 1).

These differences between black and Hispanic men versus whites remained significant when the researchers limited the analysis of 1231 men taking antiretrovirals for at least 6 months. In other words, not receiving antiretroviral drugs did not explain the viral load differences between blacks and Hispanics versus whites.

In these 1231 men receiving antiretrovirals for at least 6 months, undetectable viral load rates were generally lower for younger men (under 40 versus older), for men with public insurance (Medicaid or Medicare) versus private insurance, and for men receiving care in public clinics versus private clinics-- regardless of whether men were black, Hispanic, or white.

Statistical analysis to determine the impact of several factors on chances of reaching an undetectable viral load took into account race, length of antiretroviral use, public versus private insurance, and CD4 count. This analysis determined that blacks had a 13% lower chance of reaching an undetectable viral load than whites--regardless of the other three factors. In the same analysis, Hispanics did not differ from whites in chance of reaching an undetectable viral load.

Among 485 men who completed the computer-assisted survey about sex behavior, 331 said they had sex with another man in the past 6 months. Among these 331 men, 194 (59%) said they had anal sex without a condom with an HIV-negative partner or a partner whose HIV status they did not know. Twenty-one of these men (6.3% of 331) may have had a detectable viral load when having condom-free anal sex with an HIV-negative partner or a partner whose HIV status they did not know. Because they may have had a detectable viral load, these men risked passing HIV to their sex partner when having sex without a condom.

What the results mean for you. This large study of gay or bisexual men in care for HIV in the United States made three major findings (Figure 1):

1. Higher proportions of blacks and Hispanics than whites were not taking antiretroviral therapy.

2. Lower proportions of blacks and Hispanics than whites had an undetectable viral load.

3. Lower proportions of blacks and Hispanics than whites had an undetectable viral load on all measures.

For all these comparisons, black men had worse results than Hispanics, and Hispanics had worse results than whites (Figure 1).

There are several possible reasons why black and Hispanic men had worse viral load results than whites. The study shows clearly that not getting a prescription for antiretroviral therapy did not explain the viral load differences. And for black men, relying more often on public insurance than private insurance or using a public clinic (reflecting lower income) did not explain the difference. However, the computer-assisted interviews of a subgroup of men found less consistent antiretroviral pill taking (adherence) by blacks and Hispanics than by whites.

Taking all antiretrovirals exactly as your provider directs is essential to reaching an undetectable viral load and to keeping the viral load undetectable. If you have trouble taking your antiretrovirals regularly-- because of side effects or other reasons--talk to your provider about it. Your provider can give you advice to help make pill-taking easier. Sometimes an antiretroviral causing side effects can be switched to another drug.

Other factors not measured in this study could also contribute to the worse viral load results in blacks and Hispanics. Those factors could include poverty, breaks in health insurance or too little insurance, worse access to health care, use or abuse of dangerous drugs, and mental health conditions like depression. If you have any of these problems, your HIV provider can help address them by referring you to a case worker or other specialists.

Once someone tests positive for HIV they should follow a step-by-step agenda that will ensure successful treatment:

1. Begin care for HIV infection.

2. Start antiretroviral therapy.

3. Take all antiretroviral doses exactly as your provider directs.

4. Reach and maintain an undetectable viral load.

5. Keep all medical appointments and remain in care for HIV infection.

6. Discuss difficulties in taking antiretrovirals or keeping appointments with providers and related healthcare professionals.

REFERENCES

(1.) Buchacz K, Armon C, Tedaldi E, et al. Disparities in HIV viral load suppression by race/ethnicity among men who have sex with men in the HIV Outpatient Study. AIDS Res Hum Retroviruses. 2018;34. Jan 9. doi 10.1089/AID.2017.0162.

(2.) Hall HI, Tang T, Johnson AS, Espinoza L, Harris N, McCray E. Timing of linkage to care after HIV diagnosis and time to viral suppression. J Acquir Immune DeficSyndr. 2016;72:e57-e60.

(3.) Paz-Bailey G, Pham H, Oster AM, et al. Engagement in HIV care among HIV-positive men who have sex with men from 21 cities in the United States. AIDS Behav. 2014;18(Suppl 3):348-358.

(4.) Hoots BE, Finlayson TJ, Wejnert C, Paz-Bailey G. Early linkage to HIV care and antiretroviral treatment among men who have sex with men--20 cities, United States, 2008 and 2011. PLoS One. 2015;10:e0132962.

(5.) Bradley H, Mattson C, Beer L, Huang P, Shouse RL. Increased ART prescription and HIV viral load suppression among persons receiving clinical care for HIV infection, 2009-2013. AIDS. 2016;30:2117-2124.

* Words in boldface are explained in the Technical Word List at the end of this issue.

([dagger]) CDC, Centers for Disease Control and Prevention.
Table 1. Use of public insurance and public HIV
clinics by race or ethnicity *

                   White   Black   Hispanic

Public insurance   24.9%   57.8%    37.40%
Public clinic      13.8%   64.0%    36.70%

* Use of public insurance (Medicaid or Medicare) and a public
clinic can indicate lower income.

Figure 1. In a study of 1303 US gay or bisexual men with HIV,
a lower proportion of white men than black or Hispanic men
were not taking antiretroviral therapy (ART) (left row). A higher
proportion of white men than blacks or Hispanics had an
undetectable viral load (VL) around January 1, 2015 (middle
row). And a higher proportion of white men than black or
Hispanic men had an undetectable viral load on all tests (right
row).

Treatment and viral load in US gay blacks,
Hispanics, and whites

          Not taking ART   Undetectable VL   All VL undetectable

White      21.1%             71.8%               52.3%
Hispanic   9.4%              80.6                66.2%
Black      5.1%              91.1%               71.5%

Note: Table made from bar graph.
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Title Annotation:ARTICLE 4
Publication:HIV Treatment: ALERTS!
Geographic Code:1USA
Date:Dec 1, 2018
Words:1775
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