African American race and HIV virological suppression: beyond disparities in clinic attendance

Abstract

Racial disparities in clinic attendance may contribute to racial disparities in plasma human immunodeficiency virus type 1 : HIV-1) RNA levels among HIV-positive patients in care. Data from 946 African American and 535 Caucasian patients receiving HIV care at the University of North Carolina Center for AIDS Research HIV clinic between January 1, 1999, and August 1, 2012, were used to estimate the association between African American race and HIV virological suppression (i.e., undetectable HIV-1 RNA) when racial disparities in clinic attendance were lessened. Clinic attendance was measured as the proportion of scheduled clinic appointments attended (i.e., visit adherence) or the proportion of six 4-month intervals with at least 1 attended scheduled clinic appointment (i.e., visit constancy). In analyses accounting for patient characteristics, the risk ratio for achieving suppression when comparing African Americans with Caucasians was 0.91 (95% confidence interval: 0.85, 0.98). Lessening disparities in adherence or constancy lowered disparities in virological suppression by up to 44.4% and 11.1%, respectively. Interventions that lessen disparities in adherence may be more effective in eliminating disparities in suppression than interventions that lessen disparities in constancy. Given that gaps in care were limited to be no more than 2 years for both attendance measures, the impact of lessening disparities in adherence may be overstated.

Keywords: clinic visits; cohort studies; health status disparities; human immunodeficiency virus; viral load.

Figure 1.

Exclusion criteria applied to identify the 1,481 human immunodeficiency virus (HIV)–infected patients who were included in the analysis sample, University of North Carolina Center for AIDS Research HIV clinical cohort, 1999–2012. The numbers of patients who died and remained alive among the 1,481 included patients during the 1,456 person-years of follow-up that occurred during the window of 2–3 years after their first clinic visit are also included.

Figure 2.

Causal diagram for the influence of African American race on virological suppression, University of North Carolina Center for AIDS Research HIV clinical cohort, 1999–2012. Boxes represent conditioning.