Undocumented Hispanics With HIV Present Late But Do Well With Treatment

Daniel M. Keller, PhD

October 26, 2010

October 26, 2010 (Vancouver, British Columbia) — In a study from Texas, Hispanic people without legal residency (n = 186) were diagnosed later in the course of their HIV disease, but once they received treatment, they had outcomes at least as good as legally document Hispanic (n = 280), white (n = 170), and black (n = 984) people.

Thomas Giordano, MD, MPH, from the Department of Medicine at Baylor College of Medicine and the Houston Health Services Research and Development Center of Excellence, in Texas, and colleagues conducted a retrospective analysis of the database of patients who were naïve to antiretroviral therapy and who presented for a first intake visit at the Thomas Street Health Clinic from 2003 to 2009. The clinic is a large university-affiliated facility in Houston that treats HIV-infected people regardless of ability to pay.

The results were presented here at the Infectious Diseases Society of America 48th Annual Meeting.

Legal residency status was evidenced by the possession of a valid Social Security Number (which the authors note might or might not be an accurate indicator of status).

Undocumented Hispanics were generally younger than the other groups (82.9% had a median age of 30 years or younger), reported no injection drug use, presented with CD4 cell counts lower than the black and white groups (P < .0001), and had higher median viral loads than all other groups (P < .0001). They also had the lowest percentage of females and the highest percentage of Spanish-only speakers. The black group had the highest proportion with incomes below the federal poverty level.

Twelve months after the intake visit, undocumented Hispanics had a higher increase in CD4 counts and a higher proportion reaching a target of less than 400 virus copies/mL than documented Hispanics, blacks, and whites. All 4 groups had similar retention in care (calendar quarters with clinic visits); however, compared with undocumented Hispanics, black patients had significantly lower retention. A multivariate analysis revealed that blacks had a significantly lower odds ratio for retention in care and for achieving a viral load of less than 400 copies/mL.

Values at Baseline and at 1 Year

Population Baseline median CD4 count (cells/mL) Baseline median viral load (log10) Proportion reaching a viral load <400 copies/mL at 1 year (%)
Undocumented Hispanics 132 5.4a 82.4
Documented Hispanics 166 5.1a 78.2b
Documented whites 264 5.1a 80.8c
Documented blacks 226 5.0a 58.8d
a. significant difference between all groups
b. P = .45 vs undocumented Hispanics
c. P = .82 vs undocumented Hispanics
d. P < .0001 vs undocumented Hispanics

"Our main findings are that undocumented Hispanics with HIV infection in Houston are diagnosed with more advanced HIV disease than many other persons with HIV infection," Dr. Giordano said. "But once diagnosed, they did as well as or better than legal residents and American citizens. . . .  They stayed in care at the same rate, had the same amount of viral suppression, and had the same amount of immune recovery in response to HIV treatment as the documented Hispanic and the American-citizen Hispanic and white populations. And they actually did better than the black patients on those outcomes."

Joel Gallant, MD, professor of medicine and epidemiology in the Division of Infectious Disease at Johns Hopkins University School of Medicine in Baltimore, Maryland, said: "I think that was a really important study." He noted that a large segment of the country is against spending any public money on illegal immigrants. "And yet when you look at infectious diseases such as tuberculosis, sexually transmitted diseases, and HIV, not treating people has an enormous impact on the community [and] public health," he said.

Because the undocumented Hispanics presented with more advanced disease, it is logical to think to assume that they could not or did not know how to access diagnostic services, or that they accessed them and then did not follow up. "This showed that people who are undocumented delay access to healthcare, delay testing, could be spreading HIV during that time, but actually do very well once they get on treatment. I think regardless of what you feel about immigration, it's in our interests to be treating everybody who lives in our communities," Dr. Gallant emphasized.

Dr. Giordano agreed, and said that "healthcare systems, like our publicly funded clinic that gets federal, state, and local funds to care for patients, regardless of legal citizenship or legal residency and regardless of ability to pay, really do work. We conclude that improvements need to be made in HIV testing for overlooked and difficult to reach populations, like undocumented Hispanics. We have to make sure they get into care if diagnosed."

Finally, Dr. Gallant speculated why undocumented Hispanics do better with care than black citizens. He said people making the arduous trip north across the border are probably more robust and relatively healthier — given the fact that they have been able to make that journey. He said they are probably less afflicted with mental illness and homelessness, which are known to be associated with poor adherence and substance abuse, both risk factors for poor outcomes.

Dr, Giordano has disclosed no relevant financial relationships. Dr. Gallant reports receiving grant support and consulting fees from Gilead Sciences; receiving consulting fees from Abbott Laboratories; and being a scientific advisor to Bristol-Myers Squibb, Merck, Sangamo BioSciences, and Tibotec.

Infectious Diseases Society of America (IDSA) 48th Annual Meeting: Abstract 1127. Presented October 23, 2010.


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