Risk for HIV Infection in US Dips, but Racial Gap Still Wide

Marcia Frellick

February 24, 2016

BOSTON — The estimated lifetime risk of being diagnosed with HIV in the United States is now 1.01%, or one in 99 Americans, according to a new Centers for Disease Control and Prevention (CDC) analysis. That's down slightly from the 2004 estimate of 1.29%, or one in 78.

With these numbers, "policymakers and outreach workers can have a better understanding of the risks people are experiencing," Kristen Hess, PhD, from the CDC, told Medscape Medical News.

Clinicians can use the information to better explain risks overall and in subgroups, she added.

The results were presented here at the Conference on Retroviruses and Opportunistic Infections 2016.

Large Racial and Gender Gaps

Dr Hess and her colleagues from the CDC usedHIV diagnosis, mortality, and census population data to determine lifetime and age-conditional risk across the United States. The study is the first of its kind to break down risk by subgroup and by state.

Risk was much higher for males (one in 62) than for females (one in 221). And the racial gap was large as well. The highest lifetime risk was for black males (one in 20) and black females (one in 48).

The estimated lifetime risk for Hispanic and Latino males was one in 48, and for Hispanic and Latina females was one in 227. The risk for white males was one in 132 and for white females was one in 880.

Numbers were highest in the subgroup of men who have sex with men; the risk was one in two for black men, one in four for Hispanic men, and one in 11 for white men.

"It's already known that these groups account for the largest proportion of HIV diagnoses," Dr Hess said during a news conference after her presentation. "Presenting it in this manner can more effectively communicate the level of risk and large disparities to the general public."

The CDC numbers show that "we need to do more aggressive programming and outreach to people who are in our most vulnerable populations because we do have very highly effective prevention and we can change those numbers," said Susan Buchbinder, MD, director of Bridge HIV at the San Francisco Department of Public Health.

Estimates varied by state, from one in 51 in Georgia to one in 670 in North Dakota. The highest lifetime risk was in Washington, DC, at one in 13.

Those Infected Average 13 Fewer Years

Although the gap in expected lifespan between those with and without HIV is narrowing, it is still present, said Julia Marcus, PhD, from Kaiser Permanente Northern California in Oakland.

Antiretroviral therapy has greatly increased the lifespan of HIV-positive people, and now more than half are 50 years and older, she reported. However, life expectancy in this subgroup still falls below a normal lifespan.

In previous studies, life expectancies have been compared in HIV-positive people and the general population, but the results might have underestimated the lifespan gap because such studies did not directly compare people in the same healthcare system, Dr Marcus and colleagues point out.

In their study, the team compared life expectancies for those with and without HIV who were part of the Kaiser Permanente system in California.

They found that 20-year-olds with HIV were expected to live another 49.3 years (total age, 69.3 years), whereas 20-year-olds without HIV were expected to live another 62.3 years (total age, 82.3 years) — a gap of 13.0 years.

This is an improvement over estimates from 1996 to 2006, when the life expectancy of a 20-year-old with HIV was 36.0 years and of a 20-year-old without HIV was 62.3 years — gap of 26.3 years.

Complicating Risk Factors

When the analysis of 20-year-olds involved only HIV-positive people who received antiretroviral therapy early — when their CD4 counts were at least 500 cells/mm³, which is now recommended for everyone — the 13-year gap narrowed to 7.9 years, Dr Marcus reported.

This means that programs such as smoking cessation take on new importance in the HIV population. "We know that smoking is much higher among HIV patients," she said.

In fact, "a recent study out of Denmark has shown that smoking may be contributing more to HIV mortality than HIV itself," she told Medscape Medical News.

Dr Marcus said there might be other factors related to the shorter life expectancy in HIV-positive people, such as depression, cardiovascular disease, and cancer. "Those are comorbidities we want to look at in future studies to see if they actually explain that remaining gap," she said.

Jonathan Shuter, MD, professor of medicine in the division of infectious diseases at the Montefiore Medical Center in Bronx, New York, said he agrees.

"The fact that the lifespan of those with HIV infection did not match that of HIV-uninfected individuals, even when adjusted for smoking, viral hepatitis, and other substance use, is likely due to other unreported variables, such as poverty, educational status, stigmatization, and perhaps other medical diagnoses, such as hypertension and renal disease," he told Medscape Medical News.

"The good news is that most of the survival gap between the two groups is amenable to treatment, through effective cessation therapies for tobacco and other substances, as well as new medical treatments for viral hepatitis. As we work on optimally addressing these daunting challenges, it will certainly be appropriate to identify and target other factors that limit the survival of this vulnerable population," Dr Shuter explained.

Dr Hess and Dr Shuter have disclosed no relevant financial relationships. Dr Marcus reports receiving support from Merck.

Conference on Retroviruses and Opportunistic Infections (CROI) 2016: Abstract 52. Presented February 23, 2016.

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