Correspondence

Race, Sex, Drug Use, and Human Immunodeficiency Virus Disease

N Engl J Med 1996; 334:123-124January 11, 1996

Article

To the Editor:

In their report, Chaisson and colleagues (Sept. 21 issue)1 suggest that their findings are inconsistent with our finding that lower income at base line was associated with shorter subsequent survival in our cohort of homosexual men infected with the human immunodeficiency virus (HIV).2,3 The following could explain the differences.

First, patients were recruited into the cohort of Chaisson et al. well after HIV infection had occurred. From the data in Table 2 of their article, it is clear that the majority of study participants already had late-stage HIV disease. For example, 75 percent of the participants had CD4 cell counts of less than 500 per cubic millimeter at enrollment, and almost 40 percent of the patients had received antiretroviral therapy before enrollment. In addition, over half the patients in this cohort had the acquired immunodeficiency syndrome (AIDS) at base line. In this situation, complex interrelations will exist between income, functional status, rate of disease progression, and comorbidity that can obscure subtle associations between socioeconomic status and survival. In our study, we were able to assess this relation in the subgroup of men for whom income data were collected before they acquired HIV infection.

Second, as the authors acknowledge, their subjects were impoverished, with a median annual income of $5,000 or less, forming a much more homogeneous group than ours with respect to income. The ability to discern associations involving income in such a group is attenuated, particularly since the hazard ratio is likely to be lower than ours, which itself was in the range of only 1.5. Interestingly, Chaisson and colleagues did find a protective effect of having a job at base line, a result similar to that of many studies that show a positive benefit of employment. They attribute this to confounding with impaired functional status, which is one possibility but not the only one.

Finally, the authors draw their conclusions on the basis of a very short follow-up (median, 1.6 years). We believe that to assess the strength of the association between socioeconomic status and mortality properly would require a substantially longer follow-up.

Robert S. Hogg, Ph.D.
Kevin Craib, M.Math.
Julio S.G. Montaner, M.D.
Martin T. Schechter, M.D., Ph.D.
British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC V6Z 1Y6, Canada

3 References

1. 1

   Chaisson RE, Keruly JC, Moore RD. Race, sex, drug use, and progression of human immunodeficiency virus disease. N Engl J Med 1995;333:751-756
   Full Text | Web of Science | Medline

2. 2

   Schechter MT, Hogg RS, Aylward B, Craib KJ, Le TN, Montaner JS. Higher socioeconomic status is associated with slower progression of HIV infection independent of access to health care. J Clin Epidemiol 1994;47:59-67
   CrossRef | Web of Science | Medline

3. 3

   Hogg RS, Strathdee SA, Craib KJ, O'Shaughnessy MV, Montaner JS, Schechter MT. Lower socioeconomic status and shorter survival following HIV infection. Lancet 1994;344:1120-1124
   CrossRef | Web of Science | Medline

To the Editor:

Chaisson et al. refer to a study by our group1 as showing striking differences in survival among people with AIDS. In fact, our population-based study of over 1000 women and nearly 2000 men with AIDS found that among nonusers of drugs, the adjusted hazard of death after a diagnosis of AIDS among women (1.09) was not higher than that among men (95 percent confidence interval, 0.90 to 1.33). Among drug users, women had a slightly lower adjusted hazard of death (0.84; 95 percent confidence interval, 0.72 to 0.98).

Although large differences in survival were not observed, the delivery of health care did differ substantially according to sex. The differences were most evident among nonusers of drugs. Although women who did not use drugs had more ambulatory visits than men in the year before the diagnosis of AIDS and were equally likely to receive care from an HIV or AIDS specialist, women were significantly less likely than men to receive zidovudine or prophylaxis for Pneumocystis carinii pneumonia in the year before the diagnosis of AIDS (P<0.001).

The conclusions of our paper and those of Chaisson et al. are quite similar. Both studies report that women and men with AIDS have a similar prognosis but that there are significant differences in the health care they receive.

Barbara J. Turner, M.D., M.S.Ed.
Leona E. Markson, Sc.D.
Jefferson Medical College, Philadelphia, PA 19107

Thomas R. Fanning, Ph.D.
New York State Department of Social Services, Albany, NY 12243

1 References

1. 1

   Turner BJ, Markson LE, McKee LJ, Houchens R, Fanning T. Health care delivery, zidovudine use, and survival of women and men with AIDS. J Acquir Immune Defic Syndr 1994;7:1250-1262
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We thank our colleagues for their comments about our study. Hogg and coworkers offer several suggestions regarding the differences in the association of income and survival between our study and theirs.1 As we noted, our patients were considerably poorer than those studied by Hogg et al., and this may have limited our ability to find significant differences in survival that were related to income. As Hogg et al. correctly point out, our patients very often had advanced HIV infection at base line and may have been impoverished by their illness. We were not able to assess the influence of previous income on the progression of disease. Nonetheless, in our cohort of treated patients we found that clinical and therapeutic factors were the major predictors of HIV disease progression and survival. Unfortunately, universal health coverage does not guarantee equal access to medical care. We have previously shown that the use of zidovudine varied substantially among patients with AIDS who were enrolled in Maryland Medicaid, despite the full prescription-drug coverage for all.2 In addition, we have also reported that race is significantly associated with the treatment of HIV disease, independently of insurance status or income level.3 Thus, important differences in access to medical care for HIV infection may exist even among patients with adequate health insurance.

Turner and coworkers point out that their study4 generally supports the findings of our paper. We agree. As we noted, however, Turner et al. did find substantial differences in survival within various demographic categories. For example, they found that the median survival after a diagnosis of AIDS among drug users 13 to 29 years of age was 19 months for women but 13 months for men. They also found significant differences between the sexes in the treatment of HIV infection with zidovudine and in prophylaxis against pneumocystis pneumonia. Our study was able to incorporate demographic data with important clinical variables, such as the CD4 lymphocyte count, in a diverse cohort of similarly treated patients. Both our study and that of Turner and colleagues underscore the importance of improving access to high-quality medical care for all people with HIV infection.

Richard E. Chaisson, M.D.
Richard D. Moore, M.D., M.H.Sc.
Johns Hopkins University School of Medicine, Baltimore, MD 21287-6220

4 References

1. 1

   Hogg RS, Strathdee SA, Craib KJ, O'Shaughnessy MV, Montaner JS, Schecter MT. Lower socioeconomic status and shorter survival following HIV infection. Lancet 1994;344:1120-1124
   CrossRef | Web of Science | Medline

2. 2

   Moore RD, Hidalgo J, Sugland BW, Chaisson RE. Zidovudine and the natural history of the acquired immunodeficiency syndrome. N Engl J Med 1991;324:1412-1416
   Full Text | Web of Science | Medline

3. 3

   Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994;330:763-768
   Full Text | Web of Science | Medline

4. 4

   Turner BJ, Markson LE, McKee LJ, Houchens R, Fanning T. Health care delivery, zidovudine use, and survival of women and men with AIDS. J Acquir Immune Defic Syndr 1994;7:1250-1262
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   U. M. Cowgill. (1997) The distribution of selenium and mortality owing to acquired immune deficiency syndrome in the continental United States. Biological Trace Element Research 56:1, 43-61
   CrossRef