Higher mortality risk of publicly insured HIV patients in the US shows importance of screening for co-morbidities

Mortality rates are significantly higher among HIV-positive patients in the US whose care is paid for by public compared to private insurance, investigators report in the online edition of AIDS.

The study included individuals enrolled in the HIV Outpatient Study (HOPS) who received care between 1996 and 2007.

Among patients with a CD4 cell count above 200 cells/mm³, mortality rates were significantly higher in patients whose care was paid for by public insurance. This finding remained significant after controlling for potential confounders.

Non-AIDS-related illnesses were an important cause of death among patients relying on public funds, and the investigators believe that much of this mortality could be avoided with appropriate screening and care.

But their findings do not, the investigators stress, show that public-funded HIV care was inferior.

However, they do believe that they have important implications for current debates in the US about the funding of healthcare. They comment, “the population of persons whose access to healthcare was principally through public sources was significantly enriched in patients diagnosed with comorbidities – usually treatable and often preventable.”

Thanks to antiretroviral therapy the prognosis many patients with HIV now excellent. However, even with treatment mortality are higher for patients with HIV compared with individuals in the general population.

Few studies have investigated the factors associated with an increased risk of death for patients taking HIV therapy.

Therefore researchers from the HOPS study examined the medical records of patients who had at least two follow-up visits and had taken potent antiretroviral therapy for at least 75% of their time in care.

The 3752 patients eligible for inclusion in the study were predominantly male (84%) and racially diverse. Most (60%) were white, 29% were black and 12% Hispanic. The majority of patients (57%) had private insurance with 32% having public insurance. A history of substance abuse was reported by a third of patients, 54% were smokers, and 62% had an AIDS diagnosis at baseline.

Patients were followed for a median of 4.7 years. During this time a total of 311 individuals died, providing an overall mortality rate of 1.6 per 100 person years.

Initial analysis showed that publicly insured individuals had a higher risk of death than patients who had private insurance (p < 0.05).

Other factors associated with a higher risk of death were older age, injecting drug use, progression to AIDS, nadir and baseline CD4 cell count, a lower CD4 cell count at the time HIV therapy was started, a higher baseline viral load, co-infection with hepatitis B and/or hepatitis C, smoking, and lack of an HIV resistance rest.

Further analysis showed that it was only among patients with a CD4 cell count above 200 cells/mm³ that public versus private insurance was associated with an increased risk of death (adjusted harazard ratio, 2.03, 95% CI, 1.32-3.14).

“This finding suggests that the increased risk of death was not a consequence of HIV-related morbidity per se,” comment the researchers.

Causes of death were then examined by the investigators.

They found that that when compared to privately insured patients a higher proportion of deaths in publicly insured patients were due to cardiovascular disease (30% vs. 15%) and liver disease (24% vs. 12%).

Furthermore, compared to white patients, deaths in black patients were more likely (p < 0.05) to be due to cardiovascular disease (32% vs. 20%) or renal disease (23% vs. 7%).

An analysis of serious non-HIV-related illness in the patients who died showed that those with public insurance were more likely (p < 0.05) than patients with private insurance to have cardiovascular disease (26% vs. 13%), renal disease (25% vs. 13%), and hepatitis B/and or hepatitis C (48% vs. 18%).

Finally, the investigators looked at the characteristics of all patients with a CD4 cell count above 200 cells/mm³ and that publicly insured patients had a higher prevalence (p < 0.05) of hepatitis co-infections (29% vs. 9%), hypertension (35% vs. 19%), diabetes (7% vs. 2%) and chronic obstructive pulmonary disease (6% vs. 1%).

“Obesity and viral hepatitis coinfection as well as many other comorbidities that were differentially increased among publically insured…participants represent preventable often treatable conditions,” write the authors, “hence timely identification and treatment of comorbidities has emerged as an important component of HIV medical care.”