SEGMENT 4: D Dr. Freiberg discusses health disparities in HIV care.

Dr. Gary H. Gibbons, Director, National Heart, Lung, and Blood Institute:  You have described a very powerful platform and process for asking and answering questions. There is one other element that I am curious about, that relates to a programmatic priority of our institute. It relates to the diversity of the nation and health disparities. How have you addressed that, particularly since there is some heterogeneity? You move out of the VA system across various systems. As you say, you want to virtualize the United States of America; it is a nation with diverse degrees of access to care, systems and technology. How do you address that, as you try to put this data together? 

Dr. Matthew Freiberg, University of Pittsburgh:  When we think about HIV increasing cardiovascular risk, we compartmentalize it into four groups. We think about HIV the virus itself. We think about the treatment, and what it may mean by dyslipidemia insulin resistance. We think about the comorbidities that may travel with HIV, so higher rates of substance use such as smoking and/or alcohol, or other comorbidities, dyslipidemia, etc. But then there’s also this piece that is less well-studied, though there have been several papers that have come out in Circulation and others asking the question of whether disparities in care makes sense. 

Well, let’s think about that for a minute. We know in the United States anyway, that 50% of all new cases of HIV infection, I think last documented in 2010 on the CDC website, are African Americans and the majority of the people, for new infections, may be minorities. We know, outside the HIV realm, that there have been issues with disparities in the receipt of cardiovascular care between Caucasians and African Americans, as an example, and that minorities may be more susceptible to not getting the highest quality of care. That has been studied. 

When you think about HIV, at least in the VA, and I think most people would agree, it’s a vulnerable population for a lot of reasons. Let’s say you’re HIV-infected and that makes you vulnerable. Then you are African American or a minority, which may make you vulnerable. You put them both together, and it’s not a huge leap to suggest that these people may be susceptible to disparities in the receipt of care for a variety of reasons. 

Within the VA, quality of care has been a huge issue for a long time. I’m part of the Center for Health Equity Research and Promotion, which is a center of excellence within the VA that looks at disparities. We’re starting to ask, are HIV-infected people, and HIV-infected people and African Americans in particular has been one of our focus areas, are they receiving the same quality of care? We know, for instance, other studies have suggested—I remember in one national study the rates of receiving these interventions like PTCA or bypass grafts were less in the positive HIV infected people than the negative, uninfected people. 

We have shown in the VA that the receipt of lipid-lowering therapy was less among positives than it was among the people who met NCEP ATP3 criteria to receive such therapy. Now, it’s really important to understand that that doesn’t mean with one paper that is actually what is happening. There are a lot of things to understand. HIV-infected people by virtue of having potential high risk for liver disease, people may not be rushing to give them statin therapy if they’re concerned that the side effects of statins may hurt their liver because they’re hepatitis-C infected/HIV-infected may have alcohol. We need to dig deeper to understand that. 

When you look at the first pass superficially, there suggests there may be some signal there that’s worth pursuing. Because at the end of the day, if we spend all this time understanding how HIV works and we think, hey, it’s increasing their risk of cardiovascular disease, and we know it’s really important and we have to control it. But if at the end of the day people are not getting the medications that prevent it or the treatments they need after they have a heart attack, we are falling down at the finish line. The goal of the NIH is science and care; it’s both of these things. 

From our group’s perspective, and I believe I’m speaking for many others within our community, what we want to do is understand the mechanisms, because then we can come up with new interventions. But on balance, we also have things that we’ve learned in the general population, like controlling blood pressure, controlling lipids, controlling diabetes, smoking cessation, that are profound risk factors in this population. We know that reducing these risk factors will improve outcomes. We have therapies that work. There is no reason not to make sure that we are getting that done in this population, particularly because we believe they’re at higher risk. 

The VA has been a very good partner for us with that. They are very committed to that. They want to improve care, and that’s one of the great things about working in the VA is they are allowing us to have access to these data, helping us build these tools that we talked about earlier to get at some of these questions. 

So yes, I think quality and disparity of care within this community is something we’re definitely going to be looking at, and not only us, but I think other groups will as well. It should be, in my opinion, a model for everyone. Understand how the disease works, understand if it increases risk, and then once you think you have that, or if there are therapies right now you can improve the health of these people, you should be ensuring that as well. 

We’re trying to look as deep as we can within the VA for our veteran population to make sure that we are delivering that high quality care because they are vulnerable and because they are at high risk.