1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62

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Erica lelong N Johnson 1 2 , Mollie P Roediger 1 3 , Michael L Landrum 1 2 , Nancy F Crum-Cianflone lelong 1 4 , Amy C Weintrob lelong 1 5 , Anuradha Ganesan 1 5 , Jason F Okulicz 1 2 , Grace E Macalino 1 , Brian K Agan 1 * and the Infectious Disease Clinical Research Program HIV Working Group
The electronic version of this article is the complete one and can be found online at: http://www.aidsrestherapy.com/content/11/1/10 Received: 24 August 2013 Accepted: 15 January 2014 Published: 24 January 2014
This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity. Methods
Participants in the U.S. Military lelong HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated lelong with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm 3 . Multiple lelong logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR). Results
1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated lelong in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). lelong Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk. Conclusions
No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions. Keywords: HIV; HAART; Race; Ethnicity; Indications for HIV treatment; Disparities in care; African Americans Introduction
HIV has become a treatable illness in the era of highly active antiretroviral therapy (HAART), and HAART is associated with a reduction in morbidity and mortality among those with severe immunosuppression [ 1 ]. There is increasing evidence that HAART is associated with reduced lelong mortality lelong among those initiating HAART at higher CD4 cell counts as well [ 2 - 7 ]. Thus the optimal timing of HAART initiation may result in a more robust immunologic and virologic response, which may improve outcomes. However there are factors other than the degree of immune suppression involved in the decision to start HAART.
Despite the known benefits of HAART, certain groups appear to be more vulnerable to treatment disparities, and these disparities have persisted over time. In a U.S. study of HIV-infected persons, delays of three or more months between diagnosis and an initial specialty encounter occurred more frequently among patients who lacked access to care at diagnosis lelong and among those of African American or Latino race/ethnicity [ 8 ]. Delays in the initiation of HAART and failure to receive PCP prophylaxis occurred more frequently among blacks or Latinos, women, and the underinsured compared with other HIV patients [ 9 ]. Among a national sample lelong of patients eligible to receive HAART by published guidelines, African American race/ethnicity, female gende