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Racial and Ethnic Differences in Outcome in Zidovudine-Treated Patients With Advanced HIV Disease
Philippa J. Easterbrook, MD, MRCP, MPH;
Jeanne C. Keruly, RN;
Terri Creagh-Kirk, MS;
Douglas D. Richman, MD;
Richard E. Chaisson, MD;
Richard D. Moore, MD, MHS;
the Zidovudine Epidemiology Study Group;
John Bartlett, MD;
Grace Link, RN;
Sharon McAvinue, RN;
Yvonne Bryson, MD;
Helene Cohen, CNP;
Margaret Fischl, MD;
Terry Bolin;
Harold Kessler, MD;
Yvonne Burrough, RN;
Donna Mildvan, MD;
Alice Fox, PA;
Douglas Richman, MD;
Ben Freeman, LPN;
Gary Simon, MD;
Kathy Ward Grabowy, RN;
David Chernoff, MD;
Patricia Duff, RN;
Sumner Thompson, MD;
Kara Barrett, RN;
Robert Awe, MD;
Ruby Chapman, RN;
Shirley Leonard, RN;
Paul Turner, MD;
Marge Hawkins;
Henry Murray, MD;
Jill Bowers, RN;
Hugh H. Tilson, MD;
Elizabeth Andrews, PhD;
Lynn Smiley, MD;
Clifford Lane, MD, PhD
JAMA. 1991;266(19):2713-2718.
Abstract
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Objectives.
—To determine if racial-ethnic differences exist in survival, disease progression, and development of myelosuppression in zidovudine-treated patients with advanced human immunodeficiency virus (HIV) disease.
Design.
—Prospective observational study.
Setting.
—Hospital and private clinics in 12 metropolitan centers.
Patients.
—The study included 754 non-Hispanic white, 165 black, and 106 Hispanic patients with the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex (ARC) who received up to 2 years of zidovudine therapy.
Outcome Measures.
—Survival, development of Pneumocystis carinii pneumonia (PCP), other opportunistic infections, and myelosuppression.
Results.
—At initiation of zidovudine therapy, Hispanic and particularly black patients had more advanced HIV disease than white patients, as indicated by lower baseline CD4+ counts, hematocrits, and AIDS-defining diagnoses. Black patients with AIDS also had a worse prognosis compared with white and Hispanic patients with AIDS. The product-limit survival rates at 2 years for white, black, and Hispanic patients with AIDS were 40%, 27%, and 39%, respectively (black vs white, P =.01; Hispanic vs white, P =.32, by the log-rank test). The respective proportions of patients who developed PCP at 2 years were 46%, 66%, and 44% (black vs white, P =.0001; Hispanic vs white, P =.86) and for other opportunistic infections the proportions were 56%, 63%, and 63%, respectively (black vs white, P =.03; Hispanic vs white, P =.09). There were no significant racial-ethnic differences in survival or in the development of opportunistic infections for patients with ARC, and there were no differences in the incidence of myelosuppression or dose reduction or suspension for patients with either ARC or AIDS. After adjusting for more advanced HIV disease (mainly low CD4+ counts and hematocrits), black race was no longer a significant independent predictor of survival. Adjustment for racial differences in the use of PCP prophylaxis accounted for most of the excess risk for the development of PCP in black patients compared with white patients with AIDS.
Conclusions.
—Racial differences in survival and the development of opportunistic infections are mainly due to the more advanced HIV disease in black patients when zidovudine therapy is started and to their less frequent use of PCP prophylaxis. Innovative approaches are needed to ensure more widespread use of and earlier access to zidovudine therapy and PCP prophylaxis.
(JAMA. 1991;266:2713-2718)
Author Affiliations
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The Johns Hopkins University School of Medicine, Baltimore, Md; UCLA School of Medicine, Los Angeles, Calif; University of Miami (Fla); Rush Presbyterian-St Luke's Medical Center, Chicago, Ill; Beth Israel Medical Center, New York, NY; Veterans Affairs Medical Center, San Diego, Calif; George Washington University Medical Center, Washington, DC; University of California San Francisco AIDS Clinic; Emory University, Atlanta, Ga; Lyndon Baines Johnson General Hospital, Houston, Tex; Kaiser Permanente Medical Group, Los Angeles, Calif; Cornell University Medical Center, New York, NY; Burroughs Wellcome Co, Research Triangle Park, NC; National Institutes of Allergy and Infectious Diseases, Bethesda, Md.
From the Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md (Drs Easterbrook, Chaisson, and Moore, and Ms Keruly); the Burroughs Wellcome Co, Research Triangle Park, NC (Ms Creagh-Kirk); and the Departments of Medicine and Pathology, University of California, San Diego (Dr Richman).
Footnotes
Presented at the Seventh International Conference on AIDS, Florence, Italy, June 20,1991.
Reprint requests to The Johns Hopkins Hospital, 1830 Monument St, Room 8059, Baltimore, MD 21205 (Dr Moore).
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