HIV-related disparities: it is not all about HAART accessibility.

Simple is not always true or useful in medicine and in particular in public health, where most phenomena have multiple determinants; the lack of data could complicate the attempt to understand some epidemiological situations and leaves an open territory for debate. Studies performed since the first years of the AIDS epidemic described one or more factors related to disparities in clinical outcomes of HIV-infected people; social status, gender, drug usage, sexual minorities, race/ethnicity are the determinants more frequently involved as explanations for these differences. The outcome of HIVinfected people was greatly improved after the introduction of the highly active antiretroviral therapy (HAART) in 1996. But, at the beginning, HAART was available only in some countries; the late and incomplete access to HAART in subSaharan Africa, the region with the largest number of people living with HIV infection, aggravated the racial disparities and the injustice feelings at the global level. Another factor contributed to this perception: even in developed countries, the access to medication was more difficult for people belonging to some minority groups. The situation could be considered as a denial of the right to health as it is defined in international treaties because of: unavailability of HIV-related structures, services or goods; existence of cultural/social/religious barriers to access prevention, diagnosis and/or treatment; disparities in accessibility and lack of quality of HIV management 1 In the past decade racial/ethnic disparities were registered in the United States, with a better clinical outcome for whites when compared with Hispanics or with black Americans, despite the general access to antiviral medication. However, many studies describe only the differences without any explanatory approach, allowing a hypothesis about inequities in the quality of antiretroviral treatment. An attempt to assess the differences in the quality of prescribed therapy was performed for the specific case of white and black people with HIV infection on antiretroviral treatment and the results are published in this issue of Southern Medical Journal. The selected indicator was the percentage of patients on treatment with antiretrovirals who received a HAART regimen. The analysis of a high amount of dataValmost 3 million HIV/AIDS patient visits for a period of 11 yearsVrepresents a very good way to obtain results with great statistical significance; the authors concluded that access to HAARTwas lower for black patients during the years 1996Y1999, but the access rates were similar for both groups of patients since 2000. The authors’ statement could be true, and probably it is related to the access to HAART. Unfortunately, the HAART/all antiretroviral regimens ratio is an imperfect indicator for quality of prescribed therapy. Indeed, some HAART regimens could be inadequate for a given patient due to some pre existing conditions or to opportunistic infections; for example a greater use of nonnucleoside reverse transcriptase inhibitors and a lower use of protease inhibitors (PI) in black American patients, as indicated by authors, could be scientifically sustained as related to more frequent associated infections (ie, tuberculosis); but the database doesn’t include such data and in their absence it is possible to speculate about a greater efficacy of regimens containing PI, more frequently prescribed for white patients. The authors themselves mentioned several other limits of their study: the absence of data concerning the disease stage at the moment of starting therapy (demonstrated to be related to life expectancy), the patients’ adherence to therapy and the missing visits with delayed failure diagnosis (determinants of durability of treatment success). In most parts of the world the same situation exists: equality of access, but disparities of HIV infection outcomes in some groups (ie, defined by age, social status, drug usage, ethnicity) due to the lack of adherence to treatment and to monitoring: virologic failures, viral multiresistance, and heavy burden of associate infections; the explanation often consists in a specific attitude concerning health status and health care. In other countries the formal rights do not imply a real accessibility to healthcare services because of medication shortages, the complete unavailability of medication or a restricted access related to nonmedical criteria. In 2008, the United Nations performed a global analysis of response to HIV at a national level; at least 84 of 133 reporting countries indicated some laws or policies that represent obstacles for the access to Invited Commentary