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Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV.

AIDS 2023 December 15
BACKGROUND: Over 45% of people with HIV (PWH) in the United States ≥50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV-status can be explained by demographics, medical characteristics, substance use history, and geography.

METHODS: The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV-status could be explained by individual characteristics.

RESULTS: 6,250 PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol, and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting (adjusted hazard ratio [aHR]: 0.43, 95% confidence interval [CI]: 0.46-0.48, p < 0.001). Controlling for demographics, medical characteristics, substance use, and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, p < 0.001).

CONCLUSIONS: PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.

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