AM Kilbourne, VA Pittsburgh Center for Health Services Research; D Zingmond, General Internal Medicine/Health Services Research, UCLA; AC Justice, VA Pittsburgh Center for Health Services Research; N Wenger, General Internal Medicine/Health Services Research, UCLA; M Rodriguez-Barradas, Health Services Research and Development Center of Excellence, VA Houston Healthcare System; L Rabeneck, Health Services Research and Development Center of Excellence, VA Houston Healthcare System; D Taub, Gerontology Research Center, National Institute of Aging, NIH; SA Bozzette,VA San Diego Healthcare System; S Weissman, VA Cleveland Medical Center; J Briggs,VA Cleveland Medical Center, Joseph Wagner, VA Pittsburgh Healthcare System, and Susan Smola, VA Pittsburgh Healthcare System

Objectives: Older HIV+ patients are often sicker than their younger counterparts at diagnosis, and age is a strong risk factor for HIV-related mortality. Survival differences may arise from under-identification of HIV-related symptoms or greater disease severity from additional comorbidities. Previous work in the HIV Costs and Services Utilization Study (HCSUS) suggests that survival differences are greatest for older nonwhites. The purpose of this study is to examine differences in disease expression between older nonwhite and younger white HIV+ individuals, by comparing results in HCSUS with a more recent cohort of HIV+ individuals in care within the VA system: the Veterans with HIV/AIDS Cohort Study (VACS). We wish to further explore results from HCSUS by comparing symptoms and HIV-related comorbidities reported by older nonwhite and younger white HIV+ individuals across the two cohorts, and compare symptom and HIV comorbidity findings with disease severity results.

Methods: VACS is a multi-site cohort of 881 HIV+ adults from Cleveland, Manhattan, and Houston VAs assembled between 6/99-7/00. HCSUS is a nationally representative sample of 2864 HIV+ adults receiving care in the U.S. interviewed 1/96-2/97. Patients in both studies were queried regarding symptoms and HIV-related comorbidities. Based on separate analyses of VACS and HCSUS data (HCSUS results were weighted to account for represented population), we compared the prevalence of 8 symptoms and 18 HIV-related comorbidities common to both studies, stratified by age and race: younger (<50) whites (reference group), older (>50) whites, younger nonwhites, and older nonwhites. Illness severity was assessed in VACS using provider-reported probability of 10-year survival and in HCSUS using CD4 count.

Results: VACS compared to HCSUS participants were more likely nonwhite and older (respectively 67% vs. 51% nonwhite-P<0.001; 44% vs. 10% >50 years-P<0.001). In both studies, older nonwhites were less likely to report experiencing common symptoms than younger whites (older white and younger nonwhite results were intermediate and will be presented). Symptom counts were lower among older nonwhites compared to younger whites (VACS: 3.5 vs. 4.4-P<0.001; HCSUS: 2.5 vs. 3.1-P=0.07) in both studies. In VACS and HCSUS, older nonwhites compared to younger whites were less likely to have common HIV-related comorbidities, including candida (VACS: 24% vs. 16%, P<0.05; HCSUS: 29% vs. 16%, P<0.01) and peripheral neuropathy (VACS: 23% vs. 13%, P<0.01; HCSUS: 28% vs 16%, P<0.05). In VACS, compared to younger whites, providers estimated lower probability of surviving 10 years among younger nonwhites (P<0.05) and older nonwhites (P<0.01). In HCSUS, compared to younger whites, younger nonwhites (P<0.01) and older nonwhites (P<0.01) reported lower CD4 counts.

Conclusions: VACS and HCSUS results consistently demonstrate that older nonwhites report fewer symptoms and HIV-related comorbidities than younger whites. However, in both studies, older, nonwhite participants appear more severely ill than younger whites, suggesting that HIV-related symptoms and conditions may be underreported.

Impact: As the HIV epidemic enters its 3rd decade, researchers are faced with an aging population of long-term survivors and newly infected older individuals, many of whom are nonwhite. Efforts to better understand the clinical manifestation of HIV among older nonwhite patients will improve HIV disease management and outcomes.