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

Abstract

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.