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More Focus Needed on Prescribing Disparities for INSTI HIV Treatment


Data from 2 patient cohorts show that by increasing awareness of such influences as clinic location and patient age and transgender status, gaps in prescription decisions for integrase strand transfer inhibitors (INSTIs) can be lessened.

A new examination of 9558 persons living with HIV in Washington, DC, and Baltimore, MD, shows that despite HHS’ recommendation of integrase strand transfer inhibitors (INSTIs) as initial antiretroviral therapy (ART) for most patients, certain factors continue to influence clinician decision-making.

Findings from a study that looked at data from the Johns Hopkins HIV Clinical Cohort—for patients receiving their HIV care at the John G. Bartlett Specialty Practice at Johns Hopkins Medicine—and the DC Cohort—for patients receiving care at 15 clinics in Washington, DC—in particular show that patient age, whether they are transgender, and their clinic location may lead to INSTI prescribing disparities that are rooted in nonclinical reasons.

These results appeared in a recent issue of Open Forum Infectious Diseases.

“If disparities exist, they may be detrimental in terms of overall HIV outcomes because INSTIs are favored due to their potency and tolerability,” the authors wrote. “Our objective was to describe INSTI prescribing prevalence and examine disparities in INSTI prescribing in 2 different locations in the Mid-Atlantic States area.”

Among the study participants—all of whom had at least 1 HIV clinic visit from April 1, 2017, to March 31, 2019, and had been prescribed ART prior to that—most were aged 50 and older, a cisgender male having sex with another man, and non-Hispanic Black, with public insurance coverage. The investigators found that among the entire study cohort (n = 6839 currently taking an INSTI; n = 754 previously on an INSTI; n = 1965 never prescribed an INSTI), 79.4% had ever been prescribed an INSTI, and that of this group, 71.5% had a current prescription (dolutegravir, 47.9%; elvitegravir, 27.7%, bictegravir, 16.8%; raltegravir, 7.5%) and 7.9% had a previous prescription.

The investigators analysis produced these results:

  • Participants most likely to be currently taking an INSTI were cisgender heterosexual men (72.6%) and women (72.1%), aged 18 to 24 years (81.2%), Hispanic (73.3%), and uninsured (75.5%).
  • Those with previous INSTI prescriptions were most likely transgender women (10.6%), aged 50 and older (8.3%), non-Hispanic Black (8.0%), and on private insurance (9.5%).
  • Individuals never prescribed an INSTI were most likely transgender women (31.8%), aged 40 to 49 years (23.7%), of other/unknown ethnicity (26.1%), and uninsured (23.1%).
  • A majority of each group was virally suppressed (< 200 copies/mL)—78.7% currently taking an INSTI, 74.9% with a previous prescription, 78.2% never prescribed—and median years since their first HIV-related clinic visit were close to equal, ranging from 9.4 to 9.6.

Adjusting for covariates, the authors also found a 97% greater chance of being prescribed an INSTI from receiving care at Hopkins vs in DC (adjusted odds ratio [aOR], 1.97; 95% CI, 1.69-2.29) and a 115% greater likelihood of being a younger age (aOR, 2.15; 95% CI, 1.42-3.26). Alcohol use disorder and having mutations resistant to nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs were also associated with greater odds of having a current/previous INSTI prescription, at 29%, 85%, and 50%, respectively.

The odds of ever being prescribed an INSTI markedly dropped, however, if patients were transgender women (aOR, 0.62; 95% CI, 0.43-0.89) or had a longer HIV duration (aOR, 0.98 per 5-year increase; 95% CI, 0.97-0.99).

The authors wrote that their findings “uniquely add to the HIV medical literature” because they demonstrate INSTI use disparities, particularly on the part of transgender women and their clinicians who may express hesitation toward newer ART agents due to possible interactions with hormones. Transgender women also have a greater chance of facing health care–related discrimination, so they have poor care retention and a lesser likelihood of being virally suppressed, the authors noted.

“Identifying disparities may allow clinicians to focus their attention on these individuals,” they concluded, “and ensure that therapy decisions are grounded in valid clinical reasons.”


Monroe AK, Levy M, Greenberg AE, et al. Integrase inhibitor prescribing disparities in the DC and Johns Hopkins HIV Cohorts. Open Forum Infect Dis. 2021;8(8):1-5. doi:10.1093/ofid/ofab338

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