Study examines trends in HIV mortality

Overall death rates due to human immunodeficiency virus (HIV) infection declined over time between 1993 and 2007 for most men and women by race/ethnicity and educational levels, with the largest absolute decreases for nonwhites, but rates remain high among blacks, according to a report published Online First by Archives of Internal Medicine, a JAMA Network publication.

Widespread use of highly active antiretroviral therapy (HAART) has resulted in steep declines in HIV-related mortality, but not all groups have benefited equally from its availability. Many factors influence racial and ethnic disparities in HIV mortality rates, including differentials in the prevalence of HIV infection, delays in diagnosis and an extended period before the initiation of HAART treatment, according to the study background.

Edgar P. Simard, Ph.D., M.P.H., of the American Cancer Society, and colleagues examined trends in HIV mortality by individual levels of educational attainment as a proxy for socioeconomic status (SES) and by sex and race/ethnicity. The authors' analysis included 91,307 deaths due to HIV from 1993-2007 among individuals 25 to 64 years of age in 26 states reported to the National Vital Statistics System.

"In this large population-based analysis of trends in HIV death rates, we document overall significant, yet different, absolute and relative declines in mortality by sex, race/ethnicity and individual-level educational attainment as a proxy for SES. There were strong declines for all groups except for non-Hispanic black women of low SES," the authors note. "Relative declines were generally greater for those with higher educational attainment and for non-Hispanic whites, and these trends resulted in widening gaps between these groups."

Among men with the most education, mortality rates per 100,000 population decreased from 117.89 to 15.35 in blacks vs. from 26.42 to 1.79 in whites. Rates were unchanged for the least-educated black women (26.76 during 2005-2007) and remained high for similarly educated black men (52.71), the study results show.

"Notably, HIV death rates among non-Hispanic black men with 12 or fewer years of education (52.71 per 100,000 population in 2005-2007) were higher than rates among similarly educated non-Hispanic white men before widely available HIV therapies (25.77 per 100,000 population in 1993-1995)," the authors note.

Among men, the disparity rate ratio (comparing the least and the most educated) increased from 1.04 during 1993-1995 to 3.43 during 2005-2007 for blacks and from 0.98 to 2.82 for whites, according to the results.

"We documented substantial absolute declines in HIV death rates during 1993-2007 for all groups, although relative declines were greatest among those with the highest vs. lowest levels of SES, leading to widening inequalities. Notably, HIV death rates remained markedly high among non-Hispanic black men of all SES levels and were unchanged for non-Hispanic black women in the lowest SES strata," the authors conclude. "These findings suggest the need for focused interventions and resources to facilitate the identification of high-risk individuals, as well as entry and retention into care for these most vulnerable groups affected by the HIV epidemic in the United States."

HIV Racial Disparities

In an invited commentary, William Cunningham, M.D., M.P.H., of the University of California, Los Angeles, writes: "Currently, there is great excitement and hope in the human immunodeficiency virus (HIV) prevention, care and research communities regarding the conceivable end of AIDS, although not the end of HIV."

"However, there is a strong countercurrent to the enthusiasm for the prospects of a person living with HIV in the United States. That is because disparities among people of color have been observed for more than a decade during the era of highly active [antiretroviral therapy] (ART) (HAART)," Cunningham continues.

"The article by Simard et al adds solid evidence based on individual-level data in the United States showing that between the period 1993 to 1995 (before HAART) and the period 2005 to 2007 (after HAART), mortality decreased for most men and women by race/ethnicity and educational levels. Also, the greatest absolute decreases were for African Americans and Latinos owing to higher baseline rates. However, of most importance for this discussion, among African Americans in the least educated group (i.e., the lowest SES group), mortality remained the highest. As the authors note, more must be done to eliminate continuing racial/ethnic and SES disparities in HIV mortality in the United States," Cunningham concludes.