New US research has revealed enormous
differences in HIV mortality rates between patients according to their race and
social and economic status. Published in the online edition of the Archives of Internal Medicine, the study
showed that mortality rates are especially high among black patients of low
social and economic status.
“The time has come for a major commitment
of resources to address these shameful disparities in HIV outcomes in the
United States,” writes Dr William Cunningham of the UCLA Medical School in his
editorial accompanying the study, “there continue to be important disparities
among minority populations in the United States that deserve greater attention
than they have received thus far.”
Thanks to the availability of effective and
tolerable antiretroviral therapy, many people with HIV now have an
But not all groups in the US have benefited
equally from recent improvements in HIV treatment and care. Most strikingly, HIV
is the ninth most important cause of death among black people, but ranks only 24th
for white people.
A team of US investigators wanted to
determine the effect of race, sex and social and economic status on HIV
Mortality rates were analysed for the
period 1993-95 (before the introduction of effective HIV therapy) and 2005-07
(the modern antiretroviral therapy era). Data were obtained from 26 states for
people aged between 25 and 64.
Changes in mortality between the two
periods were compared according to sex, race and social and economic status.
The latter was defined by level of educational attainment: high school (least
educated); some college; graduate or postgraduate (most educated).
A total of 91,307 HIV-related deaths were
eligible for inclusion in the study.
The proportion of deaths involving white patients
declined between 1993 and 2007, while over the same period the proportion
involving black patients increased.
Regardless of sex or race, most deaths
occurred among people with the lowest levels of educational attainment, and
this proportion increased over time.
Nevertheless, there were significant
declines in HIV-related mortality for most groups. The largest absolute fall
was seen in black and Hispanic people. However, this was because these groups
had higher mortality rates at baseline.
Falls in HIV-related mortality were
greatest among the people with the highest level of educational attainment:
93% in white men and 88% in white women.
However, mortality rates were virtually
unchanged for the least educated black women (1993-95, 29 per 100,000; 2005-07,
27 per 100,000). Between 1993 and 2007 disparities in
mortality rates widened between the most educated white men and the least
educated white and black men.
In 2005-07 the mortality rate among the
most educated white men was 2 per 100,000 compared to a rate of 53 per 100,000
in the least educated black men.
The difference in mortality rates between
the most educated white women and the least educated black women widened from
being four times higher in 1993-95 to 18 times higher during 2005-07.
Within every educational category,
mortality rates remained significantly higher among black men compared to white
men. Among the most educated men, rates in black men were four times higher than
white men in 1993-95, but were nine times higher in the period 2005-07.
Strikingly, mortality rates among the most
educated black men in 2005-07 were more than three times higher than those seen
in the least educated white men (15 vs 5 per 100,000).
“We posit that non-Hispanic black men and
minority women…and in particular those with low social and economic status, may
be exceptionally vulnerable to HIV deaths owing to a combined lack of knowledge
of HIV prevention, lack of knowledge of their own HIV status, lack of access to
the health care system, social stigma, and marginalization,” write the authors.
They believe their 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 those
most vulnerable groups affected by the HIV epidemic in the United States".