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 excellent prognosis.
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.
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".
Simard EP et al. The influence of sex, race/ethnicity and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007. Arch Intern Med, online edition, 2012.
Cunningham W HIV racial disparities: time to close the gaps. Arch Interm Med, online edition, 2012.