Death rates among people with HIV are more than twice as great in many Southern states compared with other states, even after adjusting for racial and age differences, according to a sobering new analysis reported by U.S. Centers for Disease Control and Prevention (CDC) researchers. The findings, published online ahead of print by the journal AIDS, also suggest that death rates among people with HIV are high even in states where people with HIV make up a small percentage of age-matched deaths documented in the general population.
HIV remains a major public health concern in the United States. About 53,000 new infections continue to occur annually, and while deaths due to HIV infection declined dramatically after the introduction of potent antiretroviral (ARV) therapy in the mid-1990s, the decline in death rates has slowed in recent years.
The National HIV/AIDS Strategy for the United States has prioritized the reduction of health disparities among demographic groups, notably women and people of color. However, such disparities may be largely dependent on geography, given that health care access varies with state policies regarding funding for medical care, prescription drugs and supportive services. Yet few studies have examined interstate disparities in HIV-related health outcomes in the modern-day treatment era. Such data are needed to refine funding streams in ways to help meet National HIV/AIDS Strategy goals.
To explore the important issue of geographic survival disparities, David Hanna, MS, and his CDC colleagues evaluated two sets of data in 37 states, representing 70 percent of the U.S. population, fully participating in the national HIV/AIDS Reporting System. They first looked at the rates of deaths of people living with HIV—deaths from any cause, not necessarily HIV-related health problems—compared with those of the general HIV-negative population. Then they looked at death rates exclusively among people living with HIV. In both analyses, interstate comparisons were made.
After adjusting for age, the researchers found that death rates among people with HIV, as a percentage of the general population, were highest in New York, New Jersey, North Carolina, South Carolina, Florida, Louisiana and Mississippi and lowest in northern Midwest states. These results are not surprising, as the states with the highest HIV-associated deaths are among the states with the highest HIV prevalence.
Of particular interest was the shift in rankings when the CDC team looked at death rates exclusively among people with HIV in the 37 states included in the analysis. For example, Wyoming’s rank moved up 27 places—whereas it had the second lowest number of deaths (36/37) of people with HIV in the general population, reflecting the low prevalence of HIV in that state, it had the ninth highest death rate (9/37), compared with other states, of people living with HIV dying.
Similarly, Iowa had the 34th lowest death rate of people with HIV, as a proportion of the state’s general population, but it had the 17th highest death rate when only counting people with HIV, compared with other states.
Rankings of death rates among people living with HIV also increased in Oklahoma, Arkansas, Alabama and Tennessee.
In states like New York and Connecticut, ranked 3rd and 12th in terms of HIV-associated death rates as percentages of the general population, death rates as percentages of people with HIV were among the lowest: They ranked 30th and 35th out of 37 states, respectively.
Other states demonstrated no major change in ranks. For example, Louisiana had the second highest rates of deaths of HIV-positive people, both in its general population and among its residents living with HIV, compared with other states. In Mississippi, Florida and the Carolinas death rates among people living with HIV were doubled those documented in many Northeastern, Midwestern and Pacific states.
The comparatively low death rates among people living with HIV in states such as New York and Connecticut, the CDC team writes, “suggests good secondary and tertiary prevention of HIV disease, which could be due in part to earlier screening or entry into care, better adherence to medical instructions, or better care, compared to many other states.”
In states where death rates are highest among residents with HIV, they add, the study findings “[suggest] that services to those with HIV may be inadequate.”
“The elimination of HIV-related health disparities is a national priority,” Hanna and his CDC colleagues conclude. “Our study shows that state of residence should be considered as a geographic unit of analysis when assessing disparities, in addition to categorizations like sex, race/ethnicity, and transmission category. Our findings also support earlier work identifying disparities in the [Southern United States] for earlier consequences of HIV infection, namely AIDS diagnosis. Examination of these rate disparities is a crucial step in addressing their causes, and can guide policymakers to consider area-level factors as well as individual factors when choosing interventions.”