Racial Disparity in HIV Mortality Hits Less Educated Hardest
October 8, 2012 — Blacks with a high school education or less continue to die from HIV at much higher rates than whites of any education level, despite the emergence of treatment that has reduced overall mortality, according to a study published online October 8 in the Archives of Internal Medicine.
Edgar P. Simard, PhD, MPH, senior epidemiologist, Surveillance Research Program, American Cancer Society, and colleagues looked at National Vital Statistics System records of 91,307 HIV deaths among people aged 25 to 64 years between 1993 and 2007. The researchers analyzed the data according to sex and individual education level, using education as a surrogate for socioeconomic status (SES). They compared death rates from 1993 to 1995 (before the emergence of highly active antiretroviral therapy [HAART]), with death rates between 2005 and 2007.
Although the high baseline rate of HIV infection in blacks led to a steep decline in the absolute number of HIV deaths with the emergence of HAART, the death rate among blacks remains considerably higher than the rate among whites.
Black women with a high school education or less showed no decline in the HIV death rate between 1993 to 1995 and 2005 to 2007. The death rate for black men with 12 or fewer years of education fell from 122.02 per 100,000 (95% confidence interval [CI], 114.67 - 129.38) during 1993 to 1995 to 52.71 per 100,000 (95% CI, 48.96 - 56.45) during 2005 to 2007.
Despite the improvement, the death rate in this least-educated group of black men is still considerably higher than the death rate among white men of all education levels before the emergence of HAART (26.54/100,000; 95% CI, 25.75 - 27.34) during 1993 to 1995, and even considerably higher than the rate among less-educated white men in 1993 to 1995 (25.77/100,000; 95% CI, 24.62 - 26.92).
"On the basis of these findings, we posit that non-Hispanic black men and minority women (ie, non-Hispanic blacks and Hispanics), and in particular those with low SES, 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," the authors write.
The authors also note that a previous study in a managed care organization failed to find racial disparities. Therefore, "[i]ncreased access to the health care system may be particularly important," the authors write.
Other contributing factors could include poor adherence to HAART or that some blacks are not receiving the therapy. A presence of comorbid conditions could also play a role.
Men with 16 years or more of education fared best among blacks and saw the largest absolute mortality decline of any segment in the study. However, even among the most educated blacks, the death rate was more than 8 times higher than in similarly educated white men and 3 times higher than in the least-educated white men.
The number of deaths among white men with 16 or more years of education fell from 26.42 per 100,000 (95% CI, 24.93 - 27.92) between 1993 and 1995 to 1.79 (95% CI, 1.50 - 2.08) between 2005 and 2007. The rate among blacks with 16 or more years of education fell from 117.89 (95% CI, 101.08 - 134.70) to 15.35 (95% CI, 12.08 - 18.62). The rate among whites with 12 or fewer years of education fell to 5.04 per 100,000 (95% CI, 4.59 - 5.50) between 2005 and 2007.
The disparity rate ratio among black men, comparing the least educated to the most, rose from 1.04 (95% CI, 0.89 - 1.21) from 1993 to 1995 to 3.43 (95% CI, 2.74 - 4.30) from 2005 to 2007. The disparity rate ratio among white men rose from 0.98 (95% CI, 0.91 - 1.05) to 2.82 (95% CI, 2.34 - 3.40).
"In addition, the black-to-white mortality disparities were generally similar across educational levels in both periods (1993-1995 and 2005-2007), highlighting racial disparities in HIV prevalence, treatment, and prevention within each level of education, which may be due to a combination of societal and environmental factors," the authors write.
In an accompanying editorial, William Cunningham, MD, MPH, professor, Department of General Internal Medicine, University of California, Los Angeles, School of Medicine, said the findings suggest a need to increase research into improved early detection methods, better treatment, and retention in care.
"However, the current level of commitment to this kind of research is frankly relatively small compared with the dedication of billions of dollars by the National Institute of Allergy and Infectious Diseases to basic research into HIV vaccines, for example," Dr. Cunningham writes.
The mortality rate for non-Hispanic black women fell slightly across all education levels, from 22.50 per 100,000 (95% CI, 20.75 - 24.24) to 16.97 (95% CI, 15.74 - 18.20). However, it did not decrease significantly in women with 12 or fewer years of education from 29.89 (95% CI, 27.14 - 32.63) during 1993 to 1995 to 26.76 (95% CI, 24.30 - 29.23) during 2005 to 2007.
The mortality rate for Hispanic men fell from 58.67 per 100,000 (95% CI, 52.21 - 65.14) to 8.09 (95% CI, 6.85 - 9.34) for all education levels.
The morality rate Hispanic women fell from 12.24 per 100,000 (95% CI, 9.60 - 14.87) to 2.32 (95% CI, 1.62 - 3.02) across all levels of education.
The authors have disclosed no relevant financial relationships.
Arch Intern Med. Published online October 8, 2012