AIDS Trends and HIV/AIDS Mortality

Highly active antiretroviral therapy (HAART) was introduced in 1996. These medications have been effective in the treatment of HIV infection and, since that time, have altered the natural progression of HIV infection. HAART has delayed the progression from HIV to AIDS and from AIDS to death for many people infected with HIV. Because of the widespread use of these HIV treatments, Louisiana, along with the rest of the nation, has seen declines both in the number of new AIDS cases diagnosed and the number of AIDS-related deaths. For this reason, AIDS surveillance data no longer accurately represent trends in HIV transmission. Rather, AIDS surveillance data now reflect differences in access to testing and treatment, as well as the failure of certain treatments. Consequently, AIDS incidence and deaths, since 1996, provide a measure for identifying and describing the populations for whom treatment may have not been accessible or effective.

AIDS Trends

From 1997 to 2000, the number of new cases declined steadily each year. However, the number of new AIDS cases increased in 2001 for the first time since the introduction of HAART in 1996 (Figure 13).

Figure 13: Trends in AIDS Cases
Louisiana, 1997-2001

In 2001, most of the new AIDS cases occurred in men (69%), blacks (75%), and persons ages 25–44 (66%) (Table 14). Although progression to AIDS may indicate disparities in access to care or the effectiveness of treatment, the proportional distribution of persons with a new diagnosis of AIDS is also related to the characteristics of persons living with HIV/AIDS. For example, if there were no disparities in the progression of HIV infection to AIDS, one would expect the characteristics of persons with a recent diagnosis of AIDS to resemble the characteristics of persons living with HIV in the preceding calendar year. In 2000, 68% of persons living with HIV (non-AIDS) were black (data not shown); however, blacks represented 75% of persons in whom HIV infection progressed to AIDS in 2001, which may indicate some disparities in access to testing and treatment.

The New Orleans region (Region I) is the largest region in the state. This area had the highest number of new AIDS cases diagnosed in 2001, as well as the largest population of persons living with HIV. However, in 2001, as in years past, the Baton Rouge region (Region II) surpassed the New Orleans region in rates of diagnosis of HIV/AIDS. In Louisiana, more than two thirds of persons with a new diagnosis of AIDS and persons living with AIDS reside in either the New Orleans or Baton Rouge regions.

Although the number of new AIDS cases has increased statewide, among patients enrolled in the ASD study in New Orleans, the occurrence of new opportunistic infections has generally declined over time (Figure 14). Although the proportion of patients with Pneumocystis carinii pneumonia (PCP) and Kaposi's sarcoma (KS) has declined significantly since 1995, this decline seems to have moderated in 2001. The proportion of patients with esophageal candidiasis has remained relatively stable.

Figure 14: Trends in Selected Opportunistic Infections
New Orleans, Adult Spectrum of Disease Study, 1993-2001

Mortality Trends

The mortality data that follow are presented in a variety of ways and are drawn both from surveillance data and vital statistics data. In some instances, data on the characteristics of persons living with AIDS has been included to provide context and to assist interpretation.

From 1999 through 2001, the estimated number of deaths of persons with AIDS has remained relatively stable (Figure 15). Since 1996, AIDS-related mortality has declined sharply, coinciding with the emergence of HAART. Although this decline has continued, the slowing of the declines in the number of deaths in recent years may reflect limited access to, or use of, health care services, and the limitations of current therapies among persons in care.

Figure 15: Deaths of Persons with AIDS
Louisiana, 1997-2001

In 2001, most of the persons with AIDS who died were men (72%), which is consistent with the fact that 78% of persons living with AIDS were men (Table 15). Although blacks represented 60% of persons living with AIDS in 2001, they made up 75% of persons who died. This disparity may indicate a disparity in access to, or use of, health care services or differences in the effectiveness of antiretroviral medications. Similarly, 32% of AIDS deaths were of persons living in Region II, although only 20% of persons living with AIDS reside in this region.

Data from the Louisiana Office of Vital Statistics on deaths that were attributed to HIV infection or AIDS were not yet available for 2001; therefore, the data in Table 16 are for calendar year 2000. The rates were calculated on the basis of overall population numbers in each group, and they describe the population-level effect of HIV/AIDS mortality on each subgroup. They do not address the differences among HIV-infected persons that could result in higher mortality in some groups than in others. To address this disparity, compare the distribution of deaths (Table 16) with the distribution of persons living with AIDS (Table 17).

In 2000, nearly 9 of every 100,000 persons statewide died of a cause related to HIV infection. The AIDS death rate among blacks was more than 7 times that among whites. More than half (57%) of all deaths due to HIV/AIDS were of black men. The death rate among black men was 6 times the rate among white men and more than twice that among black females. Rates were not calculated for other ethnic groups because of the small number of cases.

The greatest disparity in rates of persons living with AIDS and persons dying of AIDS is that between black men and white men. Although more than a third (34%) of persons living with AIDS in 2000 were white men, this group accounted for only 19% of deaths. In contrast, black men accounted for 42% of persons living with AIDS and 57% of AIDS deaths.

In 1999, the most recent year for which these data are available, HIV/AIDS was the 2nd leading cause of death in Louisiana among blacks aged 25–44 years. Statewide, HIV/AIDS was responsible for 13% of all deaths of blacks in this age group (Table 18). Nearly 3 times as many blacks aged 25–44, compared with whites in this age group, died of HIV/AIDS.

References
Fleming PL, Byers RH, Sweeney PA, Daniels D, Karon JM, Janssen RS. HIV prevalence in the United States, 2000. In: Program and abstracts of the 9th Conference on Retroviruses and Opportunistic Infections. February 18–24, 2002; Seattle, Washington. Abstract 11.

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