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Mortality Among Blacks or African Americans with HIV Infection — United States, 2008–2012

Please note: An erratum has been published for this article. To view the erratum, please click here.

Azfar-e-Alam Siddiqi, MD, PhD1, Xiaohong Hu, MS1, H. Irene Hall, PhD1 (Author affiliations at end of text)

A primary goal of the National HIV/AIDS Strategy is to reduce HIV-related health disparities, including HIV-related mortality in communities at high risk for human immunodeficiency virus (HIV) infection (1). As a group, persons who self-identify as blacks or African Americans (referred to as blacks in this report), have been affected by HIV more than any other racial/ethnic population. Forty-seven percent of persons who received an HIV diagnosis in the United States in 2012 and 43% of all persons living with diagnosed HIV infection in 2011 were black. Blacks also experienced a low 3-year survival rate among persons with HIV infection diagnosed during 2003–2008 (2). CDC and its partners have been pursuing a high-impact prevention approach and supporting projects focusing on minorities to improve diagnosis, linkage to care, and retention in care, and to reduce disparities in HIV-related health outcomes (3). To measure trends in disparities in mortality among blacks, CDC analyzed data from the National HIV Surveillance System. The results of that analysis indicated that among blacks aged ≥13 years the death rate per 1,000 persons living with diagnosed HIV decreased from 28.4 in 2008 to 20.5 in 2012. Despite this improvement, in 2012 the death rate per 1,000 persons living with HIV among blacks was 13% higher than the rate for whites and 47% higher than the rate for Hispanics or Latinos. These data demonstrate the need for implementation of interventions and public health strategies to further reduce disparities in deaths.

Data from the National HIV Surveillance System for 2008–2012 and reported to CDC through June 2014 were used to determine the numbers of deaths and rates of death among black persons living with HIV aged ≥13 years at the time of death. Numbers and rates for the total U.S. population and for whites and Hispanics or Latinos were calculated for comparison. Two sets of death rates were calculated overall and by age, race/ethnicity and sex: 1) deaths per 100,000 population and 2) deaths per 1,000 persons living with HIV. The numerator for each rate was the estimated number of deaths by year of death. The denominators for the rates per 100,000 population were calculated using year-specific census or postcensus data (for persons aged ≥13 years) from the U.S. Census Bureau for the years 2008–2012 (4). For a given year (year X), the denominator for the rate per 1,000 persons living with HIV was calculated by adding the number of new HIV diagnoses among persons aged ≥13 years during year X to the number of persons living with diagnosed HIV aged ≥13 years at the end of the year X-1. For rates by HIV transmission category, only rates per 1,000 persons living with HIV could be calculated because the U.S. Census does not collect the data needed for calculating rates per 100,000 population. The number of deaths was statistically adjusted for reporting delays and missing transmission category (5).

In 2012, an estimated 8,165 (48%) deaths occurred among black persons living with HIV, which was 1.5 times the number of deaths among whites (5,426) and 3.2 times the deaths among Hispanics or Latinos (2,586). During 2008–2012, there was a consistent decline in the number of deaths and rates of death among blacks. The number of deaths decreased 18%, and rate per 100,000 population decreased 21%; rate per 1,000 persons living with HIV decreased 28%. Although deaths also decreased among other race/ethnicity groups, the decreases generally were greater and more consistent among blacks than among other races/ethnicities (Table 1).

In 2012, deaths per 1,000 persons living with HIV among blacks were higher among older persons compared with younger persons, with the highest rate (41.3) among those aged ≥55 years. By transmission category, among black males, the lowest death rate (per 1,000 persons living with HIV) was among males whose HIV infection was attributed to male-to-male sexual contact (15.3), and the highest rate was among males who had their HIV infection attributed to injection drug use (33.1). Among black females, the death rate among those with HIV infection attributed to heterosexual contact (17.9) also was lower compared with the rate among those black females with infection attributed to injection drug use (29.2). These patterns were consistent across all races/ethnicities (Table 2).

Racial/ethnic disparities varied among states. In 23 states and the District of Columbia, the death rate per 1,000 persons living with HIV in blacks was higher than that in whites, whereas in 27 states blacks had a death rate that was lower than that in whites. The rate among blacks was higher than that among Hispanics/Latinos in 37 states and the District of Columbia. In 2012, the highest and lowest rates per 1,000 persons living with HIV among blacks were in West Virginia (28.9) and Nebraska (9.3), respectively, and among the 10 states with the highest death rates per 1,000 persons living with HIV in blacks, seven were in the South. The highest and lowest rates per 100,000 population among blacks were in the District of Columbia (98.4) and Alaska (5.2), respectively, and the largest number of deaths (1,147) occurred in Florida (Table 3).

Discussion

The results of these analyses indicate that black persons living with HIV experienced higher numbers and rates of deaths during 2008–2012 than other races/ethnicities. However, the numbers and rates of death declined consistently during the same period. The death rate per 1,000 persons living with HIV among blacks decreased 28% during 2008–2012, more than the overall decline (22%) seen among all persons living with HIV. Other than among blacks, such a consistent decline was observed only among Hispanics or Latinos.

Despite differences in the magnitude of the death rates, the mortality pattern among blacks by age, sex, and transmission category was similar to that seen in other races/ethnicities. In all three races/ethnicities, the highest rates of death were observed in the oldest persons living with HIV infection (aged ≥55 years), who might have been living longer with HIV and had more complications from HIV, and who also might have a higher all-cause mortality because of their age. By transmission category, in all races/ethnicities, men who have sex with men had lower death rates than persons in most other transmission categories; whereas persons who had their infection attributed to injection drug use had the highest death rate. This finding is consistent with reports that persons who use injection drugs are more likely to have comorbid conditions and an increased all-cause mortality than nonusers of injection drugs (6).

Whereas the overall disparity in deaths per 1,000 blacks living with HIV compared with whites living with HIV has narrowed over the period covered by this analysis (from 37% in 2008 to 13% in 2012), in 2012, the death rate was still higher (20.5) among blacks compared with whites (18.1) and Hispanics or Latinos (13.9). In general, blacks with HIV are less likely to have their infection diagnosed, with 15% unaware of their infection in 2011 compared with 12% of whites (7). Among blacks whose HIV was diagnosed in 2012, 77% were linked to care, which was lower than the percentage among any other race/ethnicity; in 2011, the percentages of black persons living with HIV who were retained in care (48%) or who had a suppressed viral load (40%) were lower than the percentages among whites and Hispanics or Latinos (7).

The findings in this report are subject to at least one limitation. The report evaluates all-cause mortality in persons living with HIV and does measure mortality resulting from HIV. Therefore, the report does not allow for any direct evaluation of possible differences in quality of care among persons living with HIV, by race/ethnicity. However, because HIV infection causes immune suppression, which in turn results in fatal comorbidities such as cancers and opportunistic infections, all-cause mortality likely is a better indicator of the actual mortality experience than cause-specific mortality.

CDC, with its partners, has been pursuing a high-impact prevention approach to advance the goals of the National HIV/AIDS Strategy and to maximize the effectiveness of current HIV prevention and care methods (3). CDC also supports projects focused on blacks aimed at optimizing outcomes along the continuum of care, such as HIV testing (the first essential step for entry into the continuum of care) and projects that support linkage to, retention in, and return to care for all persons infected with HIV (8). The results of the analyses in this report show that, although disparities in mortality by race/ethnicity persist, the overall outlook for all persons living with HIV has improved, and the gaps between different races/ethnicities have narrowed. Focusing prevention and care efforts on minority populations with a disproportionate HIV burden could lead to further reduction, if not elimination, of health disparities, such as higher mortality, and help achieve the goals of the National HIV/AIDS Strategy.

1Division of HIVAIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (Corresponding author: Azfar-e-Alam Siddiqi, asiddiqi@cdc.gov, 404-639-5353)

References

  1. Office of National AIDS Policy. National HIV/AIDS strategy for the United States. Washington, DC: Office of National AIDS Policy; 2010. Available at http://aids.gov/federal-resources/national-hiv-aids-strategy/nhas.pdf.
  2. CDC. HIV surveillance report, 2012. Vol. 24. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/hiv/library/reports/surveillance.
  3. HIV prevention in the United States: expanding the impact. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/nchhstp/newsroom/hivfactsheets/future/index.htm.
  4. US Census Bureau. Population estimates [entire data set]. Washington, DC: US Census Bureau; 2014. Available at http://www.census.gov/popest/data.
  5. Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.
  6. Liappis AP, Laake AM, Delman M. Active injection drug-abuse offsets healthcare engagement in HIV-infected patients. AIDS Behav 2015;19:81–4.
  7. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2012. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/hiv/library/reports/surveillance.
  8. CDC. Secretary's minority AIDS initiative fund for the Care and Prevention in the United States (CAPUS) Demonstration Project. May 29, 2014. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/hiv/prevention/demonstration/capus.

What is already known on this topic?

In 2012, blacks accounted for 47% of persons who received a human immunodeficiency virus (HIV) diagnosis, and in 2011, they accounted for 43% of persons living with HIV. During 2008–2011 more deaths among black persons living with HIV occurred each year than among any other race/ethnicity.

What is added by this report?

During 2009–2012, the number of deaths among black persons living with HIV declined 18%, and the rate of death per 1,000 persons living with HIV declined 28%. In 2012, the number of deaths per 1,000 black persons living with HIV was 20.5 among blacks compared with 18.1 among whites and 13.9 among Hispanics or Latinos.

What are the implications for public health practice?

To achieve the National HIV/AIDS strategy's objective of reducing health disparities, efforts are needed to increase entry into and retention in care of black persons living with diagnosed HIV. Rates of death caused by HIV infection vary by geographic area, and efforts tailored to each area's unique needs and situations might be needed to reduce the rates of early deaths among blacks.


TABLE 1. Estimated number and rate of deaths of persons aged ≥13 years with diagnosed HIV infection,* by race/ethnicity — United States, 2008–2012

Race/Ethnicity

2008

2009

2010

2011

2012

No.

Rate per 100,000 pop.

Rate per 1,000 PLWH§

No.

Rate per 100,000 pop.

Rate per 1,000 PLWH§

No.

Rate per 100,000 pop.

Rate per 1,000 PLWH§

No.

Rate per 100,000 pop.

Rate per 1,000 PLWH§

No.

Rate per 100,000 pop.

Rate per 1,000 PLWH§

Black/African American

9,920

33.1

28.4

9,596

31.7

26.5

8,682

28.3

23.3

8,444

27.2

21.9

8,165

26.0

20.5

Hispanic/Latino

2,949

8.5

18.5

2,913

8.2

17.5

2,809

7.4

16.3

2,799

7.2

15.6

2,586

6.5

13.9

White

5,662

3.3

20.8

5,545

3.2

19.8

5,395

3.2

18.8

5,307

3.1

18.1

5,426

3.2

18.1

Other races

890

5.5

22.8

998

6.1

24.6

1,003

5.5

23.9

946

5.0

21.8

989

5.1

22.0

Total

19,421

7.7

23.7

19,052

7.5

22.5

17,890

7.0

20.5

17,496

6.8

19.4

17,166

6.6

18.5

Abbreviations: HIV = human immunodeficiency virus; PLWH = persons living with diagnosed HIV infection.

* Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. Deaths of persons with a diagnosis of HIV infection might have resulted from any cause.

Estimates include statistical adjustment that accounted for reporting delays, but not for incomplete reporting.

§ Rate per 1,000 population aged ≥13 years living with diagnosed HIV infection (PLWH). Denominator was estimated as (no. PLWH at the end of [year X-1]) + (no. new diagnoses during year X).


TABLE 2. Estimated number and rate of deaths of persons aged ≥13 years with diagnosed HIV infection,* by race/ethnicity and selected characteristics — United States, 2012

Characteristic

Black/African American

Hispanic/Latino

White

Total

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

Age at death (yrs)

13–24

141

1.8

4.7

33

0.3

3.7

30

0.1

4.1

215

0.4

4.4

25–34

710

13.0

10.8

205

2.4

6.4

254

1.0

8.2

1,227

2.9

9.0

35–44

1,324

26.0

14.1

417

5.5

7.9

788

3.2

11.7

2,696

6.7

11.9

45–54

2,698

50.0

21.0

927

15.7

15.4

2,160

7.2

17.9

6,123

13.8

18.9

≥55

3,292

41.8

41.3

1,003

14.8

31.5

2,194

3.5

29.6

6,905

8.4

35.7

Transmission category 

Males

 

 

 

 

 

 

 

 

 

 

 

 

Male-to-male sexual contact

2,257

15.3

940

9.4

3,189

15.1

6,777

14.0

Injection drug use

1,448

33.1

584

26.1

530

33.8

2,723

32.1

Male-to-male sexual contact and injection drug use

456

27.7

215

22.0

530

24.3

1,303

25.3

Heterosexual contact

1,182

24.6

205

14.8

254

26.7

1,719

23.2

Other**

40

12.2

18

12.4

57

25.5

124

17.0

Subtotal

5,383

36.4

20.8

1,962

9.7

13.3

4,559

5.5

17.5

12,645

9.9

18.0

Females

 

 

 

 

 

 

 

 

 

 

 

 

Injection drug use

847

29.2

251

26.3

401

30.8

1,611

29.7

Heterosexual contact

1,894

17.9

359

12.9

451

17.5

2,832

17.0

Other**

42

11.6

15

11.7

14

13.3

79

12.6

Subtotal

2,782

16.7

20.1

625

3.2

16.2

866

1.0

21.7

4,521

3.4

19.9

Total

8,165

26.0

20.5

2,586

6.5

13.9

5,426

3.2

18.1

17,166

6.6

18.5

Abbreviations: HIV = human immunodeficiency virus; PLWH = persons living with diagnosed HIV infection.

* Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. Deaths of persons with a diagnosis of HIV infection might have resulted from any cause.

Includes other races.

§ Estimates include statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.

Rate per 1,000 population aged ≥13 years living with diagnosed HIV infection (PLWH). Denominator was estimated as (no. PLWH at the end of [year X-1]) + (no. new diagnoses during year X).

** Includes hemophilia, blood transfusion, perinatal exposure, and risks factor not reported or not identified.


TABLE 3. Estimated number and rate of deaths of persons aged ≥13 years with diagnosed HIV infection,* by race/ethnicity and state/area of residence — United States, 2012

State/Area

Black/African American

Hispanic/Latino

White

Total

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

No.§

Rate per 100,000 pop.

Rate per 1,000 PLWH

Alabama

212

20.7

26.8

4

2.6

10.7

103

3.8

28.9

333

8.3

27.1

Alaska

1

5.2

14.5

1

4.1

21.1

7

1.8

23.2

13

2.3

21.1

Arizona

26

12.4

19.7

45

3.1

12.0

134

4.1

19.0

223

4.1

17.2

Arkansas

40

11.3

18.0

3

2.3

11.3

49

2.6

20.3

99

4.1

19.4

California

369

20.0

17.6

468

4.2

11.7

831

6.3

16.2

1,786

5.7

14.9

Colorado

15

9.5

9.5

28

3.4

12.0

56

1.8

7.6

106

2.5

9.1

Connecticut

72

25.1

21.1

46

11.8

13.7

77

3.5

22.5

200

6.6

19.1

Delaware

47

29.8

24.4

3

4.5

10.8

10

1.9

11.7

60

7.8

19.6

District of Columbia

255

98.4

21.7

17

34.1

17.0

19

9.4

7.8

298

54.0

18.9

Florida

1,147

47.6

23.5

306

8.4

14.7

538

5.5

18.8

2,047

12.4

20.3

Georgia

442

18.3

16.5

23

3.5

6.5

128

2.7

16.3

613

7.6

15.4

Hawaii

1

6.7

13.0

2

2.4

10.1

9

3.2

7.5

20

1.7

8.3

Idaho

0

0.0

0.0

0

0.0

0.0

20

1.8

29.3

20

1.5

22.9

Illinois

270

18.1

16.1

62

4.0

10.2

154

2.2

15.0

530

5.0

15.1

Indiana

65

13.7

19.2

6

2.2

8.8

106

2.4

21.3

187

3.5

19.8

Iowa

6

8.2

16.6

0

0.0

0.0

25

1.1

19.8

33

1.3

17.5

Kansas

14

10.4

18.8

4

2.0

10.4

26

1.4

17.3

49

2.1

17.2

Kentucky

50

18.0

26.4

2

2.5

7.4

79

2.5

23.9

135

3.7

23.5

Louisiana

337

28.8

26.1

7

4.0

8.3

114

4.9

23.7

471

12.4

24.9

Maine

0

0.0

0.0

0

0.0

0.0

8

0.8

8.5

10

0.9

8.2

Maryland

555

39.2

23.2

27

7.1

16.7

103

3.8

21.7

736

15.0

23.2

Massachusetts

54

15.2

9.7

63

12.2

13.4

121

2.8

14.8

244

4.3

12.8

Michigan

223

19.8

26.0

9

2.8

12.7

96

1.5

19.4

344

4.2

22.9

Minnesota

29

13.8

12.3

5

2.7

7.5

57

1.5

15.5

96

2.2

13.5

Mississippi

175

20.0

26.6

7

11.6

30.7

48

3.3

26.8

235

9.6

26.1

Missouri

94

16.9

18.2

6

3.4

9.0

115

2.8

19.8

222

4.4

18.6

Montana

0

0.0

0.0

1

4.9

62.0

4

0.6

13.5

6

0.7

14.0

Nebraska

4

6.9

9.3

1

0.9

4.7

13

1.0

12.8

22

1.4

12.0

Nevada

42

23.2

25.3

35

6.4

20.9

75

5.9

20.2

159

7.0

21.2

New Hampshire

0

0.0

0.0

3

8.6

17.4

12

1.2

15.0

16

1.4

13.6

New Jersey

416

44.1

22.4

141

10.9

14.4

155

3.5

19.3

759

10.2

19.5

New Mexico

3

10.9

25.7

24

3.2

19.0

16

2.2

17.3

54

3.2

20.7

New York

1,081

45.5

20.2

731

25.9

16.9

372

3.8

14.0

2,409

14.6

18.3

North Carolina

351

20.6

20.1

15

2.5

8.4

148

2.7

21.8

541

6.7

20.1

North Dakota

0

0.0

0.0

0

0.0

0.0

2

0.4

15.8

2

0.4

10.6

Ohio

137

12.1

16.4

12

4.4

11.9

189

2.4

21.0

347

3.6

18.3

Oklahoma

26

11.4

20.2

5

2.1

10.6

69

3.1

22.6

117

3.7

21.5

Oregon

6

10.1

15.5

9

2.7

12.9

78

3.0

19.4

98

3.0

18.4

Pennsylvania

321

29.2

20.5

89

15.4

18.0

243

2.8

24.5

701

6.5

21.9

Rhode Island

7

14.1

13.2

2

1.9

3.8

8

1.1

8.1

18

1.9

8.3

South Carolina

216

20.4

19.8

6

3.5

10.6

67

2.6

18.8

291

7.4

18.9

South Dakota

0

0.0

0.0

0

0.0

0.0

5

0.8

18.0

7

1.0

15.3

Tennessee

247

28.4

26.6

4

1.9

6.3

178

4.3

30.2

437

8.1

26.8

Texas

514

21.0

19.2

323

4.4

14.7

456

4.6

21.0

1,394

6.6

19.0

Utah

2

10.1

10.1

1

0.5

2.5

16

0.9

9.2

24

1.1

9.4

Vermont

0

0.0

0.0

0

0.0

0.0

3

0.5

6.6

4

0.7

7.9

Virginia

234

18.2

17.8

26

5.1

15.7

99

2.2

14.9

377

5.5

16.9

Washington

17

8.4

10.4

6

1.0

4.1

134

3.1

18.0

172

3.0

15.2

West Virginia

13

23.7

28.9

2

12.1

37.1

16

1.1

15.0

32

2.0

19.6

Wisconsin

27

9.9

13.3

6

2.6

9.6

29

0.7

11.5

65

1.4

11.8

Wyoming

0

0.0

0.0

0

0.0

0.0

5

1.1

27.4

5

1.0

19.2

Total

8,165

26.0

20.5

2,586

6.5

13.9

5,426

3.2

18.1

17,166

6.6

18.5

Abbreviations: HIV = human immunodeficiency virus; PLWH = persons living with diagnosed HIV infection.

* Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. Deaths of persons with a diagnosis of HIV infection might have resulted from any cause.

Includes other races.

§ Estimates include statistical adjustment that accounted for reporting delays, but not for incomplete reporting.

Rate per 1,000 population aged ≥13 years living with diagnosed HIV infection (PLWH). Denominator was estimated as (no. PLWH at the end of [year X-1]) + (no. new diagnoses during year X).



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