Wide variations between US states in HIV mortality rates

There are large differences in HIV-related mortality rates between individual US states, according to research published in the online edition of AIDS. Overall, the highest mortality rates were seen in southern states and were up to twice as high as the rates recorded in states with the lowest mortality.

“Effective interventions are needed to address these interstate disparities as part of a comprehensive approach to controlling the HIV epidemic,” write the investigators.

The introduction of effective antiretroviral therapy in the US in the late 1990s led to a significant fall in the number of deaths in patients with HIV. However, the overall risk of death remains higher for HIV-positive patients compared to individuals in the general population.

Moreover, there is little information on differences in HIV-related outcomes between US states.

National statistics on HIV-related mortality show wide differences in mortality rates between states (from 0.8 to 8.3 per 100,000). However, these reports are potentially flawed because both HIV-positive and HIV-negative individuals are included in the denominator to determine HIV-related mortality in the population overall.

A more accurate way of determining mortality rates is to calculate case-fatality rates. This only assesses mortality in the HIV-positive population.

Therefore investigators conducted a study to determine case-fatality rates in 37 US states between 2001 and 2007. All these states used names-based HIV reporting. After controlling for age, sex, race/ethnicity and late diagnosis, the investigators compared case-fatality rates between individual states.

Overall, the HIV case-fatality rate was 21 per 1000 HIV-infected person years. The corresponding conventional HIV mortality rate was 6 per 100,000 person years.

Using the case-fatality rate substantially affected the position of some states in mortality ‘league tables.’ For instance, Wyoming moved up 27 places (from 36 to nine) and Iowa 17 places (from 34 to 17).

In contrast, some states with a large HIV prevalence moved down, in the case of New York by 27 places (from three to 30).

“New York’s conventional HIV death rate was the third highest among states examined attributable in part to its high HIV prevalence,” note the authors. “Its comparatively low case-fatality rate…suggests good secondary and tertiary prevention of HIV disease, which could in part be due to earlier screening or entry into care, better adherence to medical instructions, or better care, compared to many other states.

Colorado had the lowest adjusted case-fatality mortality. Twelve of the fourteen states in the South had case-fatality which was twice as high (for example Georgia, RR = 2.53; 95% CI, 2.27-2.80).

“We identified significant interstate differences in US HIV case-fatality rates, with rates in many southern sates being more than twice those in other states even after adjusting for differences in racial/ethnic and age distributions,” comment the investigators.

Case-fatality rates were significantly higher in black patients compared to white patients (p < 0.001).

The investigators calculated that the disparities between states meant that there were approximately 800 avoidable HIV-related deaths each year.

“Monitoring state-specific HIV case fatality rates could contribute to improved allocation of national and state resources for HIV-related care by focusing attention on states where better secondary and tertiary prevention of HIV is needed, such as those in the southern US,” conclude the researchers.