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October 3 -7, 2019
San Francisco, CA
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AIDS Mortality Does Not Differ by Race
in US Group--But "Room for Improvement"

  IDWeek, October 2-6, 2019, Washington, DC
Mark Mascolini
AIDS-attributable mortality did not differ significantly between blacks and whites in care for HIV in 1996-2011 at the University of Cincinnati [1]. Neither group had adequate HIV control in the months before death, and blacks had important clinical disadvantages compared with whites: lower CD4 count, higher percentage with substance use, and more missed visits. The researchers saw "substantial room for improvement" of mortality numbers in blacks and whites.
Some research indicates higher death rates in African Americans than in whites in the United States. But University of Cincinnati researchers who conducted this study found no published studies of attributable mortality by racial or ethnic group. They aimed to evaluate differences in attributable mortality between blacks and whites at their center in the first decade and a half of combination antiretroviral therapy.
This retrospective analysis involved people in care for HIV at the University of Cincinnati who died from 1996 through 2011. Everyone had to be self-reported African American or white and have sufficient medical data for the study. The researchers identified deaths reported to the Social Security national database. They used EuroSIDA CoDe methodology to assign attributable mortality to study participants.
During the study period, 275 blacks and 303 whites died. The white group included a significantly higher proportion of men (88.8% versus 80.7%) and lower proportions of women (10.2% versus 16.7%) and transgenders (1.0% versus 2.6%) (P < 0.02). HIV acquisition risk factors also differed significantly between blacks and whites (8.8% versus 6.3% drug injection, 24.3% versus 10.8% heterosexual, 48.9% versus 62.3% sex between men, P < 0.004). Blacks included a marginally higher proportion of substance users at HIV diagnosis (29.7% versus 19.8%, P = 0.0613). But the groups did not differ significantly in smoking, alcohol use, or weight, or AIDS diagnosis at HIV diagnosis (58.1% and 53.5%, P = 0.75). Follow-up was marginally shorter among blacks (4.5 versus 5.8 weeks, P = 0.0593).
Medical visit ratio (missed/missed + kept) proved low in both blacks and whites, but worse in blacks (0.15 versus 0.048, P < 0.0001). AIDS contributed to death in a marginally lower proportion of blacks than whites (45.5% versus 54.7%, P = 0.0862). But AIDS as a primary diagnosis noted in association with death was similar in blacks and whites (22% and 24%). Other primary mortality-associated diagnoses in blacks and whites were respiratory (9% and 7%), bacterial/sepsis (6% and 3%), cardiac (7% and 3%), kidney (5% and 2%), solid organ malignancy (4% and 4%), and hepatitis/liver (2% and 4%). Cause of death was not determined in 35% of blacks and 44% of whites.
Median viral load at HIV diagnosis was high in both blacks and whites (75,000 and 78,897 copies), and lower but still far from controlled at death (21,773 and 10,875 copies). Median CD4 count was lower in blacks than whites at HIV diagnosis (167 and 218) and at death (68 and 103).
The University of Cincinnati investigators concluded that blacks did not differ significantly from whites in AIDS-related attributable mortality occurring from 1996 through 2011, even though blacks had important prognostic disadvantages compared with whites: lower median CD4 count at diagnosis and within 3 to 6 months of death, higher percentage of substance use 3 to 6 months before death, and more missed visits.
The researchers stressed that HIV-positive people who died did not have well-controlled HIV replication regardless of racial group and that both groups frequently missed scheduled visits. They saw "substantial room for improvement in preventable mortality in people with HIV," including interventions to keep people engaged and retained in care and to improve HIV control. The Cincinnati team noted that findings may change as they analyze data from 2011 through 2018, when antiretroviral regimens improved.
1. Cihlar J, Fichtenbaum C. Comparison in AIDS related mortality between African Americans and whites with human immunodeficiency virus during the HAART era. IDWeek, October 2-6, 2019, Washington, DC. Abstract 1255.