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HIV mortality across the 30 largest U.S. cities: assessing overall trends and racial inequities. Black people were approximately 2-8 times more likely to die from HIV compared to White people at both time points.
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Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015 - (06/09/21)
- The highest mortality rates per 100 person-years were observed for Black patients among cisgender men (1.8, 95% CI 1.7-2.0), and for Indigenous patients among cisgender women (3.0, 95% CI 1.7-5.4), respectively.
- In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05).
- Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.....cancers, depression, COPD.
- In adjusted analyses, Black and Indigenous cisgender men were approximately 1.5 times likelier to be hospitalized than White cisgender men, and transgender patients 1.4 times likelier than cisgender men
Medicare PLWH: Blacks & Latinos 4-Fold Greater Risk - (06/14/21)
HHS-Older PLWH Reduced Survival by 3.6 times & More Comorbidities - (06/14/21)
IAS: Aging PLWH & Higher Readmission Hospital Rates than the General Population Hospital Readmissions Fall in Big HIV Group But Still High vs Non-HIV Patients - (07/23/21)
Assessing the health status and mortality of older people over 65 with HIV - greater mortality, more comorbidities - (06/07/21)
These results showed that Medicare beneficiaries living with HIV have a significantly higher hazard of mortality compared to older people without diagnosed HIV (3.6 times the hazard).
- Adherence to treatment and viral suppression are both associated with better health outcomes [51]. Nonetheless, we found that older people with HIV have a higher overall hazard of mortality as well as a higher odds of having depression (2.7times higher), chronic kidney disease 2.3 times higher), COPD(1.67 times higher), osteoporosis (2.6 times higher), colorectal cancer, lung cancer, hypertension, ischemic heart disease (60% higher), diabetes (25% higher), chronic hepatitis, and end-stage liver disease compared to those without HIV, [look at table 5 below] even after adjusting for demographic characteristics. Some of these differences were quite large in magnitude, particularly for hepatitis and end-stage liver disease. Finally, we found that the incidence of diagnosis over time of every condition analyzed is higher for people with HIV, after accounting for the competing and differential risk of mortality.
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Black people were approximately 2-8 times more likely to die from HIV compared to White people at both time points.
- The Black:White mortality rate ratios (RR) indicate that the Black HIV mortality rate in the U.S. was over ten times the White rate in T1 (RR = 10.7, 95%CI[10.4-10.9]) and over nine times the White rate in T2 (RR = 9.5, 95%CI[9.3-9.8]) (Table 1). At the city level, all cities with sufficient data to calculate race-specific rates had statistically significant Black:White rate ratios at both time points.
- The worst performing cities were those with relatively high levels of overall mortality and high levels of inequity as measured by the Black:White mortality rate ratio (Figure 2). This quadrant included the following seven cities: Jacksonville, New York, Baltimore, Chicago, Houston, Charlotte, and Philadelphia. The remaining cities performed well in terms of either mortality or equity. Some cities had overall high mortality rates but a low degree of inequity, such as Dallas. Others had low overall mortality but high inequity, such as Louisville.
- Discussions with public health officials, health care providers, and HIV advocates in those model cities may reveal useful insight and guidance.
- Our analyses showed huge variability in HIV mortality and inequities within the most populous cities in the U.S. The positive news is that the vast majority of big cities saw significant improvements in HIV mortality between the first and second half of the previous decade. However, some big cities do not fare as well as others, with the highest HIV mortality rate (Baltimore) being almost 20 times higher than the lowest city rate (San Jose). The second critical finding concerns racial inequities in HIV mortality. In all of the cities in this analysis, Black individuals were approximately two to eight times more likely to die from HIV compared to White individuals in the most recent time period. Importantly, only one city (Charlotte) was able to statistically significantly reduce the racial inequity over time.
Multiple cities (such as San Diego, Indianapolis, Columbus, and Phoenix) experienced low total HIV mortality as well as relatively low racial inequities in HIV mortality at T2. However, we also found cities with both high total HIV mortality and a large racial inequity, including Jacksonville, New York, and Baltimore. Other cities either performed better than average for overall HIV mortality or inequities within.
Public Health Implications: Our analyses document huge variation in HIV mortality rates between the 30 largest cities in the U.S. and between Black and White populations in these cities. Importantly, we showed that while racial disparities existed across all cities and both time points, the degree of inequity differed substantially between cities. The city-specific data provided here can help motivate stakeholders, empower communities, and guide decisions related to funding, programs, and policies. Health advocates need this type of actionable data to achieve the national HIV priorities set forth by the Healthy People initiative, the National HIV/AIDS strategy, and Ending the HIV Epidemic: A Plan for America (HHS, 2015, 2019; HRSA, 2019). In countries like the U.S., HIV is a manageable chronic condition that should no longer be a substantial contributor to mortality. This has been largely realized within the White population and it is time to make this a reality for everyone living in the U.S.
HIV mortality across the 30 largest U.S. cities: assessing overall trends and racial inequities
14 Jun 2021 AIDS Care
ABSTRACT
Background
Despite decreases in overall HIV mortality in the U.S., large racial inequities persist. Most previous analyses of HIV mortality and mortality inequities have utilized national- or state-level data.
Methods
Using vital statistics mortality data and American Community Survey population estimates, we calculated HIV mortality rates and Black:White HIV mortality rate ratios (RR) for the 30 most populous U.S. cities at two time points, 2010-2014 (T1) and 2015-2019 (T2).
Results
Almost all cities (28) had HIV mortality rates higher than the national rate at both time points. At T2, HIV mortality rates ranged from 0.8 per 100,000 (San Jose, CA) to 15.2 per 100,000 (Baltimore, MD). Across cities, Black people were approximately 2-8 times more likely to die from HIV compared to White people at both time points. Over the decade, these racial disparities decreased at the national level (T1: RR = 11.0, T2: RR = 9.8), and in one city (Charlotte, NC).
Discussion
We identified large geographic and racial inequities in HIV mortality in U.S. urban areas. These city-specific data may motivate change in cities and can help guide city leaders and other health advocates as they implement, test, and support policies and programming to decrease HIV mortality.
Introduction
Following the introduction of highly active antiretroviral therapy (HAART) in 1996, HIV mortality rates among the U.S. population have significantly declined (CDC, 2020; National Center for Health Statistics, 2018; Singh et al., 2013). However, biomedical advances in treatment and prevention have not equally benefitted all Americans. Non-Hispanic Black (Black) Americans experience a mortality rate that is much higher than that for Non-Hispanic White (White) Americans. Indeed, after introduction of HAART, the HIV mortality disparity between Black and White populations in the U.S. widened as more White people had access to this life-saving therapy (Allgood et al., 2016; CDC, 2020; NCHS, 2017; Singh et al., 2013). For example, the Black:White national mortality rate ratio (a measure of inequality) grew from 4.3 in 1990-1994 to 11.4 in 2005-2009 (Allgood et al., 2016).
Inequity in HIV outcomes begins with unequal HIV incidence and prevalence among Black and White populations in the U.S. In 2018, the incidence of HIV in the Black population was 39.2/100,000 compared to 4.8/100,000 among the White population (CDC, 2020). The HIV prevalence rate was 1,034/100,000 for the Black population and 154/100,000 for the White population (CDC, 2020). Inequities are further exacerbated by Black:White disparities along the HIV care continuum, encompassing both primary and secondary prevention. These disparities include lower rates of: Pre-Exposure Prophylaxis (PrEP) use, linkage to and retention in HIV care, HAART use, and HIV viral load suppression among Black populations relative to White (Beer et al., 2016; CDC, 2020; Crepaz et al., 2018; Dasgupta et al., 2016; Hall et al., 2012, 2013; Kanny et al., 2019; Lee et al., 2017). Each of these activities is a potential point of intervention for cities looking to improve levels of equity within HIV mortality.
While understanding the inequities in HIV mortality between Black and White populations at the national level is important for identifying trends and setting goals, analyses of large geographic areas can mask considerable local variation. Although it is difficult to find HIV mortality rates at the state level, several previous studies have documented striking differences in rates at the county level (El Bcheraoui et al., 2018; McDavid Harrison et al., 2008; Rebeiro et al., 2019). In fact, HIV is the infectious disease with the highest between-county mortality differences in the U.S., ranging from 64.9 per 100,000 in Union County, Florida to 0.15 in Saint Croix County, Wisconsin (El Bcheraoui et al., 2018). Racial inequities in HIV mortality rates also vary widely between counties, though almost all showed higher Black rates than White rates, as well as increasing inequities over time (Levine et al., 2007). This wide geographic variability in HIV mortality rates, and racial inequities within, highlights the local nature of the epidemic, which demands a local response, guided by local data. Thus, data from even smaller geographic units are needed.
More specifically, city officials, public health professionals, funders, and other organizations need city-level data to enable them to make evidence-based decisions as it relates to the prevention of, and screening for, sexually transmitted infections like HIV (Cuffe et al., 2017; DeSalvo et al., 2017; Leichliter et al., 2016). This is particularly true for HIV mortality information, as over 95% of HIV positive individuals live in urban areas (CDC, 2020). It is the local departments of public health, and other city agencies and offices, who develop and enforce many health and social policies, provide related services, and allocate funding for these initiatives. Yet, while there are studies that examine HIV mortality within individual cities, or even neighborhoods, we only found one study that examined HIV mortality rates across US cities as part of a study investigating life expectancy in the 25 largest U.S. cities (Fenelon & Boudreaux, 2019). However, this study did not assess Black:White HIV mortality inequities (Fenelon & Boudreaux, 2019). The present study fills this critical gap in the literature by: (1) examining HIV mortality rates for the 30 largest U.S. cities; (2) assessing racial inequities in HIV mortality in these cities; and (3) comparing city-level trends in HIV mortality rates (and inequities within) over the past decade. Reducing overall HIV mortality and racial inequities in mortality are national priorities set forth by the Healthy People 2020 campaign, the National HIV/AIDS strategy, and the President's Ending the HIV Epidemic: A Plan for America (HHS, 2015, 2019; HRSA, 2019). City-level data on HIV mortality and mortality inequities can help guide the design of public health initiatives to achieve these ambitious public health goals.
Discussion
Our analyses showed huge variability in HIV mortality and inequities within the most populous cities in the U.S. The positive news is that the vast majority of big cities saw significant improvements in HIV mortality between the first and second half of the previous decade. However, some big cities do not fare as well as others, with the highest HIV mortality rate (Baltimore) being almost 20 times higher than the lowest city rate (San Jose). The second critical finding concerns racial inequities in HIV mortality. In all of the cities in this analysis, Black individuals were approximately two to eight times more likely to die from HIV compared to White individuals in the most recent time period. Importantly, only one city (Charlotte) was able to statistically significantly reduce the racial inequity over time.
Multiple cities (such as San Diego, Indianapolis, Columbus, and Phoenix) experienced low total HIV mortality as well as relatively low racial inequities in HIV mortality at T2. However, we also found cities with both high total HIV mortality and a large racial inequity, including Jacksonville, New York, and Baltimore. Other cities either performed better than average for overall HIV mortality or inequities within.
It is vital for each city to know which of these outcomes (i.e., mortality rates or equity in rates) needs the most attention because public health interventions aimed at improving overall health outcomes in a population differ from those needed to improve disparities in that outcome. For example, increasing the use of HAART can effectively lower viral load among individuals with HIV (thus, potentially reducing mortality); however, Black individuals are less likely to receive this type of treatment, potentially exacerbating racial inequities (Levine et al., 2007). Cities performing poorly in overall HIV mortality or equity (or both) can also look to cities that have lowered their mortality rates or achieved equity. Discussions with public health officials, health care providers, and HIV advocates in those model cities may reveal useful insight and guidance.
City health departments play a pivotal role in prevention of sexually transmitted infections such as HIV, especially those departments that are considered the safety-net systems of their jurisdiction (Cramer et al., 2014; Cuffe et al., 2017; Leichliter et al., 2016). City health departments are better able to tailor services to the needs of local populations at risk for HIV, compared to state health departments (Cuffe et al., 2017; Leichliter et al., 2016). Examples of this include efforts to improve HIV testing rates in Washington, DC, Houston, and the Bronx, and a targeted initiative to improve access to testing, diagnosis, and linkage to HIV care among transgender women of color that was implemented in nine U.S. cities, and CDC grants to the cities of San Francisco, Philadelphia, Baltimore, and Washington, DC to scale up HIV prevention services (Branson et al., 2018; Castel et al., 2012; Hallmark et al., 2014; Myers et al., 2012; Rebchook et al., 2017; Zigman, 2020).
Similar programs are needed to strategically target HIV mortality at the city level. An important first step in this process is the implementation of routine screening in healthcare settings, particularly emergency departments (ED). For many underserved populations, an ED visit may provide the only opportunity to learn one's HIV status. This critical juncture then provides another important opportunity - provision of linkage to care services. Patient navigation has been shown to be an effective model for engaging and retaining in care persons living with HIV, ultimately leading to viral suppression, the key to long-term health among this population (Cunningham et al., 2018; Mizuno et al., 2018). The data provided in this paper can help to identify where these critical resources are needed. In addition, the city-level mortality disparities presented here help to fill the knowledge gap left by previous investigations of local inequities across the HIV prevention and care continuums (Kay et al., 2016; Parsons et al., 2017).
Public health implications
Our analyses document huge variation in HIV mortality rates between the 30 largest cities in the U.S. and between Black and White populations in these cities. Importantly, we showed that while racial disparities existed across all cities and both time points, the degree of inequity differed substantially between cities. The city-specific data provided here can help motivate stakeholders, empower communities, and guide decisions related to funding, programs, and policies. Health advocates need this type of actionable data to achieve the national HIV priorities set forth by the Healthy People initiative, the National HIV/AIDS strategy, and Ending the HIV Epidemic: A Plan for America (HHS, 2015, 2019; HRSA, 2019). In countries like the U.S., HIV is a manageable chronic condition that should no longer be a substantial contributor to mortality. This has been largely realized within the White population and it is time to make this a reality for everyone living in the U.S.
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