Not All Have Benefited Equally from HIV Therapy

A new study by American Cancer Society Senior Epidemiologist Edgar P. Simard, Ph.D., M.P.H., and colleagues finds that the widespread use of highly active antiretroviral therapy (HAART) has resulted in steep declines in HIV-related mortality (HIV infection is a risk factor for some solid cancers and lymphomas), but not all groups have benefited equally from its availability. Death rates declined over time between 1993 and 2007 for most men and women by race/ethnicity and educational levels, with the largest absolute decreases for nonwhites, but rates remain high among blacks. The study is published today in Archives of Internal Medicine.

Dr. Simard and his team examined trends in HIV mortality by individual levels of educational attainment as a proxy for socioeconomic status (SES) and by sex and race/ethnicity. The analysis included 91,307 deaths due to HIV from 1993-2007 among individuals 25 to 64 years of age in 26 states reported to the National Vital Statistics System.

We asked Dr. Simard about the study.

How did this work come to be?

The American Cancer Society studies disparities in cancer incidence and death rates to evaluate progress in the fight against cancer. The Society also monitors disparities in cancer risk factors, such as smoking and obesity, and in this case, HIV, infection, which is a risk factor for some solid cancers and lymphomas.

This study is the first to evaluate disparities in HIV death rates by the combined characteristics of sex, race/ethnicity, and individual-level educational attainment, which in fact really reflects socioeconomic status. Understanding how and among whom disparities develop can help make prevention programs more effective and can identify groups that require additional interventions.

What did we already know and not know about education and chronic disease mortality?

Monitoring disparities in chronic diseases is important because disparities may change over time due to a variety of factors, such as patterns of diagnosis and treatment. Previous studies of disparities in cancer death rates (for example, lung, colorectal, breast, prostate, and cervical cancers) by educational attainment have generally found that death rates tend to be higher among those with low versus high educational attainment, reflecting differences in risk factors and access to prevention, screening, and treatment.

HIV is now considered a chronic disease because people can live for many decades after diagnosis as a result of therapies that first became available in 1996. However, the extent to which HIV death rates vary by sex, race/ethnicity, and educational attainment was not previously known.

For our study, we looked at deaths from HIV and found there were significant drops in HIV death rates for most groups between 1993-1995 and 2005-2007, a time during which effective therapies became widely available. However, the drop in these death rates varied substantially by sex, race/ethnicity, and educational attainment.

Absolute declines (or the differences) in rates between the two calendar periods were greatest for nonwhites across all levels of education, likely as a result of the higher death rates among these groups at the beginning of the study. When we looked at relative declines within each racial/ethnic group by level of education (comparing rates among the least versus the most educated in 1993-1995 and 2005-2007), we found that changes were greatest for the most-educated non-Hispanic white and non-Hispanic black men and women. So, overall, nonwhites had the largest drops in HIV death rates, but changes were more pronounced for the most educated individuals.

The faster declines among the most educated resulted in widening inequalities in death rates, especially for non-Hispanic black men and women with low educational attainment. These findings likely reflect differences in access to HIV treatment, as well as differences in HIV rates among these groups.

What are the implications of this work? What can we do as a society, and perhaps as individuals, to address the gap?

These findings advance our understanding of the development of disparities between population groups (specifically for those with low education attainment) and provide information for clinicians and the public health community regarding which groups have the highest burden of HIV-related deaths and for whom additional interventions are needed. As individuals and a society concerned with health disparities we should encourage equitable access to prevention, screening, and treatment for all chronic diseases including HIV  as well as cancer.

Article: Arch Intern Med. Published online October 8, 2012.  (doi:10.1001/archinternmed.2012.4508).

About David Sampson

I am the director of medical and scientific communications for the American Cancer Society national home office.
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