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Invited Commentary
Nov 12, 2012

HIV Racial DisparitiesComment on “The Influence of Sex, Race/Ethnicity, and Educational Attainment on Human Immunodeficiency Virus Death Rates Among Adults, 1993-2007”

Author Affiliations

Author Affiliation: Department of General Internal Medicine, UCLA (University of California, Los Angeles) School of Medicine.

Arch Intern Med. 2012;172(20):1599-1600. doi:10.1001/2013.jamainternmed.613

Currently, there is great excitement and hope in the human immunodeficiency virus (HIV) prevention, care, and research communities regarding the conceivable end of AIDS, although not the end of HIV. The energy behind the recent wave of hope regarding the end of AIDS was apparent at the recent International AIDS Conference (AIDS 2012), as well as in the literature of the past several years and particularly of the last year.1 It is based on mounting, convincing evidence revealing that treatment with the current generation of powerful antiretroviral therapy (ART) is able to prevent progression to AIDS and to greatly reduce mortality among persons with HIV who are appropriately treated.2,3 When taken by the infected partner, ART is also highly effective at preventing HIV transmission to the uninfected partner.4 Consistent with these findings, ART has been shown to be effective at preventing acquisition of HIV infection during male-to-male sexual contact, a strategy known as PreP.5

However, there is a strong countercurrent to the enthusiasm for the prospects of a person living with HIV in the United States. That is because disparities among people of color have been observed for more than a decade during the era of highly active ART (HAART); specifically, African Americans and Latinos have higher HIV incidence rates6 or lower HIV treatment rates7 and worse health outcomes, including higher mortality, compared with whites.810 The literature is peppered with evidence demonstrating this trend, despite the overall reduction in mortality since the advent of HAART in the mid- to late 1990s and continuing into the first decades of the new millennium. A parallel but not entirely overlapping group of studies1113 has shown that groups with low socioeconomic status (SES) also have higher HIV incidence rates and higher HIV mortality on the basis of a wide number of different measures of SES, including income and educational level assessed at aggregate geographic area levels.

The article by Simard et al14 adds solid evidence based on individual-level data in the United States showing that between the period 1993 to 1995 (before HAART) and the period 2005 to 2007 (after HAART), mortality decreased for most men and women by race/ethnicity and educational levels. Also, the greatest absolute decreases were for African Americans and Latinos owing to higher baseline rates. However, of most importance for this discussion, among African Americans in the least educated group (ie, the lowest SES group), mortality remained the highest. As the authors note, more must be done to eliminate continuing racial/ethnic and SES disparities in HIV mortality in the United States.

The findings by Simard et al are based on a unique, methodologically sound analysis at the individual level, not merely at the geographic area level as in recent related research that the authors cite. Although the overall trend of decreased mortality due to HIV certainly is cause for applause, data on racial and socioeconomic disparities, such as those in the accompanying research, provide a cautionary note and a cause for action. Funders and some advocates are attracted at this time to supporting biomedical primary prevention research, such as administering ART to prevent primary infection. However, this is not a strategy that will reduce the incidence of HIV infection due to injection drug use, and it is unlikely that financing will ever be sufficient to provide ART to prevent primary infection for low-income persons. It might be more productive to devote resources to other strategies that are more likely to be effective in reducing the incidence of new infections in low-income persons of color, as well as to investigate the reasons for these disparities. We need a variety of different studies, including observational studies, as well as interventions to find the most effective and cost-effective interventions that can reverse this trend.

In this context, the efforts of the National Institute on Drug Abuse and other agencies at the National Institutes of Health to support research on innovative methods of addressing early detection, treatment, linkage, and retention in care are crucial.15,16 Addressing these issues is likely to be the key for low SES and racial/ethnic minority groups, such as African Americans and Latinos, and support for studies on these topics is to be applauded. Therefore, the current level of commitment to this research by the National Institutes of Health and other agencies is an important first step toward having a meaningful effect on the disparities in mortality that have characterized the epidemic from its inception. However, the current level of commitment to this kind of research is frankly relatively small compared with the dedication of billions of dollars by the National Institute of Allergy and Infectious Diseases to basic research into HIV vaccines, for example. The latter research focus, while also important, has an unclear direct benefit to addressing the real problems of underserved groups, such as African Americans and Latinos with low SES. Other agencies, such as the Centers for Disease Control and Prevention and the Agency for Health Research and Quality, as well as the Health Resources and Services Administration, have beenheroically attempting to address such issues but with relatively miniscule budgets that are constantly under threat of further cuts. The time has come for a major commitment of resources to address these shameful disparities in HIV outcomes in the United States. Without such a commitment, the field will be unable to attract a new generation of scholars who are naturally interested in this area but who need the prospect of a potential future career to consider it as their life's work. Although it is remarkable that a large volume of resources has been dedicated internationally to HIV prevention and treatment for black Africans through the President's Emergency Plan for AIDS Relief and other programs, there continue to be important disparities among minority populations in the United States that deserve greater attention than they have received thus far.

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Article Information

Correspondence: Dr Cunningham, Department of General Internal Medicine, UCLA School of Medicine, 911 Broxton Ave, Los Angeles, CA 90024 (wcunningham@mednet.ucla.edu).

Published Online: October 8, 2012. doi:10.1001/2013.jamainternmed.613

Conflict of Interest Disclosures: None reported.

Online-Only Material: Listen to an author interview about this article, and others, at http://bit.ly/OSqSNt.

References
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2.
Ray M, Logan R, Sterne JA,  et al; HIV-CAUSAL Collaboration.  The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals.  AIDS. 2010;24(1):123-137PubMedArticle
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Simard EP, Fransua M, Naishadham D, Jemal A. The influence of sex, race/ethnicity, and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007 [published online October 8, 2012].  Arch Intern Med. 2012;172 (20):1591--1598
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