Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective

Abstract

Objectives: We examined changes in socioeconomic status (SES) and Black to White inequalities in HIV/AIDS mortality in the United States before and after the introduction of highly active antiretroviral therapy (HAART).

Methods: Taking a fundamental cause perspective, we used negative binomial regression to analyze trends in county-level gender-, race-, and age-specific HIV/AIDS mortality rates among those aged 15 to 64 years during the period 1987-2005.

Results: Although HIV/AIDS mortality rates decreased once HAART became available, the declines were not uniformly distributed among population groups. The associations between SES and HIV/AIDS mortality and between race and HIV/AIDS mortality, although present in the pre-HAART period, were significantly greater in the peri- and post-HAART periods, with higher SES and White race associated with the greatest declines in mortality during the post-HAART period.

Conclusions: Our findings support the fundamental cause hypothesis, as the introduction of a life-extending treatment exacerbated inequalities in HIV/AIDS mortality by SES and by race. In addition to a strong focus on factors that improve overall population health, more effective public health interventions and policies would facilitate an equitable distribution of health-enhancing innovations.

FIGURE 1

HIV/AIDS deaths per 100 000 population among (a) Whites aged 15 to 64 years and (b) Blacks aged 15 to 64 years, by age group and year: United States, 1987–2005.

FIGURE 2

Incidentrate ratios from negative binomial regression analysis comparing HIV/AIDS mortality among low-SES and high-SES counties during the pre-, peri-, and post-HAART periods: United States, 1987–2005. Note. HAART = highly active antiretroviral therapy; IRR = incident rate ratio; SES = socioeconomic status. For each period, the results from the model were adjusted for age, gender, and urbanicity. Low-SES counties were at the 95th percentile and high-SES counties were at the 5th percentile (reference group).

FIGURE 3

Incidentrate ratios from negative binomial regression analysis comparing HIV/AIDS mortality among Blacks and Whites during the pre-, peri-, and post-HAART periods: United States, 1987–2005. Note. HAART = highly active antiretroviral therapy; IRR = incident rate ratio. For each period, the results from the model were adjusted for age, gender, and urbanicity. Whites were the reference group.