Disparities among US states in HIV-related mortality in persons with HIV infection, 2001–2007

Abstract

Objective: To examine interstate variation in US HIV case–fatality rates, and compare them with corresponding conventional HIV death rates. Design: Cross-sectional analysis using data on deaths due to HIV infection from the National Vital Statistics System and data on persons 15 years or older living with HIV infection in 2001–2007 in 37 US states from the national HIV/AIDS Reporting System. Methods: State rankings by age-adjusted HIV case–fatality rates (with HIV-infected population denominators) were compared with rankings by conventional death rates (with general population denominators). Negative binomial regression determined case–fatality rate ratios among states, adjusted for age, sex, race/ethnicity, year, and state-level markers of late HIV diagnosis. Results: On the basis of 3 096 729 HIV-infected person-years, the overall HIV case–fatality rate was 20.6 per 1000 person-years [95% confidence interval (CI) 20.3–20.9]. Age-adjusted rates by state ranged from 9.6 (95% CI 6.8–12.4) in Idaho to 32.9 (95% CI 29.8–36.0) in Mississippi, demonstrating significant differences across states, even after adjusting for race/ethnicity (P < 0.0001). Many states with low conventional death rates had high case–fatality rates. Nine of the 10 states with the highest case–fatality rates were located in the southern United States. Conclusion: Case–fatality rates complement and are not entirely concordant with conventional death rates. Interstate differences in these rates may reflect differences in secondary and tertiary prevention of HIV-related mortality among infected persons. These data suggest that state-specific contextual barriers to care may impede improvements in quality and disparities of healthcare without targeted interventions.