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Understanding Disparities in HIV Outcomes to Drive Testing, Care Linkage Program Efforts

Jaime Rosenberg
Using 2 decades' worth of data, researchers were able to identify disparities in HIV outcomes across more than 25,000 people living with HIV in Tennessee.
With 45% of the people living with HIV in the United States residing in the South, and with the region accounting for over half of new diagnoses, it’s crucial for public health efforts to understand the populations and the disparities among them in order to drive targeted efforts to improve outcomes.

For example, in Tennessee, race, age, and certain risk behaviors play a role in the progression of HIV infection to AIDS and in the risk of death, according to a study published in The American Journal of Public Health.

The HIV epidemic is largely driven by injection drug use and male-to-male sexual contact. However, the study found that injection drug use on its own was linked to an increased risk of death. In fact, men who have sex with men (MSM) had less of a risk compared with heterosexual men.

Compared with MSM, those who had a history of injection drug use had a 27% increased risk of death, and heterosexual men had a 12% increased risk. Similarly, those who had a history of injection drug use and heterosexual men were more likely to have their HIV infection progress to AIDS compared with MSM.

The data comes from 2-decade’s worth of data on 25,645 people diagnosed with HIV in Tennessee between 1996 and 2016, 10,709 (41.8%) of whom remained alive and AIDS-free throughout the entirety of the study, 13,442 (52.4%) of whom were diagnosed with AIDS, and 1494 (5.8%) of whom died before an AIDS diagnosis. According to the authors, until this point, wide surveillance data has not been used to look at trends in disease progression or HIV outcome disparities after the introduction of antiretroviral therapy in the mid-1990s.

Analyzing the data, the researchers also found that race played a role in disease progression and mortality risk, with those who were black being more likely to have their HIV infection progress to AIDS and more likely to die of all causes compared with those who were white.

“The fact that black patients progress to death, whether overall or before being diagnosed with AIDS, more rapidly than white patients means that there should be redoubled efforts in intervening appropriately in the neediest populations,” wrote the researchers.

However, the researchers noted that the racial disparities observed in the study were less apparent than in other research. While other research has documented mortality rates that are as much as 30% higher among black patients, the current study found that black patients were 21% more likely to die compared with white patients. This could be a result of the work of the Ryan White HIV/AIDS Program, which served as a safety net for people living with HIV, the researchers explained.

Age also played a role in outcomes, with those dying before AIDS diagnosis more likely to be older than those who were diagnosed with AIDS, who were in turn older than those who remained AIDS-free.

"The trends, disparities, and outcomes assessed in our analyses will directly inform TDH [Tennessee Department of Health] program design and implementation," wrote the researchers, adding that "identifying the groups with the most rapid disease progression and quantifying the degree of disparity between key populations provide direction to funding and intervention priorities."


Rebeiro P, Pettit A, Sizemore L, et al. Trends and disparities in mortality and progression to AIDS in the highly active antiretroviral therapy era: Tennessee, 1996-2016 [published online August 9, 2019]. Am J Public Health. doi:10.2105/AJPH.2019.305180.

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