From Our 2012 Archives
Despite Huge HIV Treatment Gains, Many Left Out
By Brenda Goodman, MA
Reviewed by Louise Chang, MD
Oct. 9, 2012 -- Newer drugs that fight HIV have cut AIDS death rates dramatically over the last two decades. But a new study shows that those gains have not been shared equally.
The study, published in the Archives of Internal Medicine, found that death rates have plunged over the last two decades for those who are well educated. But deaths among people with less education, which is usually an indicator of poverty, haven't really budged.
"It really is quite chilling," says researcher Edgar P. Simard, PhD, MPH, a senior epidemiologist with the American Cancer Society, in Atlanta.
The study looked at the education levels more than 91,000 adults aged 25 to 64 who died because of HIV between 1993 and 2007.
A new generation of medications called highly active antiretroviral therapies (HAART) first became available in 1996. Researchers were interested in how death rates had changed since the availability of the drugs.
Indeed, they found that overall death rates had dropped for all races. The biggest drops were seen among blacks, who also had the highest infection rates.
For example, among black men with a college degree, HIV deaths for every 100,000 people in the population plummeted from 117 before HAART to 15 after those medications became available. For similarly educated white men, those numbers slid from 26 to two.
But when researchers looked just at men and women with less education -- those who had gone no farther than high school, the numbers were alarming.
Black women with no more than a high school diploma saw almost no change in death rates from HIV over 15 years of the study. From 1993 to 1995, about 30 black women for every 100,000 people in the general population died of AIDS. From 2005 to 2007, that number was about 27.
"This is very, very striking and probably one of the bellwether findings of the study," says Simard.
Large Disparities in HIV Treatment
Though the drugs have made an impact, they aren't reaching people of all races.
For example, the study found that death rates from HIV among black men with no more than a high school education were still higher post-HAART than they were for high school-educated white men in the early 1990s, before the drugs were available.
Experts who were not involved in the study praised its methods, saying it sheds light on something about HIV treatment that often goes unnoticed.
William E. Cunningham, MD, MPH, a professor of medicine and public health at UCLA, has spent his career studying health disparities in HIV.
"I was not surprised, but I was really impressed by how stark the differences actually are," Cunningham says.
"It is this group of people who are black or Latino, but the differences are really the biggest for blacks, who are doing relatively poorly despite the fact that we have available much better treatment right now."
Solving the Problem
Simard says he thinks much of the disparity rests on diagnosis. He thinks too many people don't have access to HIV testing, or aren't aware that they need it.
According to a 2011 report from the CDC, about 1.2 million people are living with HIV in the U.S. About 240,000 people don't know they are infected.
Without a diagnosis, people don't get started on the drugs, which can help a person have a near-normal life expectancy in many cases.
"It's sounding an alarm. We see with people who have access to drugs that their mortality rates have really declined. Now this study has identified a number of really disenfranchised groups that need to have more focused interventions," so they can get access to the medications, he says.
Simard says proposed programs that could improve diagnosis include those that encourage so-called opt-out testing for HIV.
"When you go to a doctor, they don't say, 'Oh, I'm going to give you a test.' They only don't give it to you if you opt out," he says.
But those kinds of programs only work if people go to a doctor in the first place.
"I think that's why people are still falling through the cracks. There's no health care encounter," he says.
Beyond a diagnosis, economic instability can make it tough for people to stay on their medications, which are expensive, even with insurance.
Of those who do know they are infected, only 28% are getting regular medical care, taking antiretroviral drugs, and have the virus under control, according to the CDC.
"The benefit of starting these drugs early outweighs much of the detrimental effects of being on the drugs in the first place," Simard says. "If you adhere to the drugs as they're prescribed for the long-term, your survival will be much higher. You can have a near-normal life expectancy."
Other experts think the problem goes far beyond access to medication.
"It's certainly not simply about people not taking pills they already have. It's really all about the barriers to accessing the care that people actually need," Cunningham says.
He said those barriers include having reliable transportation to get to the doctor, being worried about taking time off work to get care, being depressed, not trusting the health care system or doctors, or not believing that medication really could make a difference in one's health.
"It's all these things that add up. It's people having overall difficult lives, and HIV just doesn't rise to the highest priority because HIV isn't going to kill them that day," he says.
SOURCES: Simard, E. Archives of Internal Medicine, Oct. 8, 2012. Cunningham, W. Archives of Internal Medicine, Oct. 8, 2012. Edgar P. Simard, PhD, MPH, senior epidemiologist, American Cancer Society, Atlanta. William E. Cunningham, MD, MPH, professor of medicine and public health, Center for Health Policy Research, UCLA, Los Angeles, Calif.