H.I.V. Death Rates Fell by Half 2010-2018, C.D.C. Says

November 21, 2020 

Deaths related to H.I.V. in the United States fell significantly from 2010 through 2018, regardless of sex, age, race or region, the Centers for Disease Control and Prevention reported on Thursday.

The death rate declined over all by about half, a welcome sign in the fight against the virus, experts said. But the data also highlighted some troubling trends: Gains among women, Black people and those of multiple races were much smaller. And the rate of death was about twice as high in Southern states as in the Northeast.

And it is possible the pandemic has dampened these improvements. The C.D.C. did not offer numbers on testing for H.I.V. or access to pre-exposure prophylaxis therapy over the past few months, but many facilities have shuttered their H.I.V. clinics or reported decreases in the number of people using their services, the researchers said.

Still, experts said the news was a testament to the enormous strides made in efforts to end the H.I.V. epidemic.

"The reduction in death is something that we couldn't have imagined even as recently as 2010," roughly a decade after the introduction of powerful antiretroviral drugs, said Dr. Jeanne Marrazzo, director of infectious diseases at the University of Alabama in Birmingham, who was not involved in the work. "The fact that these therapies have become so standard and turned things around for so many people is just incredibly gratifying and astonishing."

Dr. Marrazzo credited the success to investments in H.I.V. care, including through the federal Ryan White H.I.V./AIDS Program, for such services as nutritional support, social work, psychiatry and other assistance. "This is not just about the drugs. It's the entire structure that supports people," she said. "Sometimes that's lost in the dialogue."

From 1990 through 2011, deaths among people with AIDS decreased significantly. They dropped even more after 2012, when treatment guidelines began recommending antiretroviral therapy for anyone with H.I.V.

C.D.C. researchers analyzed data from the National H.I.V. Surveillance System from 2010 through 2018 of people older than 13 years who had received a diagnosis of H.I.V. They looked at raw numbers as well as age-adjusted rates of death per 1,000 people. They parsed deaths from 2010 through 2017 as resulting directly from H.I.V. or from other causes, including drug use, cardiovascular disease or other conditions.

The overall death rate among people with H.I.V. dropped by about one-third, the analysis found. But the rate of deaths directly related to H.I.V. decreased by 48.4 percent, or a decline to 4.7 deaths per 1,000 people with H.I.V., from 9.1 per 1,000, whereas deaths as a result of other causes fell by only 8.6 percent. The results were published on Thursday in the C.D.C.'s Morbidity and Mortality Weekly Report.

In 2017, more than 16,000 people with H.I.V. died, and about 5,500 of those deaths were from H.I.V.-related causes, positioning the virus among the 10 leading causes of death in certain groups.

"There's still work to be done," said Karin Bosh, the C.D.C. epidemiologist who led the study.

The earlier the diagnosis, the sooner people can get sustained care and treatment and suppress the virus in their body, Dr. Bosh said. For instance, the proportion of younger people dying from H.I.V. is higher than older people because younger people are less likely to have continuing access to care, either because they lack of health insurance, or because they don't seek care regularly.

"This is concerning, because H.I.V. deaths are preventable," Dr. Bosh said.

The lack of improvement in deaths from other causes is particularly worrying for women and substance users, other experts said.

"It really speaks to the things that we think work in public health -- mobilization and community engagement," said Dr. Eileen Scully, an infectious diseases physician at Johns Hopkins University. "And that is not how the epidemic has been among women in the United States."

Unlike gay men, women with H.I.V. "come from many different walks of life" and are often disconnected from networks of support, she said. "We still have a lot of work to do, both to build trust and to bring in particular, minority women into the health care system in ways that they feel safe and supported."

Race also played an outsized role in H.I.V. deaths, with the highest rates among Black people or those of multiple races.

Dr. Marrazzo compared the high numbers in the American South to the "Global South" -- resource-poor countries in sub-Saharan Africa and elsewhere that also cope with issues of stigma and opaque sexual networks, particularly among gay Black men.

"The fact is that a Black person living with H.I.V. in Mississippi is more than six times more likely to die of H.I.V. than a white person in New York -- and that's pretty astonishing, if you think about it," said James Krellenstein, executive director of the advocacy group PreP4All Collaboration.

Although "the top line numbers are impressive," he said, "this does point to a real crisis in the American health care system's ability to deliver H.I.V. treatment equitably."

Mr. Krellenstein also sharply criticized the C.D.C. for not closely tracking people's access to PrEP. Gilead Sciences, which manufactures the only two drugs approved for PrEP, reported an 8 percent drop in use of PrEP in the second quarter of this year, and an uptick of 4 percent in the third.

Some clinics, like Fenway Health in Boston, have reported a 20 percent decline in patients with PrEP prescriptions, researchers reported at an infectious diseases conference in July.

The C.D.C. should be gathering and reporting data on national trends in PrEP use, Mr. Krellenstein said. "It's not acceptable that they don't have an answer, and that no one really has an answer as to what's going on with PrEP."

Fenway Health, like many other clinics, also reported a steep drop in tests for H.I.V., a big worry, Dr. Marrazzo said. "The next step really is going to be continuing to ratchet up those people who are diagnosed, and diagnosed early," she said, because early treatment has been shown to be key to getting the virus under control.

"The earlier you can do it, the better."

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