High HIV incidence among blacks in the United States has been reported by the Centers for Disease Control and Prevention, with blacks accounting for more than half of all incident cases of HIV in the United States.1 The proportion of infected blacks that are women or infants is higher than observed in other racial ethnic groups.1,2 The rate of HIV incidence among Hispanics has been reported to be 3 times higher than the rate reported in whites, with rising incidence in women.3 To our knowledge, this is the first report that compares HIV-associated infant mortality and HIV-associated mortality in women of childbearing age (15-44 years) among different racial/ethnic groups.
Deaths due to HIV were identified using national multiple cause-of-death data derived from death certificate data from each of the 50 states and the District of Columbia.4 Multiple cause-of-death files used International Classification of Disease (ICD-9) codes to describe causes of death from 1990 to 1998 and ICD-10 codes from 1999-2001.5,6 Deaths due to HIV were defined as all deaths for which the underlying cause of death or any of the contributing causes of death was coded with ICD-9 codes 042-0449 or ICD-10 codes B20-B249. Demographic information (age, sex, race/ethnicity, state of residence) was obtained from vital records for all deaths that met the case definition.
Information about the size and demographic breakdown (by age, sex, and race/ethnicity) of the United States population for each year from 1990-2001 was obtained from censal and intercensal year estimates with bridged race data.7-9 Denominator data divided the United States population into 5 racial/ethnic categories: white, Hispanic, Asian/Pacific Islander, black, and Native American/Alaskan Native.
Nationally, 745 HIV-associated infant deaths (86.2% of which listed HIV as the underlying cause of death) and 43,153 HIV-associated deaths in women ages 15-44 (89.8% of which listed HIV as the underlying cause of death) were reported in the United States from 1990-2001. Blacks comprised 69.5% of infant deaths from HIV (n = 518) and 62.0% of deaths occurring in women of childbearing age due to HIV (n = 26,745).
Infant mortality rates from HIV were considerably higher in blacks than in whites (rate ratio = 16.3; 95% CI = 13.5-19.7), as were mortality rates in women of childbearing age (rate ratio = 13.5; 95% CI = 13.2 -13.8). Though mortality rates in Hispanic infants and Hispanic women of childbearing age were lower than those observed in blacks, they were still higher than observed in whites and Asians (Table 1).
Comparing reported HIV mortality rates in 2001, at the end of the study period, with reported mortality rates in 1995, when highly active antiretroviral therapy (HAART) first became available, HIV-associated mortality in women of childbearing age decreased for all racial/ethnic groups (Fig. 1). However, the decrease was less marked in black women (decrease = 54%, 95% CI = 51-56%) than in white women (decrease = 70%, 95% CI = 67-73%), Hispanic women (decrease = 75%, 95% CI = 72%-79%), or Asian women (decrease = 79%, 95% CI = 49%-92%). HIV mortality rates in infants decreased from 3.0 per 100,000 population in 1994 (95% CI = 2.4-3.5) to 0.3 per 100,000 population in 2001 (95% CI = 0.1-0.5). Eight of the 12 HIV-associated infant deaths reported in 2001 occurred in blacks.
Despite overall decreases in HIV-associated mortality following the introduction of HAART, mortality among infants and women of childbearing age remains higher in blacks than in other racial/ethnic groups. Death certificate reporting of HIV has been found to be similar across racial/ethnic groups, suggesting that these discrepancies are not a result of bias.10 Misclassification of race/ethnicity occurs in only a small fraction of death certificates for whites and blacks and is not extreme enough among Hispanics to be the cause of the racial/ethnic differences we observed in mortality.11 The observed decrease in HIV mortality was less marked in black women of childbearing age than in women of other racial/ethnic groups. Further research should investigate why HIV mortality rates have not decreased as rapidly in black women as in women of other racial/ethnic groups, and whether more effective intervention strategies are needed.
Mother-to-child transmission (MTCT) of HIV can occur in utero, during birth, or though breastfeeding. A number of prevention strategies are available, and the use of HAART can reduce MTCT rates to <2% of births to HIV-infected mothers.12-14 Prenatal identification and treatment of HIV-infected mothers is essential for prevention of HIV transmission. While treatment and perinatal prevention are important in preventing HIV mortality in infants, infant mortality from HIV can also be prevented by reducing HIV prevalence in women of childbearing age. Continued high rates of HIV incidence and mortality in young black women suggest that considerable progress has yet to be made in this area.1,2
Observed mortality rates may be low due to underreporting. Racial/ethnic differences in the accuracy of death certificate reporting of HIV may have influenced rate comparisons between racial/ethnic groups. The use of vital records information did not permit us to assess morbidity from HIV or to examine certain important variables, including the treatment of individuals who died of HIV infection. The use of death certificate data, however, also contributed important strengths to the study, allowing for a population-based approach with high specificity.
It is not surprising that HIV mortality is higher in black infants and women of childbearing age; similar trends have already been noted for HIV incidence.1,2 However, the extent to which differing incidence rates are mirrored in mortality rates has not been reported, and little attention has been paid to elevated HIV incidence and mortality among Hispanic women and infants. Our findings indicate the need for increased emphasis on prevention of HIV mortality in black and Hispanic women and infants. Reduction of HIV prevalence in young women may also prevent infant mortality from HIV by reducing MTCT.
2. CDC. Increases in HIV diagnoses: 29 states-1999-2002. MMWR Morb Mortal Wkly Rep
4. National Center for Health Statistics. Data file documentations, multiple cause-of-death, 1990-2001. Machine readable data file and documentation, CD-ROM Series 20. Hyattsville, MD: National Center for Health Statistics. 1997-2004.
5. International Classification of Diseases. 9th revision. Geneva, Switzerland: World Health Organization; 1980.
6. International Classification of Diseases. 10th revision. Geneva, Switzerland: World Health Organization; 1992.
7. National Center for Health Statistics. Bridged-race intercensal estimates of the July 1, 1990-July 1, 1999, United States resident population by county, single-year of age, sex, race, and Hispanic origin, prepared by the U.S. Census Bureau with support from the National Cancer Institute. Available at: http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm
. Accessed April 24, 2004.
8. National Center for Health Statistics. Estimates of the July 1, 2000-July 1, 2002, United States resident population from the Vintage 2002 postcensal series by year, county, age, sex, race, and Hispanic origin, prepared under a collaborative arrangement with the U.S. Census Bureau. Available at: http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm
. Accessed August 2003.
9. Ingram DD, Parker JD, Schenker N, et al. United States Census 2000 population with bridged race categories. National Center for Health Statistics. Vital Health Stat
10. Chu SY, Buehler JW, Lieb L, et al. Causes of death among persons reported with AIDS. Am J Public Health
11. Kelly JJ, Chu SY, Diaz T, et al. Race/ethnicity misclassification of persons reported with AISA. AIDS Mortality Project Group and the Supplement to HIV AIDS Surveillance Project Group. Ethn Health
12. Gray J. HIV in the neonate. J Hosp Infect
13. Bulterys M, Fowler MG. Prevention of HIV infection in children. Pediatr Clin North Am
14. Cooper ER, Charurat M, Mofenson L, et al. Combination antiretroviral strategies for the treatment of pregnant HIB-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr