Vital Signs: Deaths Among Persons with Diagnosed HIV …

Discussion

By 2018, the rate of death among PWDH in the United States had decreased by 36.6% from what it was in 2010, surpassing the 2020 national target of ≥33% (7). This decrease, which was primarily attributable to reductions in HIV-related deaths, likely reflects the increase during 2010–2018 in the proportion of persons who knew their serostatus from 82.2% to 86.2% and the implementation of updated treatment guidelines resulting in increased viral suppression among PWDH from 46.0% to 64.7% (6,8). Absolute and relative differences in HIV-related deaths among Black persons and Hispanic/Latino persons, compared with those among White persons, also decreased during 2010–2017. This reduction likely reflects a greater relative improvement during 2012–2017 in the time from diagnosis to viral suppression among Black persons, compared with White persons (9), and reduced disparities during 2010–2016 in viral suppression among Black persons and Hispanic/Latino persons, compared with White persons (10). These findings highlight how successes in identifying HIV infections, initiating treatment, and achieving viral suppression among PWDH improve health outcomes.

Despite success in reducing rates of HIV-related deaths among PWDH, differences still exist by gender, race/ethnicity, age, transmission category, and region. Variation in timely diagnosis and treatment initiation, along with ongoing treatment, likely contributes to differences in HIV-related deaths. During 2015, delays in HIV diagnosis were longer among non-White racial/ethnic groups and males with HIV infection attributed to heterosexual contact (11). Timely initiation of treatment, as measured by the proportion of persons with suppressed viral loads ≤6 months after diagnosis, and receipt of ongoing, recommended treatment, as measured by the proportion of PWDH with a suppressed viral load, varied during 2017 by gender, age, race/ethnicity, transmission category, and region (8,12); populations with higher rates of HIV-related deaths were less likely to have evidence of timely initiation of treatment and ongoing treatment as demonstrated through lower proportions of viral suppression in the population.

Prevalence of HIV infection and the number of HIV-related deaths were greatest by race/ethnicity among Black persons and by U.S. region in the South (4). Rates of HIV-related deaths were also high among these two populations. Higher levels of poverty, unemployment, and persons uninsured, challenges associated with accessing care, and HIV-related stigma likely affect timely diagnosis and access to treatment and contribute to higher rates of HIV-related deaths (13,14). Expanded efforts to address these and other structural barriers are critical to improving health outcomes, including reducing differences in HIV-related death rates, especially among Black persons and persons in the South.

Although rates of HIV-related deaths were lower among younger PWDH, the proportion of HIV-related deaths among younger PWDH (ages 13–44 years) was higher than that among older PWDH; this is concerning because HIV-related deaths are preventable. Higher proportions of undiagnosed HIV infections and lower levels of viral suppression are more common among younger persons (8,15). Additional efforts are needed to ensure younger persons are aware of their infection and able to access and adhere to recommended, ongoing HIV treatment to improve health outcomes.

CDC supports numerous activities for identifying HIV infections: initiating treatment as quickly as possible and ensuring ongoing treatment; addressing social barriers to HIV prevention and treatment efforts; and expanding opportunities for persons to test for HIV infection and receive the results on their own (i.e., self-testing), which allows persons who might not otherwise take a test to learn their HIV status (16). CDC’s Integrated HIV Surveillance and Prevention Programs for Health Departments, initiated in 2018, includes critical activities to enable state and local health departments to improve identification of HIV infections and increase viral suppression among PWDH (17). CDC’s national campaign, Let’s Stop HIV Together, supports efforts to end HIV stigma and promote HIV testing, prevention, and treatment (18). Ending the HIV Epidemic: A Plan for America is an initiative for reducing HIV infections in the United States by ≥90% by 2030; it focuses on strategies regarding diagnosis, treatment, prevention, and response to HIV infection in communities most affected by HIV (19). In addition to decreasing the risk for ongoing HIV transmission, prompt diagnosis and improving timely and continuing access to HIV treatment should also improve health outcomes for PWDH and prevent HIV-related deaths.

The findings in this report are subject to at least two limitations. First, cause-of-death information on death certificates is typically completed by funeral directors, attending physicians, medical examiners, or coroners (3). HIV-related deaths might be underreported because of lack of knowledge about the correct documentation needed or reluctance to include HIV on the death certificate because of possible stigma (5). An assessment of Florida’s HIV surveillance data for 2000–2011 indicated that HIV-related deaths were underestimated in the surveillance system by approximately 9% (20). Second, the proportion of deaths with a known cause was <100%. Overall, the proportion of deaths with a known cause was high for the United States (94.6% in 2010 and 96.7% in 2017); however, the proportion of deaths with a known cause was lower for certain demographic groups (e.g., Asian persons) and for certain jurisdictions (e.g., Hawaii during 2017).

Deaths among persons with HIV have decreased, and by 2018 had surpassed the 2020 national target, primarily because of a reduction in HIV-related deaths. Deaths caused by HIV infection have likely decreased because of improvements in diagnosing infections and in treatment and medical care. However, differences in HIV-related death rates still exist for multiple populations. Diagnosing HIV infection early, treating it promptly, and maintaining access to high-quality care and treatment over a lifetime can improve life expectancy and reduce differences in rates of deaths across all populations.