As 2020 draws to a close, we asked David Alain Wohl, M.D., a professor of medicine in the Division of Infectious Diseases at the University of North Carolina and a highly respected HIV clinician-researcher, to take stock of the year's most momentous research developments and other critical events. In this exclusive series of articles, Wohl calls attention to 10 such developments that have tremendous short-term implications for our day-to-day efforts to improve HIV prevention, treatment, patient care, and policy in the U.S., and analyzes each development with his trademark wit and clinical savvy.
Fewer people are dying from HIV infection now than ever before in the U.S., and all indicators point to improvements across the cascade of care being responsible for this decline.
According to the Centers for Disease Control, from 2010 to 2018, the rate of death among people with HIV infection fell by over 36% and, during this same period, HIV-related deaths dropped by almost 50%.
Importantly, racial and ethnic disparities in HIV-related mortality also diminished during this time. A previous difference in the absolute rate of HIV-related death between Latinx people and white people vanished, and the difference between people who are Black and who are white dropped by 66%. By 2017, the rate of HIV-related death was 7.0 per 1,000 persons for individuals of multiple races compared to 5.6 per 1,000 persons for Black individuals, and 3.9 per 1,000 persons for both white and Latinx individuals.
Rates of HIV-related death were slightly higher for cisgender women (5.4) than cis-gender men (4.5) and transgender women (4.3). Regional disparities in HIV-related mortality persisted, with a rate of 6.0 per 1,000 in the South versus 3.2 per 1,000 in the Northeast. In Mississippi specifically, for instance, the rate was 11.5 per 1,000 persons.
Death unrelated to HIV infection remained largely unchanged—and, not surprisingly, increased with age.
The Bottom Line on Mortality Trends in HIV
As we watch deaths from COVID-19 accumulate in the U.S. and elsewhere, it can be useful to reflect that there was a time when it was hard to imagine that mortality from AIDS would plummet and keep decreasing over time. HIV therapies have, of course, been remarkable; they not only flattened the HIV pandemic curve, they trounced it (albeit slowly).
The rate-limiting step to the full benefits of modern antiretroviral therapies, though, has been their delivery (something we will also have to tackle with COVID-19 vaccination). The potency and tolerability of HIV therapies have been excellent for many years. Therefore, the benefits we are seeing vis-à-vis mortality reflects not just good medicine, but good old public health coupled with access to medical care.
The CDC report is explicit in associating the positive HIV mortality trends with strong and concerted public health interventions. These have increased the proportion of people aware of their HIV status, shortened the time from diagnosis to viral suppression, and supported the engagement in care and treatment (once known as the “cascade”).
A number of federal programs are mentioned in the report as being supportive of the reported outcomes—and undoubtedly, the CDC’s surveillance systems have been critical to informing public health responses. But also included is the “Ending the HIV Epidemic in America” (EHE) plan released by the White House in 2019, which came along at the tail end of study period and is unlikely to have contributed to the declines in mortality reported. Much more relevant than EHE are the Affordable Care Act (ACA, Obamacare) and the Ryan White CARE Act.
Health insurance provides people with access to routine care, which can lead to HIV testing, early diagnosis, and linkage to care—as well as preventative services, including PrEP, for those testing HIV negative. The broad range of Ryan White programs—which support free testing, medications, medical care, mental health care, social services, and much more—has been demonstrated to save lives, prevent infections, and reduce disparities. As Jeanne Marrazzo, M.D., M.P.H., the director of infectious diseases at the University of Alabama-Birmingham, stated to the New York Times after the report was released, “This is not just about the drugs. It’s the entire structure that supports people.”
That more needs to be done is also underscored by the report, despite its upbeat headline. In 2017, the final year of the analysis, 16,000 people with HIV died in the US—including approximately 5,500 from HIV-related causes. This risk of death from HIV was much greater for people who are Black and living in the South.
Such intertwined racial and geographic inequalities speak to the consequences of applying a federalist approach to national health care issues. Southern state legislatures and governors have been reluctant to expand Medicaid under the ACA, increasing the number of people without health insurance in the South. Access to PrEP in this part of the country is also lagging, especially relative to rates of new HIV diagnoses.
The impact of COVID-19 on mortality among HIV-positive people is unclear, but the pandemic is hitting many of the same populations that have higher rates of HIV infection, and there is concern that the COVID-19 pandemic will erode the progress that has been made against HIV. The situation is not helped by the perpetual sword of Damocles hanging over the ACA. All of this may lead to a different picture the next time the CDC runs these numbers.