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Black People with HIV Have Less Linkage to Care, Higher Rate of Death


Coinciding with National Black HIV/AIDS Awareness Day last week, a pair of reports in the February 6 Morbidity and Mortality Weekly Report look at health disparities among African-Americans living with HIV. One study found that while the mortality rate among black people with HIV is falling, it is still 13% higher that that of whites. The second found that only about half of black people diagnosed with HIV were not linked to care. 

Death Rates

As described in the first report, Azfar-e-Alam Siddiqi from the Centers for Disease Control and Prevention (CDC) Division of HIVAIDS Prevention looked at trends in mortality among black people with HIV.

Nearly half (47%) of all people who received an HIV diagnosis in the U.S. in 2012 and 43% of all people living with HIV in 2011 were black, the authors noted as background. A primary goal of the National HIV/AIDS Strategy is to reduce HIV-related health disparities, and the CDC and its partners have been pursuing a "high-impact prevention" approach and supporting projects focusing on minorities to improve diagnosis, linkage to care, and retention in care, and to reduce disparities in HIV-related health outcomes.

The CDC researchers analyzed data from the National HIV Surveillance System from 2008 through 2012 (reported through June 2014) and determined the number and rate of deaths among black people age 13 or older living with HIV, both as a proportion of the entire population and of people with HIV. Numbers and rates for the whites and Hispanics/Latinos were calculated for comparison. The report focused on all-cause mortality among people living with HIV, not deaths due to HIV.


  • In 2012, an estimated 8165 total deaths occurred among black people living with HIV, which was 1.5 times the number of deaths among whites (5426) and 3.2 times the number among Hispanics/Latinos (2586).
  • The death rate among blacks age 13 or older decreased from 28.4 to 20.5 per 1000 persons with HIV between 2008 and 2012 -- a decline of 28%.
  • While deaths decreased in other racial/ethnic groups, the declines were generally greater and more consistent for blacks.
  • Despite this improvement, the death rate for blacks was 13% higher than for whites and 47% higher than for Hispanics/Latinos.
  • Comparisons differed across states, however: blacks had a higher death rate than whites in 23 states and the District of Columbia, while whites had a higher death rate in 27 states.
  • Black men infected with HIV through injection drug use had a higher death rate than men who have sex with men (33.1 vs 15.3 per 1000 persons with HIV).
  • Black women infected through injection drug use had a higher death rate than those with heterosexual sex as their main risk factor (29.2 vs 17.9 per 1000 persons with HIV).
  • In 2012, West Virginia had the highest death rate for blacks per 1000 persons with HIV (28.9) while Nebraska had the lowest (9.3).
  • Washington, DC, had the highest death rate for blacks per 100,000 population (98.4) while Alaska had the lowest (5.2).
  • 7 of the 10 states with the highest death rates for blacks were in the South.

Looking at the cascade of care, in 2012 an estimated 15% of blacks were aware they had HIV (vs 12% of whites) and 77% of these were linked to care (the lowest proportion of all races/ethnicities), the authors noted in their discussion. In 2011, 48% of black people were retained in care and 40% had viral load suppression -- also less than whites and Hispanics/Latinos.

"The results of the analyses in this report show that, although disparities in mortality by race/ethnicity persist, the overall outlook for all persons living with HIV has improved, and the gaps between different races/ethnicities have narrowed," the authors concluded. "Focusing prevention and care efforts on minority populations with a disproportionate HIV burden could lead to further reduction, if not elimination, of health disparities, such as higher mortality, and help achieve the goals of the National HIV/AIDS Strategy."

HIV Testing and Services

The second report, by Puja Seth of the CDC and colleagues, looked at HIV testing and use of service among black people. They analyzed national-level program data submitted by 61 health departments and 151 CDC-funded community-based organizations through the National HIV Prevention Program Monitoring and Evaluation system.


  • In 2013, blacks accounted for 45% of the more than 3 million CDC-funded HIV testing events.
  • Young adults age 20-29, women, and people living in the South were more likely to be tested.
  • 55% of all people newly diagnosed with HIV were black, with gay, bisexual, and other men who have sex with men most likely to be newly positives.
  • Blacks accounted for higher proportions of new positives among young people age 13-19 (69%), people age 20-29 (58%), women (69%), and people tested in the South (66%).
  • 45% of newly positive men who have sex with men were black, compared with 72% and 70% of new positive heterosexual men and women.
  • Although gay and bisexual men accounted for 9% of testing events among blacks, they accounted for 37% of newly positive blacks.
  • Among newly positive blacks, 45% were linked to medical care  (i.e., attended their first medical appointment) within 90 days, 46% were interviewed for HIV partner services, and 54% were referred to HIV prevention services.
  • HIV services were generally comparable by age and sex, but the Midwest and South lagged in service delivery.
  • Overall, a higher percentage of newly positive black gay and bisexual men were linked to HIV medical care, partner services, and HIV prevention services compared with heterosexual men and women.

"HIV testing and knowledge of HIV status are the gateway to important prevention services, and for HIV-positive persons, services along the HIV continuum of care," the authors wrote. "Early initiation and adherence to antiretroviral therapy has substantial medical benefits for HIV-positive persons and prevention benefits by reducing HIV transmission to HIV-negative partners up to 96%. Therefore, in addition to identifying new HIV-positive persons, it is critical to ensure all HIV-positive persons are linked to HIV medical care and receive necessary HIV prevention services."

Given that the National HIV/AIDS Strategy has a 2015 goal that 85% of newly diagnosed people should be linked to HIV medical care within 90 days, the current 45% figure "suggests that linkage among blacks needs to be significantly improved," they stressed.

"Continued efforts to expand routine screening as recommended by the U.S. Preventive Services Task Force and CDC guidelines and to target HIV testing services toward populations at high risk, such as [men who have sex with men] can help identify HIV-positive persons whose infection is undiagnosed, particularly in jurisdictions with the highest HIV prevalence among blacks," the authors concluded. "Programmatic efforts to increase prevention efforts among HIV-negative persons also are critical to reduce their risk for HIV infection. Finally, linkage to care and behavioral prevention activities for HIV-positive persons are critical to ensure receipt of key services to improve their health and to prevent HIV transmission to their partners."



A Siddiqi, X Hu, HI Hall. Mortality Among Blacks or African Americans with HIV Infection -- United States, 2008-2012. Morbidity and Mortality Weekly Report 64(04):81-86. February 6, 2015.

P Seth, T Walker, N Hollis, et al. HIV Testing and Service Delivery Among Blacks or African Americans -- 61 Health Department Jurisdictions, United States, 2013. Morbidity and Mortality Weekly Report 64(04):87-90. February 6, 2015.