Disparities among US states in HIV-related mortality in persons with HIV infection, 2001-2007.

Objective: To examine interstate variation in US HIV case-fatality rates, and compare them with corresponding conventional HIV death rates.

Design: Cross-sectional analysis using data on deaths due to HIV infection from the National Vital Statistics System and data on persons 15 years or older living with HIV infection in 2001-2007 in 37 US states from the national HIV/AIDS Reporting System.

Methods: State rankings by age-adjusted HIV case-fatality rates (with HIV-infected population denominators) were compared with rankings by conventional death rates (with general population denominators). Negative binomial regression determined case-fatality rate ratios among states, adjusted for age, sex, race/ethnicity, year, and state-level markers of late HIV diagnosis.

Results: On the basis of 3,096,729 HIV-infected person-years, the overall HIV case-fatality rate was 20.6 per 1000 person-years [95% confidence interval (CI) 20.3-20.9]. Age-adjusted rates by state ranged from 9.6 (95% CI 6.8-12.4) in Idaho to 32.9 (95% CI 29.8-36.0) in Mississippi, demonstrating significant differences across states, even after adjusting for race/ethnicity (P < 0.0001). Many states with low conventional death rates had high case-fatality rates. Nine of the 10 states with the highest case-fatality rates were located in the southern United States.

Conclusion: Case-fatality rates complement and are not entirely concordant with conventional death rates. Interstate differences in these rates may reflect differences in secondary and tertiary prevention of HIV-related mortality among infected persons. These data suggest that state-specific contextual barriers to care may impede improvements in quality and disparities of healthcare without targeted interventions.