Race and Sex Differences in Antiretroviral Therapy Use and Mortality among HIV-Infected Persons in Care

Background. There are conflicting data regarding race, sex, and mortality among persons infected with human immunodeficiency virus (HIV). We studied all-cause mortality among persons in care during the highly-active antiretroviral therapy (HAART) era. Methods. This retrospective cohort study included patients who made >= 1 clinic visit from January 1998 through December 2005. Results. Of 2605 patients (with 6657 person-years of follow-up), 38% were black and 24% were female. The percentage of time in care while receiving HAART was lower for blacks than for nonblacks (47% vs. 76%; P < .001) and for females than for males (57% vs. 71%; P = .01). There were 253 deaths (38 per 1000 person-years). After adjustment for characteristics at baseline, death was associated with black race (hazard ratio [HR], 1.33; P = .04), female sex (HR, 1.53; P = .007), injection drug use (IDU) as a risk factor for HIV infection (HR, 1.61; P = .009), older age (HR, 1.45 per 10 years; P < .001), a lower CD4 cell count (HR, 0.59 for 200 vs. 350 cells/mm(3); P < .001) and a higher HIV type 1 RNA level (HR, 1.35; P < .001). After adjustment for the length of time that HAART was received, black race (HR, 1.00; P = .99) and IDU (HR, 1.37; P = .09) were no longer associated with death, but female sex was (HR, 1.62; P = .002). Conclusions. Race-associated differences in mortality likely resulted from HAART use. Women had an increased risk of death even after adjustment for HAART use. Addressing racial disparities will require improved HAART utilization. Increased mortality among women requires further study.