Black-White mortality from HIV in the United States before and after introduction of highly active antiretroviral therapy in 1996.

OBJECTIVES: We sought to describe Black-White differences in HIV disease mortality before and after the introduction of highly active antiretroviral treatment (HAART). METHODS: Black-White mortality from HIV is described for the nation as a whole. We performed regression analyses to predict county-level mortality for Black men aged 25-84 years and the corresponding Black:White male mortality ratios (disparities) in 140 counties with reliable Black mortality for 1999-2002. RESULTS: National Black-White disparities widened significantly after the introduction of HAART, especially among women and the elderly. In county regression analyses, contextual socioeconomic status (SES) was not a significant predictor of Black:White mortality rate ratio after we controlled for percentage of the population who were Black and percentage of the population who were Hispanic, and neither contextual SES nor race/ethnicity were significant predictors after we controlled for pre-HAART mortality. Contextual SES, race, and pre-HAART mortality were all significant and independent predictors of mortality among Black men. CONCLUSIONS: Although nearly all segments of the Black population experienced widened post-HAART disparities, disparities were not inevitable and tended to reflect pre-HAART levels. Public health policymakers should consider the hypothesis of unequal diffusion of the HAART innovation, with place effects rendering some communities more vulnerable than others to this potential problem.

Explaining race differences in mortality among the Tennessee Medicare elderly: the role of physician services.

We investigated the impact of socioeconomic conditions, patterns of morbidity, and physician service utilization on race differences in rates of mortality, and mortality associated with specific diagnoses. Longitudinal data from the Center for Medicare and Medicaid Services (CMS) Physician Billing File data and the Medicare Enrollment Database (EDB) were analyzed to assess physician-diagnosed morbidity, health service use, and mortality, among the population of Medicare beneficiaries in Tennessee (N=665,887). Proportional hazards models were used to examine the effects of race, socioeconomic status, morbidity, and physician service utilization on mortality. Race differences in physician visits explain the largest portion of mortality differentials between African Americans and Whites. Race disparities in mortality associated with particular forms of morbidity are also mostly a function of differences in physician service use. Our examination suggested that race differences in patterns of physician service use principally explain race disparities in mortality. Further, race differences in the use of physician services were substantially responsible for race disparities in mortality associated with particular forms of morbidity.