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Study: Disparity between rich and poor mortality
Poor, disadvantaged people develop AIDS faster
Before 1996, AIDS was an equal-opportunity disease in the United States, affecting wealthy and poor alike. In fact, researchers in one of the world’s AIDS epicenters could find no disparity between wealthy populations and poor populations in disease progression.
That trend clearly has changed. A new geographical study in San Francisco, where poor and affluent neighborhoods are clearly defined, shows that people with a low economic status have higher mortality from AIDS.1 When researchers studied the same areas prior to 1996, they did not find this difference, says Willi McFarland, MD, PhD, director of HIV/AIDS statistics and epidemiology for the San Francisco Department of Public Health.
These findings are despite the fact that San Francisco has a comprehensive public health system and many programs directed at people who have HIV but lack private insurance coverage.
"We started the study to look at the geographical impact of AIDS on the city, to see which neighborhoods and areas of the city might be more or less impacted by the epidemic," McFarland says. "In doing that exercise, we said we should look at disease progression and mortality by neighborhood, and much to our surprise, we saw a big differential in survival by neighborhood."
The study found that less than 70% of the people living in the city’s poorest neighborhoods survived five years after an AIDS diagnosis, compared with more than 85% of the people living in the wealthiest neighborhoods surviving five years after an AIDS diagnosis.
"It goes to show that simply having the resources available for treatment is not necessarily sufficient to make sure they have the maximum benefit to everybody," McFarland says. "We have to be more proactive in reaching out and getting care to those who have significant barriers to accessing treatment."
The study’s findings suggest that many — if not all — U.S. cities would find a similar socioeconomic trend if the data were available, because San Francisco public health officials have taken particular pride in the success of their HIV prevention and treatment programs.
"We have more outreach and educational efforts than any other locality that I’m aware of," says Mitchell Katz, MD, director of health for San Francisco and a co-author of the study.
Everyone in the city who needs antiretroviral medications and HIV/AIDS treatment has access to these services, although not everyone is able to initiate and maintain treatment.
For the study, San Francisco was divided into 22 neighborhoods based on actual community dividing lines, such as the Castro district and the Latino Mission neighborhood, rather than the less accurate zip code approach, McFarland says.
Median household income was determined for each neighborhood.
"We looked at AIDS mortality rates prior to 1996 and after 1996, and it is more than 97% complete," McFarland says. "We know we have very complete data, and we’ve done studies of coroners’ reports of death to back it up. Very few AIDS cases escape detection."
As a result, the data show a very clear picture of how AIDS progression in the age of highly active antiretroviral therapy has disproportionately affected poor and minority neighborhoods.
If other American cities were to do a similar analysis, they likely would find socioeconomic disparity in AIDS mortality that is at least as striking as San Francisco’s, says David Bangsberg, MD, MPH, an assistant professor of medicine in residence at San Francisco General Hospital, University of California - San Francisco.
"I think it’s important for other health systems to evaluate their outcomes, and I would suspect that we probably have the best outcomes," Bangsberg says.
"We have exceptional access to primary and medical care and HIV medications," Bangsberg says. "We have much more limited access to substance abuse treatment and mental health treatment."
The latter two health services are especially important for poor HIV populations, which often have high rates of substance use and mental health problems, Bangsberg notes.
Comorbidities hamper adherence to treatment
Based on national studies of how socioeconomic status affects health among other populations with chronic diseases, it’s not terribly surprising that the same disparity now is seen with AIDS despite a public health system’s efforts to make treatment and drugs available to all who need them, Bangsberg says.
People infected with HIV who have very low incomes generally have many comorbidities, including drug dependence, mental illness, and socioeconomic problems such as unstable housing, all of which make it difficult for people in this population to adhere to their antiretroviral treatment, explains Bangsberg.
In San Francisco, where real estate generally is among the most expensive in the nation, providing affordable and low-income housing is a major problem. "The single thing we could do more of is provide support for housing," Katz says.
AIDS patients on lower rungs of the socioeconomic ladder may have trouble finding all of the public health services they need, Bangsberg says.
"With the development of effective antiretroviral therapy, the success of the health care system in delivering the therapy becomes more important," Bangsberg says. "Prior to this, it didn’t matter so much."
HIV patients who have private insurance are less likely to fall through the cracks of those systems, as are the patients who rely on the city’s public health system for their care, Bangsberg adds.
For example, the very poorest people are the homeless, and they are unlikely to make HIV treatment even one of their top three life priorities, Katz says.
And there are incredible obstacles to providing HIV treatment to people who are actively abusing alcohol or drugs, Katz says.
One of the keys to success with this population is to improve access to substance abuse and mental health services, but this is a daunting task even for a city like San Francisco, which places a higher priority on these services than most other cities, Katz says.
"We have full access to mental health services, but not full access to substance abuse treatment," Katz says. "But I’ve never had trouble getting an HIV-positive person into substance treatment."
Unfortunately, the city’s budget problems may result in cuts to the city’s mental health and substance use programs, as well as to general assistance to the poor, Bangsberg says.
"My prediction is the disparity in AIDS progression is going to get worse instead of better," says Bangsberg. "If we have this premiere health system delivering HIV care to poor people, and we’re faced with budget cuts to make this less than a premiere system, that will translate into increasing mortality among poor people with HIV."
On the other hand, it’s possible that new drug developments will help close the gap in the disparity, Katz says.
For example, when a once-a-day protease inhibitor combination becomes available, then there will be more AIDS patients who have substance use and other problems who will be able to maintain their antiretroviral regimen, particularly if the city were to start a directly observed therapy program.
1. McFarland W, Chen S, Hsu L, et al. Low socioeconomic status is associated with a higher rate of death in the era of highly active antiretroviral therapy, San Francisco. JAIDS 2003; 33:96-103.