根据10月8日发表于《内科学文献》(Archives of Internal Medicine)的一篇报告，自上世纪90年代中期以来，除教育水平较低的非西班牙裔黑人之外，其他所有人口群体的HIV相关死亡率均有显著降低。这种时间趋势不可避免地造成白人与非白人的HIV死亡率差异增大。

　　HIV已成为黑人中日益重要的死亡原因，与此同时，其在白人死亡原因中的重要性却正在降低。作者指出，近年来的数据显示，HIV是黑人中的第19位致死原因，而在白人致死原因中仅居第24位。

受到HIV感染的细胞

　　美国肿瘤学会调查研究项目的Simard博士及其同事，利用死亡证书中记录的数据以及国家卫生统计中心人口统计系统中的存档数据，评估了HIV死亡率的变化趋势。近年来，死亡证书中已纳入患者的教育程度，研究者将其作为受试者社会经济状况的一种指征。最低的教育程度定义为近亲报告接受教育 12年。研究者还根据受试者的性别和种族/民族对数据进行了分类。他们在来自26个州的年龄为25-64岁成人中对91,307例HIV相关死亡进行了评估，重点关注1993~1995年与2005~2007年数据的比较。

　　结果显示，总体上，在所有民族和所有教育水平的多数男性和女性人群中，HIV死亡率随时间进展而降低。在HIV相关死亡率全面显著降低的背景下，最主要的例外是教育水平较低(受教育年限≤12年)的非西班牙裔黑人女性，在这一人群中，HIV死亡率仍保持很高的水平。除此之外，白人中的死亡率降低幅度大大超过非白人。教育水平较高人群中的死亡率降低总体上也大大超过教育水平较低的人群。这两个趋势导致这些群体之间原本存在的巨大差异进一步加大。例如，在教育水平最高的非西班牙裔黑人男性中，HIV死亡率由117.89例/100,000骤降至15.35例/100,000，但后者仍是教育水平最高的非西班牙裔白人男性的HIV死亡率5.04例/100,000的3倍以上。

　　研究者总结认为，该研究结果提示在HIV死亡率变化中，除种族/民族外，社会经济状况也起到非常重要的作用。在HIV预防和治疗资源的分配中，需要考虑到这些因素的影响。

　　这项研究由美国肿瘤学会资助。研究者披露无相关利益冲突。

　　By: MARY ANN MOON, Ob.Gyn. News Digital Network

　　HIV-relatedmortalitydecreased markedly since the mid-1990s across all demographic groups except among non-Hispanic blacks with low levels ofeducationalattainment, according to a report published online Oct. 8 in Archives of Internal Medicine.

　　The inevitable result of these temporal trends is a widening gap between whites and nonwhites in deaths from HIV.

　　"These findings suggest the need for focused interventions and resources to facilitate the identification of high-risk individuals, as well as entry and retention into care for these most vulnerable groups affected by the HIV epidemic in the United States," said Edgar P. Simard, Ph.D., of the American Cancer Society’s Surveillance Research Program, and his associates.

　　HIV has become a more predominant cause of death among blacks at the same time that its prominence as a cause of death among whites has been on the decline. It was the ninth-leading cause of death among blacks in the most recent year for which data are available, but only the 24th-leading cause of death among whites, the authors noted.

　　Dr. Simard and his colleagues examined trends in HIV mortality using data recorded on death certificates and filed in the National Vital Statistics System, which is administered by the National Center for Health Statistics. In recent years, death certificates have included patients’ educational attainment, which these investigators used as a proxy for the subjects’ socioeconomic status. The lowest level of educational attainment was defined as less than or equal to 12 years of education as reported by next of kin.

　　The researchers also categorized the data according to the subjects’ sex and race/ethnicity. They assessed 91,307 HIV-related deaths among adults aged 25-64 years across 26 states, focusing on comparing the data from 1993-1995 against that from 2005-2007.

　　Overall, HIV mortality declined over time for most men and women of all ethnicities and educational levels. The main exceptions to the across-the-board sharp decline in HIV-related mortality were found among non-Hispanic black women of low educational attainment, in whom HIV mortality remained markedly high, and Hispanic women with 13 to 15 years of education.

　　In addition, the reductions in mortality were much greater among whites than among nonwhites. Declines in mortality also generally were much greater among people with high educational attainment than among those with lower educational attainment. Both trends caused a widening in the already large gap between these groups.

　　For example, among non-Hispanic black men with the highest educational attainment, HIV mortality decreased from 117.89 to 15.35 per 100,000, a dramatic reduction. But this rate of 15.35 is still more than three times higher than the 5.04 per 100,000 rate in non-Hispanic white men with the highest educational attainment.

　　Although this study was not designed to find the reasons underlying these disparities, "We posit that black men and minority women, in particular those with low socioeconomic status, may be exceptionally vulnerable to HIV deaths owing to a combined lack of knowledge of HIV prevention, lack of knowledge of their own HIV status, lack of access to the health care system, social stigma, and marginalization," Dr. Simard and his associates said (Arch. Intern. Med. 2012 Oct. 8 [doi:10.1001/archinternmed.2012.4508]).

　　"Our findings suggest the importance of considering individuals not only on the basis of race/ethnicity but also by socioeconomic status for the purposes of allocating resources for HIV prevention and treatment," they added.

　　This study was funded by the American Cancer Society. No financial conflicts of interest were reported.

　　View on The News
More Funding Needed to Target These Disparities

　　The findings of Edgar P. Simard, Ph.D., and his colleagues demonstrate that it is high time for "a major commitment of resources to address these shameful disparities in HIV outcomes," said Dr. William Cunningham.

　　Currently most funding is funneled to research on antiretroviral therapy and vaccines to prevent primary infection, while funding for research specifically targeting low-income persons of color "is frankly relatively small." Agencies such as the Centers for Disease Control and Prevention, the Agency for Health Research and Quality, and the Health Resources and Services Administration "have been heroically attempting to address such issues, but with relatively miniscule budgets that are constantly under threat of further cuts," he said.

　　DR. CUNNINGHAM is affiliated with the department of internal medicine at the University of California, Los Angeles. He reported no financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Simard’s report (Arch. Intern. Med. 2012 Oct. 8 [doi:10.1001/2013.jamainternmed.613]).