根據10月8日發表於《內科學文獻》(Archives of Internal Medicine)的一篇報告，自上世紀90年代中期以來，除教育水平較低的非西班牙裔黑人之外，其他所有人口群體的HIV相關死亡率均有顯著降低。這種時間趨勢不可避免地造成白人與非白人的HIV死亡率差異增大。

　　HIV已成為黑人中日益重要的死亡原因，與此同時，其在白人死亡原因中的重要性卻正在降低。作者指出，近年來的數據顯示，HIV是黑人中的第19位致死原因，而在白人致死原因中僅居第24位。

受到HIV感染的細胞

　　美國腫瘤學會調查研究項目的Simard博士及其同事，利用死亡證書中記錄的數據以及國家衛生統計中心人口統計係統中的存檔數據，評估了HIV死亡率的變化趨勢。近年來，死亡證書中已納入患者的教育程度，研究者將其作為受試者社會經濟狀況的一種指征。最低的教育程度定義為近親報告接受教育 12年。研究者還根據受試者的性別和種族/民族對數據進行了分類。他們在來自26個州的年齡為25-64歲成人中對91,307例HIV相關死亡進行了評估，重點關注1993~1995年與2005~2007年數據的比較。

　　結果顯示，總體上，在所有民族和所有教育水平的多數男性和女性人群中，HIV死亡率隨時間進展而降低。在HIV相關死亡率全麵顯著降低的背景下，最主要的例外是教育水平較低(受教育年限≤12年)的非西班牙裔黑人女性，在這一人群中，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過非白人。教育水平較高人群中的死亡率降低總體上也大大超過教育水平較低的人群。這兩個趨勢導致這些群體之間原本存在的巨大差異進一步加大。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驟降至15.35例/100,000，但後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。

　　研究者總結認為，該研究結果提示在HIV死亡率變化中，除種族/民族外，社會經濟狀況也起到非常重要的作用。在HIV預防和治療資源的分配中，需要考慮到這些因素的影響。

　　這項研究由美國腫瘤學會資助。研究者披露無相關利益衝突。

　　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.

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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]).