Original articleFemale and male differences in AIDS diagnosis rates among people who inject drugs in large U.S. metro areas from 1993 to 2007
Introduction
After the introduction of combination antiretroviral therapy (cART), there was a substantial reduction in the number of AIDS diagnoses in the United States, particularly among people who inject drugs (PWID) [1]; however, national trajectories of change in AIDS diagnoses have not been the same for female and male PWID [1], [2]. In 1995, PWID represented seven percent of persons diagnosed with AIDS among females and 19% among males [2]. In 2011, 20% of new AIDS diagnoses among females were injection related, whereas only 10% of AIDS diagnoses among males were from PWID [1]. During this time, we have estimated that PWID prevalence per 10,000 adult population in large U.S. metropolitan statistical areas (MSAs) also fell from 157 in the period from 1993 to 1995 to 133 in the period from 2005 to 2007 among males, and from 82 to 75 among females [3]. These data raise questions about changes in epidemiologic patterns of AIDS among female PWID and how these patterns may vary across geographic areas.
This article focuses on differences between female and male PWID in incident AIDS diagnosis rates (IARs) across MSAs. Analysis at the MSA level provides a useful lens through which to understand the historical and social factors that drive HIV burden in different locales. Several articles have found differences in HIV prevalence and AIDS mortality among PWID across MSAs, and this variation has been linked to MSA-level factors [4], [5], [6]. Previous research has also demonstrated that racial and/or ethnic disparities in AIDS diagnoses among PWID varied significantly across MSAs [7]. Although there is ample evidence demonstrating the success of cART in reducing morbidity and mortality in the United States [8], [9], the diffusion of cART and other important services may not have been uniform across MSAs and may have reached male and female injectors at different times. Disparities in the availability of cART and HIV care, as well as its accessibility to female PWID, may have resulted in significant sex differences in AIDS diagnoses across MSAs among injectors. In this article, we assess changes in IARs among female and male PWID across large MSAs between a pre-cART period (1993–1995) and a period well after cART was available (2005–2007).
Section snippets
Methods and materials
The unit of analysis in this article is the MSA, which is defined by the U.S. Census Bureau as contiguous counties containing a central city of 50,000 people or more and that form a socioeconomic unity [10]. Studying HIV among PWID at the MSA level [11] is useful because, as noted, each MSA has its own epidemic history and HIV prevalence rate. Analyses were conducted on a cohort of 95 of the largest MSAs in the continental United States. Preliminary analysis of trend lines over time from 1992
Results
AIDS diagnosis rates, 95% CIs, and significance of CIs for female and male PWID in each MSA and time period are listed in Table 1. Across all 95 MSAs, in the pre-cART period, IARs among females (per 10,000 female PWID) averaged 103 (SD = 124.1). In the later period, after the introduction of cART, the average IAR among females was 43 (SD = 44.9). Among males, the average IAR (per 10,000 male PWID) was 163 (SD = 138.6) in the pre-cART period and 53 (SD = 37.4) in the later period. IARs were more
Discussion
AIDS diagnosis rates among both female and male PWID decreased after the introduction of cART; however, declines were slighter for female PWID relative to male PWID. Although average IARs among males declined 67% across the 95 MSAs, they only declined an average of 58% among females. This is evident in our analysis of overlap in CIs, which showed that between the pre-cART and cART periods, IARs among males declined significantly in 86% of MSAs. For female PWID, IARs declined significantly in
Conclusions
Geographical analysis of MSA-level differences in IARs can illuminate where there have been successes and also where interventions and services are most necessary and with which populations. In this analysis, we found that although there has been substantial progress in reducing IARs among PWID over time, declines among males appear to be greater than declines among females. These findings indicate that female PWID may not be accessing and receiving health services to the same extent as male
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This study was supported by grants from the U.S. National Institute on Drug Abuse (R01 DA013336 and R01 DA037568). The authors acknowledge the NIH-funded Center for Drug Use and HIV Research (P30 DA121041) for its support and assistance.
The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
The authors have no conflicts of interest to disclose.