Current Health Disparities in HIV/AIDS

In November 2007, the CDC published a report on health disparities in HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis.¹ Based on 2000 to 2004 surveillance data, the report highlights differences in incidence rates of HIV and AIDS diagnoses by age, sex, ethnicity/race, risk factor/transmission categories, and US geographic region. Although it provides useful information on how the distribution of disease has changed since the epidemic began in the 1980s, underlying causes and mediators of these disparities are much less straightforward.

While some differences are expected or unavoidable (eg, the distribution of HIV/AIDS by age), others imply inequities or inequalities (eg, unequal rates of antiretroviral treatment administration by income, sex, or ethnicity/race) and should be the focus of attempts at remediation. Differential access to HIV resources and preventive programs, varying utilization of health services, and disparate health behaviors/beliefs can all contribute to unequal health outcomes and indicator rates.

In this article, we will summarize current research on important disparities in HIV/AIDS as well as disparities in the care of persons with HIV/AIDS. We will also include findings from treatment strategies specifically designed to target those inequalities that are potentially modifiable.

DEFINING “HEALTH DISPARITIES”
The term “health disparity” has been used broadly and somewhat inconsistently. This may be the result of diverse research and public health agendas as well as of disagreements over which disparities are preventable and which are inevitable. The Department of Health and Human Services defines “health disparities” as “differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation.”² The Health Resources and Services Administration states that the disparities are “population-specific differences in the presence of disease, health outcomes, or access to care.”³

In a 2002 Public Health Reports article, Carter-Pokras and Baquet⁴ argue that the concept ought to be viewed as a “chain of events signified by a difference in: (1) environment, (2) access to, utilization of, and quality of care, (3) health status, or (4) a particular health outcome. [Furthermore, differences should be] evaluated in terms of both inequality and inequity, since what is unequal is not necessarily inequitable.”

The distribution of current health disparities in HIV/AIDS and many other chronic illnesses has been shaped by the convergence of multiple individual and community level factors. It is thus important to distinguish those that are unavoidable from others that are preventable and/or amendable.

AGE
Despite a general decrease in new HIV/AIDS cases among persons in their late thirties from 2001 to 2004, CDC data show that this group still had the largest rate of new diagnoses out of all age ranges in 2004 (approximately 46 cases per 100,000).¹ However, 20- to 24-year-olds were the only group that had increasing rates of new diagnoses since 2001. Additional studies have confirmed increasing infection rates in the adolescent and young adult population.^5-7 These trends largely stem from a greater likelihood of high-risk behaviors in younger persons, such as drug use, unprotected sexual encounters, or multiple partners. A number of public health and research efforts have thus been devoted to developing and evaluating treatment strategies for HIV-positive adolescents and young adults. Qualitative and quantitative work has repeatedly demonstrated the importance of a social support network in this particular population.^8-10

Programs that offer age-appropriate psychosocial services may decrease fears regarding potential “stigmatization” among peers, help navigate concerns about sexuality and mental health needs, and facilitate effective engagement in medical care. Few studies have even looked at treatment and adherence issues in children and adolescents^11,12; however, these studies confirm the positive effects of stable social networks and age-appropriate care on the outcome of the disease. (For example, one pill-swallowing training intervention demonstrated an average 10% improvement in adherence with a corresponding increase in number of recipients achieving a CD4⁺ T-cell percentage greater than 25%.¹³) As programs are developed and implemented, especially for younger-age groups, the long-term benefits of comprehensive treatment, including antiretroviral use, will likely continue to emerge.

An increasing amount of health research is also accumulating about HIV-positive persons at the other end of the spectrum. Since the introduction of highly active antiretroviral therapy has extended the average lifespan for persons with HIV/AIDS in the United States, much data have been gathered about older HIV-infected persons. Persons older than 50 years are not just living longer with HIV/AIDS but are also acquiring the infection and receiving an HIV diagnosis later in life (Table 1).^14,15 Although the previous large and significant association of older age and disease progression has been attenuated with use of effective antiretroviral therapy,^16,17 some questions persist regarding treatment response by age,¹⁸ and problems of drug toxicity and polypharmacy may be more significant in older patients.

Researchers are also identifying major comorbidities and other age-related changes that affect the functioning of older persons with HIV (Table 1).^19-21 There is a growing incidence and prevalence of diabetes, cardiovascular disease, chronic liver and kidney disease, and non–HIV-related malignancies in the older HIV-infected population. Much is already known about the independent association of age with these conditions, but morbidity and mortality in those with HIV infection is further complicated by antiretroviral use (eg, use of protease inhibitors in persons with dyslipidemia) and by degree of viral progression/immune suppression.^22-28

Although it is uncertain whether current “standards of care” for such age-related complications can be applied similarly to the HIV-positive population with the same degree of projected benefit, data show that HIV clinicians who do not have generalist training or experience may be less comfortable providing general primary care services and/or may be less likely to implement routine health maintenance screening in HIV-positive persons.^29,30 Such findings underscore the importance of integrating HIV-related services with general medical and geriatric models of care to improve outcomes in the aging HIV population. Studies also show that older adults with HIV/AIDS have diverse demographic and clinical characteristics and socioeconomic stressors,^31-34 many of which are associated with an increasing risk of social isolation. Therefore, programs that assist patients in this “graying” HIV population will need to bridge the gap between current services and their evolving needs.

SEX AND GENDER
CDC data show that during 2001 to 2004, males represented the majority of cases of HIV/AIDS diagnosed in adults and adolescents in the United States.¹ In the past decade, there has also been consistent evidence of a growing proportion of heterosexually acquired infections in females, especially adolescents and young adults.³⁵ Although data are conflicting regarding unequal HIV disease progression by sex,³⁶ disparities in susceptibility and patterns of health care are, arguably, more meaningful. Infections in younger women may be due to the increased efficiency of male-to-female transmission as well as to different risk behavior patterns, such as substantially older male partners, less experience and self-efficacy in negotiating sexual practices, and high rates of asymptomatic sexually transmitted infections.

Universal prenatal HIV screening has also uncovered a number of new cases of infection in women of reproductive age.³⁷ For older women living with HIV, a body of knowledge is also developing around menopause: findings suggest that HIV-positive women undergo menopause at a slightly earlier age, although timing and degree of symptoms vary by level of immune suppression and history of drug use.^38,39

Researchers are examining the independent and combined effects of HIV infection itself and antiretroviral therapy on bone density and calcium/vitamin D metabolism, since the prevalence of osteopenia and osteoporosis in HIV-positive patients seems to be increasing. (One meta-analysis estimated that the combined prevalence of osteopenia and osteoporosis is nearly 70%.⁴⁰). However, the exact mechanisms of infection, certain medication classes, and bone metabolism are still unclear. It also remains to be seen how the endocrinology of menopause affects long-term risks of heart disease and stroke in HIV-positive women.

An important consideration in the midst of these findings is that despite improved availability of antiretroviral therapy, data still confirm varying rates of prescribed therapy between genders. Data from the HIV Research Network and other large cohorts suggest that women have been 1.5 times less likely to receive clinically indicated treatment.^41-43 Studies show gender differences in knowledge of HIV resources and in access to and utilization of medical services,^44,45 as well as a greater likelihood of perceived discrimination in women⁴⁶ that might influence engagement with primary care providers.

Women have not participated in clinical trials to the same degree as men, and there is emerging evidence that suggests they are at increased risk for toxicities from certain antiretroviral agents.⁴⁷ For example, the sex disparity in nevirapine toxicity was first uncovered 10 years after the drug’s first use when a series of complications and deaths occurred from fulminant hepatic failure in women.⁴⁸ Although pharmacodynamic differences are most likely multifactorial, more work is needed to describe the interaction between sex and medication toxicities. Finally, little is published about the care of high-risk and HIV-positive transgender/transsexual populations and their treatment outcomes. Because they are particularly vulnerable to stigmatizing and discriminatory practices, health care delivery should be not only effective but also sensitive to their unique needs.

ETHNICITY/RACE
Perhaps no other issue of HIV disparities has received as much public and academic scrutiny as ethnicity/race in the past several years. A recent PubMed search under the terms “HIV” and “race” yielded more than 3500 citations alone. The CDC reports that the HIV/AIDS rate in 2004 was highest in non-Hispanic blacks, who accounted for 50% of all cases diagnosed that year.¹ Infection rates were also higher in other minority groups-Hispanic/Latino, American Indian/Alaskan natives-than in non-Hispanic whites.

Despite an overall decrease in infection rates for both black and Hispanic/Latino populations from 2001 to 2004, these groups still bear a disproportionate share of the total HIV/AIDS cases in the United States. Among ethnic groups with increasing infection rates from 2001 to 2004, Asians and Pacific Islanders had the largest relative increase (16.5% compared with 3.5% for non-Hispanic whites). Because of these data and results from other longitudinal studies,^49,50 ethnic/racial disparities of the US HIV infection epidemic have brought focus on several areas of unmet need. As a result, several national organizations have developed initiatives to heighten preventive efforts and treatment services in minority populations, particularly African American communities (Table 2).

As with disparities in sex, disparities in several processes of care and HIV-related health outcomes have persisted in the HAART era among persons of different ethnic/racial backgrounds.^51,52 To some extent, this has been due to unequal insurance coverage and access to medical services, patterns of health care utilization, existence of other serious comorbidities, and uneven receipt of and adherence to antiretroviral therapy.^53,54 For example, African Americans have tended to present with lower CD4 counts-possibly because of later testing and/or delayed initiation of care. (One Johns Hopkins study found an average 264 days between HIV diagnosis and presentation for care for blacks compared with 102 days for whites.⁵⁵) Therefore, as programs are developed to facilitate entry into care for underserved minorities, health care workers should also identify methods of providing patient-centered and culturally sensitive comprehensive treatment to optimize health outcomes.

A number of studies have examined HIV-related disease outcomes within individual ethnic/minority groups: current research on African Americans has focused on the development and impact of cardiovascular and chronic kidney disease. Data show that in HIV-positive African Americans, end-stage renal disease (ESRD) develops at high rates⁵⁶ and that the risk of ESRD is 5 to 10 times higher in HIV-positive African Americans than in HIV-positive whites.^57,58 This may be largely because of the almost exclusive incidence of HIV-associated nephropathy in blacks.⁵⁹ Furthermore, survival rates in patients who have concurrent HIV infection and chronic kidney disease have improved with the use of antiretroviral therapy,^60,61 suggesting that antiretrovirals may not only slow the progression of nephropathy related to HIV infection but also prolong survival. Although the precise cause and pathogenesis remain somewhat unclear, HIV-associated nephropathy is now recognized as a separate clinical entity for which antiretroviral therapy is indicated, regardless of CD4 count or HIV RNA level.⁶²

Concerning cardiovascular risk and dyslipidemia, a recent AIDS Clinical Trials Group study examined the association of ethnicity/race and apolipoprotein genotype on lipid parameters and found that ethnicity/race modified the effects of protease inhibitors such that African Americans (when compared with whites) experienced a greater increase in triglyceride levels when exposed to this class of medications, even after adjusting for age, gender, and CD4 count.⁶³ Such findings may contribute to the risk of cardiovascular disease in HIV-positive African Americans in ways that still need to be determined.

In the emerging area of pharmacogenomics, recent research has shown that on a population basis, the rates of abacavir hypersensitivity may be slightly lower in African Americans than in non–African Americans,⁶⁴ although universal screening for HLA-B*5701, an allele that strongly predicts abacavir hypersensitivity, is still recommended.⁶² As data accrue from larger and more diverse populations, the clinical utility of this marker and its relation, if any, to ethnicity/race will be further clarified.

As with other ethnic minorities, the Hispanic/Latino population has been disproportionately affected by HIV disease,⁶⁵ and disparities in the prevalence of HIV/AIDS and the associated mortality even exist among various ethnic subgroups. (Puerto Ricans account for the majority of cases and deaths attributable to HIV infection in the United States.⁶⁶) Several issues may account for the unique epidemiology of HIV infection in these communities, including the complex relationships between migration/acculturation and HIV risk behaviors as well as gender roles and sexual identity in Latin cultures.

A study of risk factors for delayed presentation demonstrated that immigrants are more likely to present with lower initial CD4 counts and are more likely to have concurrent opportunistic infections at time of HIV diagnosis than US-born HIV-infected persons.⁶⁷ Authors of that study conducted interviews with Hispanic/Latino patients with newly diagnosed HIV infection and reported that “lack of knowledge regarding HIV risk, social stigma, secrecy, and symptom-driven health-seeking behavior” all contribute to delayed clinical presentation and poor engagement with the medical system.⁶⁷

However, novel treatment strategies are being employed to improve HIV-related health outcomes in this population. For example, one study found that Hispanic/Latino patients were 5 times more likely than non–Hispanic/Latinos to complete an intervention of directly observed antiretroviral therapy and also reported higher satisfaction with the program.⁶⁸ Successful treatment for HIV-infected Hispanic/Latinos will thus need to include comprehensive, linguistically appropriate care that focuses on education and prevention, improvement of access to testing and earlier diagnosis, and other self-identified needs of this culturally diverse group.

Surveillance data indicate relatively low incidence rates of HIV/AIDS in Native Americans and Asian/Pacific Islanders, but more in-depth research suggests a high prevalence of risk behaviors as well as possible racial misidentification that may result in the underestimation of disease in these minority groups.^69-71 For Native Americans especially, it has been suggested that complex tribal taboos and relationships with government-based providers inhibit effective screening.⁷⁰ However, it has been shown that antiretroviral therapy prolongs survival in this group,⁷² so programs that facilitate early diagnosis and access to care-including mental health and substance abuse treatment-may improve morbidity and mortality in this population.

HIV-infected Asian/Pacific Islanders, in contrast, use mental health/substance abuse programs and case management/housing services much less often than whites and other minorities despite attending hospital-based HIV clinics at relatively high rates.⁷³ Often underrepresented even in areas with large minority populations, Asian/Pacific Islanders and Native Americans have thus been the target of various special programs. One community-based AIDS service organization in New York City offered translation, advocacy, and case management services and found significantly improved rates of use of primary care services and self-reported quality of life after enrollment.⁷⁴

Results of these and other projects confirm that the needs of all HIV-infected minority groups are compounded by intragroup and intergroup diversities with regard to health beliefs and health-seeking behaviors. Building cultural capacity will be necessary for providers and programs to serve all these populations effectively.

TRANSMISSION RISK FACTORS
Among adult men, the highest number of HIV/AIDS cases from 2001 to 2004 were in men who have sex with men (MSM), and the rate continues to slowly increase.¹ Over that period there was an overall decrease in diagnoses among men who inject drugs or men who acquired infection through heterosexual contact. However, in women, the most common route of transmission has continued to be heterosexual contact; in 2004, this represented more than 75% of all diagnoses. Some believe the higher rates of infections in MSM are partly due to recreational substance use (eg, methamphetamines and erectile dysfunction medications) and the growing practice of “serosorting” (ie, choosing partners believed to have the same HIV status for unprotected anal intercourse); these behaviors then lead to increasing rates of unprotected encounters with more sexual partners. But even among MSM, there are still disparities between ethnic minority MSM and white MSM.

One meta-analysis of HIV risk between black and white MSM found that black men reported “less substance use, fewer sex partners, less gay identity, and less disclosure of same sex behavior.”⁷⁵ However, rates of sexually transmitted infections were higher in black MSM, despite no difference in the (reported) rates of unprotected intercourse and commercial sex work. Furthermore, those who were HIV-positive were half as likely as white HIV-positive MSM to report taking antiretrovirals.⁷⁵ Such disparities in health and health care likely contribute to the higher rates of AIDS diagnoses and poorer survival after progression to AIDS in black and minority MSM.⁷

Researchers and public health experts have also identified a particularly high-risk group of MSM who inject drugs. Studies on this “dual risk” MSM/men who inject drugs population have found relatively high rates of unprotected sex (with both male and female partners) and trading sex for money or drugs.⁷⁶ HIV-positive men who have concurrent sexual relations with men or high-risk women, or both, may partially account for the increasing rates of heterosexual HIV transmission in women, especially in minority communities.

SOCIOECONOMIC STATUS
No CDC data are available on differential socioeconomic status among persons with HIV/AIDS in the United States, but research has consistently demonstrated improved access to care, more cost-effective service utilization, increased antiretroviral use, and improved mortality in those with medical insurance.^77-79 Furthermore, health differences between persons covered by public versus private insurance have decreased over the past 10 years since the introduction of highly active antiretroviral therapy.⁷⁷

Data from the HIV Cost and Services Utilization Study show that use of antiretroviral therapy is also associated with an increased likelihood of employment,⁸⁰ and some case management programs now include vocational training/retraining services. Income has historically been a strong determinant of health status in the United States; aside from access to adequate health services and medications, data show that HIV-positive low-income persons report higher rates of perceived stigma from medical providers,⁸¹ which contributes to barriers in communication and trust.

Given the association between income and education, studies have also recently examined the specific relationships bet

ween education, health literacy, and disease outcome for persons with HIV infection. As suggested previously, increased rates of HIV/AIDS in some ethnic minorities may be due to deficits in knowledge of transmission and the decreased ability to negotiate risk-taking behaviors. Current data suggest that level of education and health literacy directly contribute to the relationship between ethnicity/race and HIV health disparities, namely medication adherence (Table 3).^82-84

HIV infection has long been associated with unstable housing and incarceration, although transmission patterns vary among HIV-positive persons who are homeless and those who are imprisoned.^85,86 It is now known how important housing is to the health of those who are already HIV-positive. Homelessness has been associated with lower CD4 counts and lower rates of medication prescription and adherence.⁸⁷ Upcoming results from the Housing and Health Study (a multisite, randomized controlled trial designed to determine the impact of stable housing on risk behaviors and outcomes of HIV-positive homeless persons) will soon demonstrate whether housing-based interventions can significantly alter treatment adherence, HIV disease progression, and mental and physical health in this particularly vulnerable population.⁸⁸ Ironically, then, it may be the relative housing “stability” experienced by prisoners and the requisite medical care in federal institutions that contributes to the observed success of antiretroviral therapy in some correctional facilities. A recent study found that almost 60% of Connecticut inmates receiving antiretroviral therapy had an undetectable HIV RNA level at the end of their incarceration period.⁸⁹

Findings such as these in the homeless and incarcerated populations lend further support to the development of (modified) directly observed therapy for HIV-positive persons at risk for poor adherence (see below). Finally, as testing and treatment strategies continue to expand in response to the HIV/AIDS epidemic in prisons, transitional services should be strengthened to ensure that ex-offenders get connected to knowledgeable primary care providers after their release.

SUBSTANCE USE AND MENTAL HEALTH/DISABILITY
Rates of HIV/AIDS acquired through injection drug use (IDU) have decreased in the past 10 to 15 years,1 but HIV-positive persons who are current or former users have not exhibited the same degree of improved HIV-related health compared with the non-IDU population.⁹⁰ Although some of this may be attributed to adverse outcomes because of concurrent viral hepatitis and/or other conditions, this group has traditionally been poorly engaged with mainstream health care systems. Inadequate access to services; poor continuity of care; and differential treatment, including delayed (or no) antiretroviral therapy, have all been well described.^90,91 Many providers are hesitant to prescribe HIV therapy for drug-using patients that may result in adverse effects with unclear clinical benefits (in addition to the increased risk of selecting drug-resistant strains).

Results from large cohorts, including the Women’s Interagency HIV Study, confirm that active drug and alcohol use are associated with increased medication errors and decreased adherence, although depression and negative attitudes toward antiretroviral medications also seem to be significant contributors.^92-94 However, as demonstrated by the success of some programs specifically designed for HIV-positive drug users,^95,96 many of these risks can be modified through a model of comprehensive medical care and mental health/substance abuse treatment. One randomized trial using directly observed therapy even demonstrated a significant difference in viral load suppression for treatment-experienced patients who received the intervention.⁹⁷ As suggested in a review of integrated HIV services,⁹⁸ programs that use multidisciplinary teams and a “biopsychosocial” need–based approach are able to retain patients in primary care more effectively.

A great deal has been published about the integration of HIV primary care in outpatient drug treatment services, and earlier experiences have focused on methadone maintenance treatment programs^99,100 (the gold standard substitution treatment for opioid dependence). There is now also a growing literature on buprenorphine in HIV-positive opioid users, and thus far preliminary studies in HIV-negative volunteers have shown buprenorphine can be safely coadministered with protease inhibitors and NNRTIs.^101,102 Future work will determine whether dosing adjustments are necessary and whether buprenorphine treatment impacts bioclinical parameters in HIV-infected persons. Because numerous studies have demonstrated that former substance users who are maintained in drug treatment programs have rates of adherence and viral suppression that approach those of HIV-positive persons who have never been users,^103,104 substance abuse treatment must continue to be an integral component of successful primary care for HIV-positive persons with substance use histories.

Persons living with severe mental illness or disability are at continued risk for substance abuse and HIV infection, but rates of screening in this population have varied by type and severity of disability. Neri and colleagues¹⁰⁵ compiled results from a 2002 National Health Interview Survey and found that even though adults with self-reported disability (as an aggregate) were more likely than nondisabled adults to report having been tested, persons with intellectual disability were the least likely to have been tested (approximately 4 times less likely than nondisabled respondents). Persons with chronic cognitive impairment may be at the most risk for HIV infection given the increased vulnerability to sexual abuse,¹⁰⁶ but poor advocacy systems and legal complexities also create additional barriers to preventive counseling and testing programs.

Even after a diagnosis of HIV infection is made in disabled persons, there are difficulties in accessing adequate care because of factors such as transportation and the need for interpreters. Residents of chronic-care facilities require comanagement among medical and nursing staff; family and legal custodians; and case managers who are experienced in this special-needs population. Very little is published about the care of HIV-positive persons with disabilities in general, but some data from Los Angeles and New York City suggest that patients with severe mental illness have more difficulty in obtaining care, less provider satisfaction, and poorer self-reported health status.¹⁰⁷ Many factors, including lack of knowledge, stigma, and fear, contribute to health disparities in this disadvantaged and extremely marginalized population.

GEOGRAPHIC LOCATION
The geographic distribution of HIV/AIDS in the United States has changed remarkably over the past 20 years. Even though the Northeast still has the highest rate of infection overall (30.1 cases per 100,000 in 2004¹), there has been a general decrease in new cases in that region over time. This is in marked contrast to increasing rates in the South, West, and Midwest (Figure).

Figure.Estimated rates (per 100,000 population) for adults and adolescents living with HIV infection, not AIDS (shaded boxes), or AIDS (open boxes), in the United States and dependent areas for 2005 (revised June 2007). Note: Rates are adjusted for reporting delays. Rates of HIV infection include only persons living with HIV infection that has not progressed to AIDS. Estimated rates for AIDS include persons whose area of residence is unknown. Since 2001, the following 37 areas have had laws or regulations requiring confidential name-based HIV infection reporting: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, American Samoa, Guam, the Northern Mariana Islands, and the US Virgin Islands. (Reproduced from Centers for Disease Control and Prevention. 2007.¹²⁰)

Many epidemiologists identify poverty as the major underlying reason for these trends: one study using national data obtained from the Health Resources and Services Administration and the Census Bureau found that counties with the largest increases in AIDS incidence had lower levels of income, education, and literacy; higher age-adjusted mortality (all causes); higher infant mortality; and more low-birth-weight infants.¹⁰⁸ Other studies based on similar epidemiological and demographic data further note that many people in the South are uninsured and that HIV/AIDS has affected African American women and rural residents disproportionately, especially in the United States–Mexico border area as well as in Appalachia and the Mississippi Delta.^109,110

Certain patterns of social and sexual networking in economically depressed areas of the South have also contributed to the predominantly heterosexual transmission of HIV: many people report concurrent sexual partnerships and drug use (particularly crack cocaine).¹¹¹ Commercial sex work and the practice of receiving financial support from multiple partners also seem to occur frequently¹¹² and support the spread of sexually transmitted infections.

Furthermore, there has been a historical lack of funding and provider experience in rural areas to encourage development of HIV prevention and treatment programs. Deficits in knowledge and/or lack of resources may be the reason HIV-positive persons living in the South initiate primary medical care quite late. One study found that 40% of persons had CDC-defined AIDS on presentation to an Alabama outpatient clinic, even though HIV infection had been diagnosed in more than 50% of this group in the preceding year.¹¹³

Delayed entry into medical care, poor quality of life, inadequate treatment of comorbid mental illness, and unequal use of antiretroviral therapy have also been documented in the South.^114,115 For HIV treatment interventions to adequately assist these patient populations, clinicians and public health leaders will need to understand the specific barriers faced by persons in the South and other geographic areas where stigma, gender/ethnic disparities, and limited resources may be especially challenging.

CONCLUSION
There are numerous emerging and meaningful health disparities and inequalities that affect HIV-infected persons in the United States today. Despite the United States having one of the most medically advanced health care systems, large numbers of people in this country remain uninsured or underinsured,¹¹⁶ and persistent trends in socioeconomic marginalization have accompanied widening health disparities for those who have or are at risk for HIV/AIDS. With the CDC’s 2006 recommendations for expanded HIV screening and much data supporting the economic and public health advantages of such a policy, it is important that the “3 million years of life” survival benefit of quality health care be realized by all HIV-infected persons.^117,118

As described above, several strategies can be employed to improve current health disparities in HIV/AIDS. These strategies include the promotion of early and routine screening, increased access to testing services (in both conventional and nontraditional settings), and improved provider knowledge (including administration of antiretroviral therapy and other relevant care). These should all be carried out in a manner that is sensitive to patients’ unique clinical and sociodemographic backgrounds.

Finally, funding agencies and policymakers will need to partner with clinicians and public health professionals (as well as community advocacy groups) to implement strategic, comprehensive, and thoughtful approaches to address HIV health inequalities. Otherwise, HIV/AIDS will continue to concentrate in the most vulnerable population groups, and the observed disparities are likely to increase over time.

No potential conflict of interest relevant to this article was reported by the authors.

References:

References1. Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention Assessment. Health Disparities in HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis in the United States: Issues, Burden, and Response. Atlanta: US Dept of Health and Human Services; November 2007.
2. Healthy People 2010: Understanding and Improving Health. 2nd ed. Rockville, Md: US Dept of Health and Human Services; November 2000.
3. Health Resources and Services Administration Workgroup for the Elimination of Health Disparities. Eliminating Health Disparities in the United States. Rockville, Md: US Dept of Health and Human Services. November 2000.
4. Carter-Pokras O, Baquet C. What is a “health disparity”? Public Health Rep. 2002;117:426-434.
5. Rangel MC, Gavin L, Reed C, et al. Epidemiology of HIV and AIDS among adolescents and young adults in the United States. J Adolesc Health. 2006;39:156-163.
6. Koenig LJ, Espinoza L, Hodge K, et al. Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection. Am J Obstet Gynecol. 2007;197(3 suppl):S123-S131.
7. Hall HI, Byers RH, Ling Q, Espinoza L. Racial/ethnic and age disparities in HIV prevalence and disease progression among men who have sex with men in the United States. Am J Public Health. 2007;97:1060-1066.
8. Ayres JR, Paiva V, Franca I Jr, et al. Vulnerability, human rights, and comprehensive health care needs of young people living with HIV/AIDS. Am J Public Health. 2006;96:1001-1006.
9. Veinot TC, Flicker SE, Skinner HA, et al. “Supposed to make you better but it doesn’t really”: HIV-positive youths’ perceptions of HIV treatment. J Adolesc Health. 2006;38:261-267.
10. Harris SK, Samples CL, Keenan PM, et al. Boston HAPPENS Program. Outreach, mental health, and case management services: can they help to retain HIV-positive and at-risk youth and young adults in care? Matern Child Health J. 2003;7:205-218.
11. Murphy DA, Belzer M, Durako SJ, et al; Adolescent Medicine HIV/AIDS Research Network. Longitudinal antiretroviral adherence among adolescents infected with Human Immunodeficiency Virus. Arch Pediatr Adolesc Med. 2005;159:764-770.
12. Williams PL, Storm D, Montepiedra G, et al; PACTG 219C Team. Predictors of adherence to antiretroviral medications in children and adolescents with HIV infection. Pediatrics. 2006;118:e1745-e1757.
13. Garvie PA, Lensing S, Rai SN. Efficacy of a pill-swallowing training intervention to improve antiretroviral medication adherence in pediatric patients with HIV/AIDS. Pediatrics. 2007;119:e893-e899.
14. Paul SM, Martin RM, Lu SE, et al. Changing trends in human immunodeficiency virus and acquired immunodeficiency syndrome in the population aged 50 and older. J Am Geriatr Soc. 2007;55:1393-1397.
15. Butt AA, Dascomb KK, DeSalvo KB, et al. Human immunodeficiency virus infection in elderly patients. South Med J. 2001;94:397-400.
16. Porter K, Babiker A, Bhaskaran K, et al; CASCADE Collaboration. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet. 2003;362:1267-1274.
17. Egger M, May M, Chene G, et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. 2002;360:119-129.
18. Gebo KA. HIV and aging: implications for patient management. Drugs Aging. 2006;23:897-913.
19. Vance DE. Olfactory and psychomotor symptoms in HIV and aging: potential precursors to cognitive loss. Med Sci Monit. 2007;13:SC1-SC3.
20. Watters MR, Poff PW, Shiramizu BT, et al. Symptomatic distal sensory polyneuropathy in HIV after age 50. Neurology. 2004;62:1378-1383.
21. Oursler KK, Sorkin JD, Smith BA, Katzel LI. Reduced aerobic capacity and physical functioning in older HIV-infected men. AIDS Res Hum Retroviruses. 2006;22:1113-1121.
22. Brar I, Shuter J, Thomas A, et al; Minorities and Women’s Task Force of the Terry Beirn Community Programs for Clinical Research on AIDS. A comparison of factors associated with prevalent diabetes mellitus among HIV-infected antiretroviral-naive individuals versus individuals in the National Health and Nutritional Examination Survey cohort. J Acquir Immune Defic Syndr. 2007;45:66-71.
23. Brown TT, Cole SR, Li X, et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med. 2005;165:1179-1184.
24. Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with HIV disease. J Clin Endocrinol Metab. 2007;92:2506-2512.
25. Friis-Moller N, Sabin CA, Weber R, et al; Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study Group. Combination antiretroviral therapy and the risk of myocardial infarction [published correction appears in N Engl J Med. 2004;350:955]. N Engl J Med. 2003;349:1993-2003.
26. De Silva TI, Post FA, Griffin MD, Dockrell DH. HIV-1 infection and the kidney: an evolving challenge in HIV medicine. Mayo Clin Proc. 2007;82:1103-1116.
27. Burgi A, Brodine S, Wegner S, et al. Incidence and risk factors for the occurrence of non-AIDS-defining cancers among human immunodeficiency virus-infected individuals. Cancer. 2005;104:1505-1511.
28. Bonnet F, Lewden C, May T, et al. Malignancy-related causes of death in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Cancer. 2004;101:317-324.
29. Fultz SL, Goulet JL, Weissman S, et al. Differences between infectious diseases–certified physicians and general medicine–certified physicians in the level of comfort with providing primary care to patients. Clin Infect Dis. 2005;41:738-743.
30. Sheth AN, Moore RD, Gebo KA. Provision of general and HIV-specific health maintenance in middle aged and older patients in an urban HIV clinic. AIDS Patient Care STDS. 2006;20:318-325.
31. Crystal S, Akincigil A, Sambamoorthi U, et al. The diverse older HIV-positive population: a national profile of economic circumstances, social support, and quality of life. J Acquir Immune Defic Syndr. 2003;33(suppl 2):S76-S83.
32. Chesney MA, Chambers DB, Taylor JM, Johnson LM. Social support, distress, and well-being in older men living with HIV infection. J Acquir Immune Defic Syndr. 2003;33(suppl 2):S185-S193.
33. Emlet CA. Experiences of stigma in older adults living with HIV/AIDS: a mixed-methods analysis. AIDS Patient Care STDS. 2007;21:740-752.
34. Linsk NL, Fowler JP, Klein SJ. HIV/AIDS prevention and care services and services for the aging: bridging the gap between service systems to assist older people. J Acquir Immune Defic Syndr. 2003;33(suppl 2):S243-S250.
35. Espinoza L, Hall HI, Hardnett F, et al. Characteristics of persons with heterosexually acquired HIV infection, United States 1999-2004. Am J Public Health. 2007;97:144-149.
36. Langford SE, Ananworanich J, Cooper DA. Predictors of disease progression in HIV infection: a review. AIDS Res Ther. 2007;4:11.
37. Jamieson DJ, Clark J, Kourtis AP, et al. Recommendations for human immunodeficiency virus screening, prophylaxis, and treatment for pregnant women in the United States. Am J Obstet Gynecol. 2007;197(3 suppl):S26-S32.
38. Schoenbaum EE, Hartel D, Lo Y, et al. HIV infection, drug use, and onset of natural menopause. Clin Infect Dis. 2005;41:1517-1524.
39. Fantry LE, Zhan M, Taylor GH, et al. Age of menopause and menopausal symptoms in HIV-infected women. AIDS Patient Care STDS. 2005;19:703-711.
40. Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS. 2006;20:2165-2174.
41. Gebo KA, Fleishman JA, Conviser R, et al. HIV Research Network. Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001. J Acquir Immune Defic Syndr. 2005;38:96-103.
42. McNaghten AD, Hanson DL, Dworkin MS. Differences in prescription of antiretroviral therapy in a large cohort of HIV-infected patients. J Acquir Immune Defic Syndr. 2003;32:499-505.
43. Eisenman D, Bogart LM, Bird CE, et al. Differential diffusion of HIV technologies by gender: the case of highly active antiretroviral therapy. AIDS Patient Care STDS. 2007;21:390-399.
44. Whetten K, Reif S, Lowe K, Eldred L. Gender differences in knowledge and perceptions of HIV resources among individuals living with HIV in the Southeast. South Med J. 2004;97:342-349.
45. Penniman TV, Taylor SL, Bird CE, et al. The associations of gender, sexual identity and competing needs with healthcare utilization among people with HIV/AIDS. J Natl Med Assoc. 2007;99:419-427.
46. Sohler N, Li X, Cunningham C. Perceived discrimination among severely disadvantaged people with HIV infection. Public Health Rep. 2007;122:347-355.
47. Ofotokun I, Chuck SK, Hitti JE. Antiretroviral pharmacokinetic profile: a review of sex differences. Gend Med. 2007;4:106-119.
48. Centers for Disease Control and Prevention. Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures-worldwide, 1997-2000. MMWR. 2001;49:1153-1156.
49. Espinoza L, Hall HI, Hardnett F, et al. Characteristics of persons with heterosexually acquired HIV infection, United States 1999-2004. Am J Public Health. 2007;97:144-149.
50. Morris M, Handcock MS, Miller WC, et al. Prevalence of HIV infection among young adults in the United States: results from the Add Health study. Am J Public Health. 2006;96:1091-1097.
51. Levine RS, Briggs NC, Kilbourne BS, et al. Black-White mortality from HIV in the United States before and after introduction of highly active antiretroviral therapy in 1996. Am J Public Health. 2007;97:1884-1892.
52. Jain S, Schwarcz S, Katz M, et al. Elevated risk of death for African Americans with AIDS, San Francisco, 1996-2002. J Health Care Poor Underserved. 2006;17:493-503.
53. McGinnis KA, Fine MJ, Sharma RK, et al. Understanding racial disparities in HIV using data from the veterans aging cohort 3-site study and VA administrative data. Am J Public Health. 2003;93:1728-1733.
54. Keruly JC, Conviser R, Moore RD. Association of medical insurance and other factors with receipt of antiretroviral therapy. Am J Public Health. 2002;92:852-857.
55. Keruly JC, Moore RD. Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clin Infect Dis. 2007;45:1369-1374.
56. Lucas GM, Mehta SH, Atta MG, et al. End-stage renal disease and chronic kidney disease in a cohort of African-American HIV-infected and at-risk HIV-seronegative participants followed between 1988 and 2004. AIDS. 2007;21:2435-2443.
57. Choi AI, Rodriguez RA, Bacchetti P, et al. Racial differences in end-stage renal disease rates in HIV infection versus diabetes. J Am Soc Nephrol. 2007;18:2968-2974.
58. Eggers PW, Kimmel PL. Is there an epidemic of HIV infection in the US ESRD program? J Am Soc Nephrol. 2004;15:2477-2485.
59. Szczech LA. Renal diseases associated with human immunodeficiency virus infection: epidemiology, clinical course, and management. Clin Infect Dis. 2001;33:115-119.
60. Atta MG, Gallant JE, Rahman MH, et al. Antiretroviral therapy in the treatment of HIV-associated nephropathy. Nephrol Dial Transplant. 2006;21:2809-2813.
61. Macrae J, Friedman AL, Eggers P, Friedman EA. Improved survival in HIV-infected African-Americans with ESRD. Clin Nephrol. 2005;64:124-128.
62. Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Rockville, Md: US Dept of Health and Human Services; January 29, 2008:1-128.
63. Foulkes AS, Wohl DA, Frank I, et al. Associations among race/ethnicity, ApoC-III genotypes, and lipids in HIV-1-infected individuals on antiretroviral therapy. PLoS Med. 2006;3:e52.
64. Symonds W, Cutrell A, Edwards M, et al. Risk factor analysis of hypersensitivity reactions to abacavir. Clin Ther. 2002;24:565-573.
65. Centers for Disease Control and Prevention. HIV/AIDS among Hispanics-United States, 2001-2005. MMWR. 2007;56:1052-1257.
66. Loue S. Preventing HIV, eliminating disparities among Hispanics in the United States. J Immigr Minor Health. 2006;8:313-318.
67. Levy V, Prentiss D, Balmas G, et al. Factors in the delayed HIV presentation of immigrants in Northern California: implications for voluntary counseling and testing programs. J Immigr Minor Health. 2007;9:49-54.
68. Garland WH, Wohl AR, Valencia R, et al. The acceptability of a directly-administered antiretroviral therapy (DAART) intervention among patients in public HIV clinics in Los Angeles, California. AIDS Care. 2007;19:159-167.
69. Zaidi IF, Crepaz N, Song R, et al. Epidemiology of HIV/AIDS among Asians and Pacific Islanders in the United States. AIDS Educ Prev. 2005;17:405-417
70. Kaufman CE, Shelby L, Mosure DJ, et al; Task force on STD Prevention and Control Among American Indians and Alaska Natives. Within the hidden epidemic: sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives. Sex Transm Dis. 2007;34:767-777.
71. Bertolli J, Lee LM, Sullivan PS; AI/AN Race/Ethnicity Data Validation Workgroup. Racial misidentification of American Indians/Alaska Natives in the HIV/AIDS Reporting Systems of five states and one urban health jurisdiction, U.S., 1984-2002. Public Health Rep. 2007;122:382-392.
72. Gorgos L, Avery E, Bletzer K, Wilson C. Determinants of survival for Native American adults with HIV infection. AIDS Patient Care STDS. 2006;20:586-594.
73. Pounds MB, Conviser R, Ashman JJ, Bourassa V. Ryan White Care Act service use by Asian/Pacific Islanders and other clients in three California metropolitan areas (1997-1998). J Community Health. 2002;27:403-417.
74. Chin JJ, Kang E, Kim JH, et al. Serving Asians and Pacific Islanders with HIV/AIDS: challenges and lessons learned. J Health Care Poor Underserved. 2006;17:910-927.
75. Millett GA, Flores SA, Peterson JL, Bakeman R. Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors. AIDS. 2007;21:2083-2091.
76. Kral AH, Lorvick J, Ciccarone D, et al. HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco. J Urban Health. 2005;82(1 suppl 1):i43-i50.
77. Goldstein RB, Rotheram-Borus MJ, Johnson MO, et al; NIMH Healthy Living Trial Group. Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus. Med Care. 2005;43:401-410.
78. Cunningham WE, Markson LE, Andersen RM, et al. Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the United States. HCSUS Consortium. HIV Cost and Services Utilization. J Acquir Immune Defic Syndr. 2000;25:115-123.
79. Bailey SL, Shinogle JA. Impact of a statewide Medicaid managed care system on healthcare utilization and outcomes for people living with HIV. Am J Med Sci. 2004;328:305-314.
80. Bernell SL, Shinogle JA. The relationship between HAART use and employment for HIV-positive individuals: an empirical analysis and policy outlook. Health Policy. 2005;71:255-264.
81. Kinsler JJ, Wong MD, Sayles JN, et al. The effect of perceived stigma from a health care provider on access to care among a low-income HIV-positive population. AIDS Patient Care STDS. 2007;21:584-592.
82. Hasnain M, Levy JA, Mensah EK, Sinacore JM. Association of educational attainment with HIV risk in African American active injection drug users. AIDS Care. 2007;19:87-91.
83. Graham J, Bennett IM, Holmes WC, Gross R. Medication beliefs as mediators of the health literacy-antiretroviral adherence relationship in HIV-infected individuals. AIDS Behav. 2007;11:385-392.
84. Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health literacy: an overlooked factor in understanding HIV health disparities. Am J Prev Med. 2007;33:374-378.
85. Robertson MJ, Clark RA, Charlebois ED, et al. HIV seroprevalence among homeless and marginally housed adults in San Francisco. Am J Public Health. 2004;94:1207-1217.
86. Macalino GE, Vlahov D, Sanford-Colby S, et al. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons [published correction appears in Am J Public Health. 2004;94:1847]. Am J Public Health. 2004;94:1218-1223.
87. Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health. 2007;97:2238-2245.
88. Kidder DP, Wolitski RJ, Royal S, et al; Housing and Health Study Team. Access to housing as a structural intervention for homeless and unstably housed people living with HIV: rationale, methods, and implementation of the housing and health study. AIDS Behav. 2007;11(6 suppl):149-161.
89. Springer SA, Friedland GH, Doros G, et al. Antiretroviral treatment regimen outcomes among HIV-infected prisoners. HIV Clin Trials. 2007;8:205-212.
90. Lert F, Kazatchkine MD. Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview. Int J Drug Policy. 2007;18:255-261.
91. Cofrancesco J, Scherzer R, Tien PC, et al. Illicit drug use and HIV treatment outcomes in a US cohort. AIDS. 2008;22:357-365.
92. Cohen MH, Cook JA, Grey D, et al. Medically eligible women who do not use HAART: the importance of abuse, drug use, and race. Am J Public Health. 2004;94:1147-1151.
93. Lucas GM, Cheever LW, Chaisson RE, Moore RD. Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. J Acquir Immune Defic Syndr. 2001;27:251-259.
94. Arnsten JH, Li X, Mizuno Y, et al; INSPIRE Study Team. Factors associated with antiretroviral therapy adherence and medication errors among HIV-infected injection drug users. J Acquir Immune Defic Syndr. 2007;46(suppl 2):S64-S71.
95. Zaller N, Gillani FS, Rich JD. A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness. AIDS Care. 2007;19:1128-1133.
96. Parsons JT, Golub SA, Rosof E, Holder C. Motivational interviewing and cognitive-behavioral intervention to improve HIV medication adherence among hazardous drinkers: a randomized controlled trial. J Acquir Immune Defic Syndr. 2007;46:443-450.
97. Macalino GE, Hogan JW, Mitty JA. A randomized clinical trial of community-based directly observed therapy as an adherence intervention for HAART among substance users. AIDS. 2007;21:1473-1477.
98. Soto TA, Bell J, Pillen MB; HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study Group. Literature on integrated HIV care: a review. AIDS Care. 2004;16(suppl 1):S43-S55.
99. Selwyn PA, Budner NS, Wasserman WC, Arno PS. Utilization of on-site primary care services by HIV-seropositive and seronegative drug users in a methadone maintenance program. Public Health Rep. 1993;108:492-500.
100. Sambamoorthi U, Warner LA, Crystal S, Walkup J. Drug abuse, methadone treatment, and health services use among injection drug users with AIDS. Drug Alcohol Depend. 2000;60:77-89.
101. McCance-Katz EF, Moody DE, Morse GD, et al. Interactions between buprenorphine and antiretrovirals. I. The nonnucleoside reverse-transcriptase inhibitors efavirenz and delavirdine. Clin Infect Dis. 2006;43(suppl 4):S224-S234.
102. McCance-Katz EF, Moody DE, Smith PF, et al. Interactions between buprenorphine and antiretrovirals. II. The protease inhibitors nelfinavir, lopinavir/ritonavir, and ritonavir. Clin Infect Dis. 2006;43(suppl 4):S235-S246.
103. Cofrancesco J Jr, Scherzer R, Tien PC, et al. Illicit drug use and HIV treatment outcomes in a US cohort. AIDS. 2008;22:357-365.
104. Hicks PL, Mulvey KP, Chander G, et al. The impact of illicit drug use and substance abuse treatment on adherence to HAART. AIDS Care. 2007;19:1134-1140.
105. Neri SV, Bradley EH, Groce NE. Frequency of HIV testing among persons with disabilities: results from the National Health Interview Survey, 2002. AIDS Educ Prev. 2007;19:545-554.
106. Murphy GH, O’Callaghan A. Capacity of adults with intellectual disabilities to consent to sexual relationships. Psychol Med. 2004;34:1347-1357.
107. Fremont AM, Young AS, Chinman M, et al. Differences in HIV care between patients with and without severe mental illness. Psychiatr Serv. 2007;58:681-688.
108. Peterman TA, Lindsey CA, Selik RM. This place is killing me: a comparison of counties where the incidence rates of AIDS increased the most and the least. J Infect Dis. 2005;191(suppl 1):S123-S126.
109. Reif S, Geonnotti KL, Whetten K. HIV infection and AIDS in the Deep South. Am J Public Health. 2006;96:970-973.
110. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. J Rural Health. 2005;21:245-253.
111. Adimora AA, Schoenbach VJ, Martinson FE, et al. Heterosexually transmitted HIV infection among African Americans in North Carolina. J Acquir Immune Defic Syndr. 2006;41:616-623.
112. Stratford D, Ellerbrock TV, Chamblee S. Social organization of sexual-economic networks and the persistence of HIV in a rural area in the USA. Cult Health Sex. 2007;9:121-135.
113. Krawczyk CS, Funkhouser E, Kilby JM, et al. Factors associated with delayed initiation of HIV medical care among infected persons attending a southern HIV/AIDS clinic. South Med J. 2006;99:472-481.
114. Reif S, Whetten K, Ostermann J, Raper JL. Characteristics of HIV-infected adults in the Deep South and their utilization of mental health services: a rural vs. urban comparison. AIDS Care. 2006;18(suppl 1):S10-S17.
115. Pence BW, Reif S, Whetten K, et al. Minorities, the poor, and survivors of abuse: HIV-infected patients in the US deep South. South Med J. 2007;100:1114-1122.
116. Young SR, Conviser R, Marconi K, Wieland MK. Trends and responsiveness in national resource allocation for needed HIV services: a five year (1996-2000) analysis. J Health Soc Policy. 2003;17:1-14.
117. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs. Ann Intern Med. 2006;145:797-806.
118. Walensky RP, Paltiel AD, Losina E, et al. The survival benefits of AIDS treatment in the United States. J Infect Dis. 2006;194:11-19.
119. Centers for Disease Control and Prevention. A Heightened National Response to the HIV/AIDS Crisis Among African Americans. Atlanta: Centers for Disease Control and Prevention; June 2007.
120. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and dependent areas, 2005. Revised June 2007. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf. Accessed February 7, 2008.