Background:  There are conflicting data regarding possible race and sex differences in mortality of HIV⁺ persons. We studied all-cause mortality over 8 years among persons in care during the HAART era.

Methods:  This retrospective cohort study included all patients in care (≥1 visit) at the Comprehensive Care Center (Nashville, Tennessee) between January 1998 and December 2005. Healthcare was available to all HIV⁺ Tennesseans during the study period. Proportion of time in care on HAART was days on HAART divided by total days in care. Fisher's exact and rank sum tests compared baseline characteristics and HAART use during follow-up. Cox regression models examined factors associated with time to death.

Results:  Of 2605 study patients (6657 person-years of follow-up), median age was 38 years; 38% were black, 24% female, and 12% had a history of injection drug use (IDU). Overall mortality was 38 deaths per 1000 person-years. Median CD4 at presentation was lower in blacks than non-blacks (304 vs 336; p = 0.003) and higher in females than males (366 vs 312; p <0.001). Proportion of time in care on HAART was less for blacks than non-blacks (47% vs 76%;p <.001) and females than males (57% vs 71%; p = 0.01). These relationships held when limited to persons with baseline CD4 <200. Loss to follow-up did not differ by race or sex. Crude all-cause mortality was higher in blacks than non-blacks (49 vs 31 deaths per 1000 person-years; HR 1.6; p <0.001), but similar for females and males (41 vs 37 deaths per 1000 person-years; HR 1.1; p = 0.47). In a multivariate analysis adjusting for characteristics at the first visit (CD4, CD4%, HIV-1 RNA, current or prior AIDS diagnosis, age, and prior ART use), death was associated with black race (HR 1.3; p = .04), female sex (HR 1.5; p = 0.006), IDU (HR 1.7; p = 0.003), AIDS diagnosis (HR 1.5; p = 0.02), older age (HR 1.03 per year; p <0.001), and lower CD4 (HR 0.8 per 100 cell increase; p <0.001). After including proportion of time in care on HAART, black race (HR 1.04; p = 0.81) and IDU (HR 1.4; p = 0.07) were no longer associated with death, but female sex was (HR 1.5; p = 0.007).

Conclusions:  Among HIV⁺ persons in care, blacks and females received less HAART than whites and males, respectively. There were race differences in mortality, likely due to differences in HAART use. Adjusting for characteristics at presentation, women had an increased risk of death even after adjusting for HAART use. Addressing survival disparities will require increased HAART utilization in blacks; the risk of death in women requires further study.