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Racial Disparity in U.S. Diagnoses of Acquired
Immune Deficiency Syndrome, 2000 –2009
Qian An, MS, Joseph Prejean, PhD, H. Irene Hall, PhD
This activity is available for CME credit. See page A3 for information.

Background: Increased attention has been focused on health disparities among racial/ethnic groups in the U.S.

Purpose: To assess the extent of progress toward meeting the targets of Healthy People 2010 objectives and eliminating disparities.
Methods: All diagnoses of AIDS during 2000 –2009 among people aged Ն13 years in the 50 states and District of Columbia, reported to national HIV surveillance through June 2010, together with census population data were used in this analysis (conducted in March 2011). This study assesses the trend in racial/ethnic disparities in rates of AIDS diagnoses both between particular groups using rate difference (RD) and rate ratio (RR) and across the entire range of racial/ethnic subgroups using three summary measures of disparity: between-group variance (BGV); Theil index (TI); and mean log deviation (MLD).

Results: The overall racial/ethnic disparity, black–white disparity, and Hispanic–white disparity in rates of AIDS diagnoses decreased for those aged 25– 64 years from 2000 to 2009. The black–white and Hispanic–white disparity in rates of AIDS diagnoses also decreased among men aged Ն65 years; however, the black–white disparity increased among young men aged 13–24 years (BGV: pϽ0.001, black–white RD: pϽ0.01) from 2000 to 2009.
Conclusions: Findings indicate overall decreases in racial/ethnic disparities in AIDS diagnoses except in young men, particularly young black men aged 13–24 years where the burden of AIDS is increasing. HIV testing, prevention, treatment and policy-making should be a priority for this group.
(Am J Prev Med 2012;43(5):461–466) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

H

uman immunodefıciency virus disproportionately affects communities of color, particularly blacks/African Americans (blacks) and Hispanics/
Latinos (Hispanics). In 2009, blacks and Hispanics comprised about 12% and 16% of the U.S. population, but comprised about 44% and 20% of estimated new infections.1 A goal of Healthy People 2010 is to eliminate health disparities among subgroups of the U.S. population.2
Reducing racial and ethnic disparities in HIV infections has been an overarching national goal of the CDC’s HIV prevention strategic plan since 2001.3,4 The 2001 CDC plan provided a valuable guide for HIV prevention, care, and treatment efforts in both the private and public sectors for the last decade. Using AIDS diagnosis rates, it is possible to assess the racial/ethnic disparity change in a decade in the
From the Division of HIV/AIDS Prevention, National Center for HIV/
AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
Address correspondence to: Qian An, MS, CDC, 1600 Clifton Rd NE,
Mailstop E-47, Atlanta GA 30333. E-mail: FEI8@cdc.gov.
0749-3797/$36.00
http://dx.doi.org/10.1016/j.amepre.2012.07.040

U.S. The present study assesses the trend in racial/ethnic disparities in rates of new diagnoses of AIDS for 50 states and the District of Columbia from 2000 to 2009 by comparing rates for blacks versus whites, and Hispanics versus whites, and across the range of race/ethnicity subgroups.
Previous studies of racial disparities in HIV diagnoses only focused on disparities between two particular groups or two particular time points using pair-wise measures such as rate ratio or rate difference.5–7 To monitor disparities in rates of AIDS diagnosis in the U.S., the current study adopts and extends the framework proposed by Harper and Lynch,8 who systematically reviewed a variety of measures of health disparity and provided recommendations for choosing measures that can be used to monitor health disparities in cancer-related health outcomes.9 –11 Given the increased attention of prevention and treatment efforts to reduce HIV disparities among racial/ethnic groups in the U.S., it is hypothesized that the racial disparity in rates of AIDS diagnoses has decreased in the past decade, particularly the black– white disparity and the Hispanic–white disparity.

Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Am J Prev Med 2012;43(5):461– 466 461

An et al / Am J Prev Med 2012;43(5):461– 466

462

Methods
Data
In 1982, the CDC implemented surveillance for what would later be identifıed as AIDS, although it was not clearly defıned at the time and went through several case defınitions in the early years.
All diagnoses of AIDS (defıned as cases with a CD4ϩ T-lymphocyte count per microliter of Ͻ200 or CD4ϩ T-lymphocyte percentage of total lymphocytes of Ͻ14, or the presence of an opportunistic illness) during 2000 through 2009 among individuals aged
Ն13 years residing in the 50 states and District of Columbia reported to national HIV surveillance through June 2010 were included in this analysis (conducted in March 2011) and were adjusted for reporting delay (time lag between the date of a case diagnosis and the date a case was reported to the national surveillance system).12 Population denominators for the calculation of rates were based on intercensal estimates for 2000 –2009 obtained from the U.S. Census Bureau.13 Rates of AIDS diagnoses were calculated for seven race/ethnicity groups: American Indian/
Alaska Native; Asian; black/African American; Hispanic/Latino
(which includes individuals of any race); Native Hawaiian/other
Pacifıc Islander; white; and multiple race (individuals who report more than one race).

Measures of Health Disparity
Three summary measures of health disparity (Theil index, mean log deviation and between-group variance) suitable for nominal groups were chosen to assess the trend of disparity across the entire range of racial/ethnic subgroups.8,9 Because blacks and Hispanics have been affected disproportionately by HIV compared to whites, pair-wise measures of health disparity (rate ratio and rate difference) were included to quantify trends in black–white and Hispanic– white disparities. Pair-wise comparison was not conducted for other racial/ethnic groups because the rates of AIDS diagnoses in those groups were unstable and results might be unreliable.
The three summary measures quantify disparities across seven racial/ethnic subgroups and factor in both the AIDS diagnosis rate and the population size of each racial/ethnic subgroup, both of which change over time and affect the overall disparity. Therefore, these summary measures are more sensitive in monitoring disparities over time than pair-wise measures.8,11 Moreover, both absolute measures and relative measures were included simultaneously to assess changes in absolute and relative disease burden because using only one type of measure could generate misleading results.
The Theil index (TI) and mean log deviation (MLD) are summary measures of relative disparity. They summarize the disproportional impact of a disease, using the rate ratio relative to the population average, weighted by population size. Given yj as the rate of health in group j and ␮ as the total population rate of health, then rj ϭ yj ␮ is the ratio of the rate of health in group j relative to that of the total population. For grouped data, TI can be calculated as TI ϭ ͚pjrj lnrj and MLD ϭ ͚pj ͓Ϫ j͔, where pj is the lnr proportion of the population in group j.8, 9 Both are positive numbers, where higher values represent more disparity.
Between-group variance (BGV) is a summary measure of absolute disparity. It summarizes the squared differences in group rates from the population average and is also weighted by population size.8 Using notations defıned previously, BGV is calculated as
BGV ϭ ͚pj ͑yj Ϫ ␮͒2 . The BGV is a positive number, with higher values representing more disparity.

ր

Rate ratio (RR) is a relative measure of disparity between two groups. Using white as the reference group, RR is calculated as
RR ϭ yj yw , where yj is the rate for group of interest and yw is the rate for the white population. Rate difference (RD) is an absolute measure of the simple arithmetic difference between two groups and is calculated as RD ϭ yj Ϫ yw.

ր

Data Analysis
For each year from 2000 to 2009, the race/ethnicity-specifıc estimated numbers of AIDS diagnoses and population estimates among people aged Ն13 years were calculated. The race/ethnicityspecifıc rates of AIDS diagnoses were calculated per 100,000 people overall and for gender groups and age groups (13–24 years,
25– 44 years, 45– 64 years, and Ն65 years). The TIs, MLDs, BGVs, black–white RRs, black–white RDs, Hispanic–white RRs, and
Hispanic–white RDs were calculated. All measures were logtransformed to satisfy the assumptions for linear regression.
Linear regressions were conducted (GLM procedure, SAS 9.2) with each log-transformed measure of health disparity as the dependent variable, year of diagnosis as the independent variable to test the signifıcance of the trend and to estimate the annual percentage change. The signifıcance of a trend was assessed at the 0.05 level. The estimated annual percentage change (EAPC) was calculated by taking the exponentiation of the parameter estimate for year of diagnosis. The 95% CI for EAPC was estimated based on a t-distribution with 8 degrees of freedom.

Results
For 2000 to 2009, there were 354,300 diagnosed AIDS cases reported to the CDC from 50 states and the District of Columbia. After adjusting for reporting delay, the total number of estimated AIDS diagnoses from 2000 to 2009 was 377,198.
Overall, all summary measures of health disparity suggest a signifıcant decreasing trend in racial disparity in the rates of AIDS diagnoses from 2000 to 2009 (pϽ0.01). The
EAPC was Ϫ1.3 (95% CIϭϪ1.9, Ϫ0.7) for TI and MLD and was Ϫ7.5 (95% CIϭϪ8.9, Ϫ6.1) for BGV (Table 1).
The black–white disparity and Hispanic–white disparity in the rates of AIDS diagnoses also decreased signifıcantly
(pϽ0.01). The EAPC was Ϫ1.0 (95% CIϭϪ1.8, Ϫ0.2) for black–white RR; Ϫ3.9 (95% CIϭϪ4.7, Ϫ3.1) for black– white RD; 1.7 (95% CIϭϪ2.5, Ϫ0.9) for Hispanic–white RR; and Ϫ5.1 (95% CIϭϪ5.9, Ϫ4.4) for Hispanic–white RD.
Among men/boys, the overall racial/ethnic disparity, black–white disparity and Hispanic–white disparity in the rates of AIDS diagnoses decreased from 2000 to 2009
(pՅ0.01; Appendix A, available online at www.ajpmonline. org). The EAPC was Ϫ1.6 (95% CIϭϪ2.4, Ϫ0.8) for TI;
Ϫ1.5 (95% CIϭϪ2.3, Ϫ0.7) for MLD; Ϫ8.0 (95% CIϭ
Ϫ9.5, Ϫ6.5) for BGV; Ϫ1.2 (95% CIϭϪ2.0, Ϫ0.3) for black–white RR; Ϫ4.2 (95% CIϭϪ5.0, Ϫ3.3) for black– white RD; Ϫ1.4 (95% CIϭϪ2.1, Ϫ0.8) for Hispanic–white
RR; and Ϫ5.0 (95% CIϭϪ5.7, Ϫ4.4) for Hispanic–white
RD (Table 2). Among women/girls, there was a decreaswww.ajpmonline.org

An et al / Am J Prev Med 2012;43(5):461– 466

463

Table 1. Measures of racial/ethnic disparity in estimated AIDS diagnosis rates and estimated annual percentage change, U.S., 2000Ϫ2009
Rates of AIDS diagnoses 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

EAPC (95% CI)

p-value

Summary indicators
Theil index (ϫ100)

54.4

55

53.2

54.0

51.7

50.2

48.6

49.4

50.0

49.9 Ϫ1.3 (Ϫ1.9, Ϫ0.7) Ͻ0.01

Mean log deviation
(ϫ100)

48

48.4

46.3

47.6

45.1

44.3

42.9

43.4

43.8

44.0 Ϫ1.3 (Ϫ1.9, Ϫ0.7) Ͻ0.01

Between-group variance 487.9 460.6 442.7 452.8 402.6 340.1 297.5 285.9 275.3 260.6 Ϫ7.5 (Ϫ8.9, Ϫ6.1) Ͻ0.01

Pair-wise comparison
BlackϪwhite
rate ratio

10.0 Ϫ1.0 (Ϫ1.8, Ϫ0.2)

10.5

10.8

10.4

10.7

10.1

9.8

9.5

9.8

10.0

0.01

HispanicϪwhite rate ratio

4

3.9

3.6

3.9

3.5

3.6

3.5

3.5

3.4

3.4 Ϫ1.7 (Ϫ2.5, Ϫ0.9) Ͻ0.01

BlackϪwhite rate difference

68.3

66.5

65.3

65.8

62.1

56.8

53

52

51.2

49.7 Ϫ3.9 (Ϫ4.7, Ϫ3.1) Ͻ0.01

HispanicϪwhite rate difference

21.3

19.9

18.3

19.4

16.9

16.6

15.5

14.6

13.7

13.3 Ϫ5.1 (Ϫ5.9, Ϫ4.4) Ͻ0.01

Note: Race/ethnicity groups are mutually exclusive; Hispanics can be of any race. Estimates of AIDS diagnoses are adjusted for reporting delay, but not complete reporting. Rate is per 100,000 people.
EAPC, estimated annual percentage change

ing trend in overall racial/ethnic disparity (pՅ0.02), and in Hispanic–white disparity (pϽ0.01); in black–white disparity, the absolute black–white RD decreased signifıcantly (pϽ0.01) but not the black–white RR (pϭ0.13).
The EAPC was Ϫ0.7 (95% CIϭϪ1.2, Ϫ0.2) for TI; Ϫ0.9
(95% CIϭϪ1.6, Ϫ0.2) for MLD; and Ϫ6.8 (95%
CIϭϪ8.8, Ϫ4.7) for BGV; Ϫ0.8 (95% CIϭϪ1.9, 0.3) for black–white RR; Ϫ3.5 (95% CIϭϪ4.6, Ϫ2.5) for black–white RD; Ϫ2.6 (95% CIϭϪ4.3, Ϫ0.9) for
Hispanic–white RR; and Ϫ5.8 (95% CIϭϪ7.3, Ϫ4.2) for
Hispanic–white RD (Table 2).

Among those aged 13Ϫ24 years, the relative summary measures suggest no change in the overall racial/ethnic disparity in the rates of AIDS diagnoses (TI: pϭ0.90, and
MLD: pϭ0.97); however, the absolute summary measure,
BGV, suggests a signifıcant increasing trend in racial disparity from 2000 to 2009 (BGV: pϽ0.01), with an
EAPC of 7.8 (95% CIϭ5.4, 10.3; Appendix B, available online at www.ajpmonline.org). Among all pair-wise measures, the black–white RD showed an increasing trend from 2000 to 2009 (pϽ0.01) with an EAPC of 3.7
(95% CIϭ2.5, 4.9), whereas the black–white RR

Table 2. Estimated annual percentage change for measures of racial/ethnic disparity in estimated AIDS diagnosis rates, U.S., 2000Ϫ2009
Men/boys

Women/girls

Aged 13Ϫ24 years

Aged 25Ϫ44 years

Aged 45Ϫ64 years

Aged Ն65 years

Measure of relative disparity
Ϫ1.6 (Ϫ2.4, Ϫ0.8) Ϫ0.7 (Ϫ1.2, Ϫ0.2)

0.1 (Ϫ0.8, 0.9)

Ϫ1.9 (Ϫ2.7, Ϫ1.0)

Ϫ2.1 (Ϫ2.5, Ϫ1.8) Ϫ2.5 (Ϫ3.7, Ϫ1.3)

Mean log deviation (ϫ100) Ϫ1.5 (Ϫ2.3, Ϫ0.7) Ϫ0.9 (Ϫ1.6, Ϫ0.2)

0 (Ϫ1.0, 1.0)

Ϫ1.9 (Ϫ2.8, Ϫ1.0)

Ϫ2.1 (Ϫ2.5, Ϫ1.8) Ϫ2.6 (Ϫ4.2, Ϫ0.9)

Theil index (ϫ100)

BlackϪwhite rate ratio

Ϫ1.2 (Ϫ2.0, Ϫ0.3) Ϫ0.8 (Ϫ1.9, 0.3)

0.6 (Ϫ0.9, 2,2)

Ϫ1.2 (Ϫ2.2, Ϫ0.2)

Ϫ2.4 (Ϫ3.0, Ϫ1.8) Ϫ3.1 (Ϫ5.0, Ϫ1.1)

HispanicϪwhite rate ratio

Ϫ1.4 (Ϫ2.1, Ϫ0.8) Ϫ2.6 (Ϫ4.3, Ϫ0.9)

Ϫ1.3 (Ϫ3.7, 1.2)

Ϫ1.5 (Ϫ2.6, Ϫ0.3)

Ϫ4.2 (Ϫ5.3, Ϫ3.2) Ϫ4.9 (Ϫ9.0, Ϫ0.7)

Ϫ8.0 (Ϫ9.5, Ϫ6.5) Ϫ6.8 (Ϫ8.8, Ϫ4.7)

7.8 (5.4, 10.3)

Measure of absolute disparity
Between-group variance

BlackϪwhite rate difference Ϫ4.2 (Ϫ5.0, Ϫ3.3) Ϫ3.5 (Ϫ4.6, Ϫ2.5)
HispanicϪwhite rate difference Ϫ5.0 (Ϫ5.7, Ϫ4.4) Ϫ5.8 (Ϫ7.3, Ϫ4.2)

Ϫ10.5 (Ϫ12.3, Ϫ8.7) Ϫ4.7 (Ϫ5.9, Ϫ3.5) Ϫ2.8 (Ϫ5.7, 0.2)

3.7 (2.5, 4.9)

Ϫ5.4 (Ϫ6.4, Ϫ4.4)

Ϫ2.6 (Ϫ3.3, Ϫ1.9) Ϫ1.5 (Ϫ3.0, 0.0)

1.4 (Ϫ1.0, 3.8)

Ϫ6.3 (Ϫ7.1, Ϫ5.5)

Ϫ5.5 (Ϫ6.5, Ϫ4.4) Ϫ3.9 (Ϫ7.9, 0.2)

Note: Race/ethnicity groups are mutually exclusive; Hispanics can be of any race. Estimates of AIDS diagnoses are adjusted for reporting delay, but not complete reporting. Rate is per 100,000 people.

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An et al / Am J Prev Med 2012;43(5):461– 466

(pϭ0.39); Hispanic–white RR (pϭ0.27); and Hispanic– white RD (pϭ0.20) showed no changes.
Among those aged 25Ϫ44 years, all summary measures and pair-wise measures suggest a decreasing trend in overall racial/ethnic disparity, black–white disparity and Hispanic–white disparity from 2000 to 2009
(pՅ0.02). The EAPC was Ϫ1.9 (95% CIϭϪ2.7, Ϫ1.0) for
TI; Ϫ1.9 (95% CIϭϪ2.8, Ϫ1.0) for MLD; Ϫ10.5 (95%
CIϭϪ12.3, Ϫ8.7) for BGV; Ϫ1.2 (95% CIϭϪ2.2, Ϫ0.2) for black–white RR; Ϫ5.4 (95% CIϭϪ6.4, Ϫ4.4) for black–white RD; Ϫ1.5 (95% CIϭϪ2.6, Ϫ0.3) for Hispanic– white RR; and Ϫ6.3 (95% CIϭϪ7.1, Ϫ5.5) for
Hispanic–white RD.
Among those aged 45Ϫ64 years, all summary measures and pair-wise measures also suggest a decreasing trend in the racial/ethnic disparity in the rates of AIDS diagnoses from 2000 to 2009 (pϽ0.01). The EAPC was
Ϫ2.1 (95% CIϭϪ2.5, Ϫ1.8) for TI and MLD; Ϫ4.7 (95%
CIϭϪ5.9, Ϫ3.5) for BGV; Ϫ2.4 (95% CIϭϪ3.0, Ϫ1.8) for black–white RR; Ϫ2.6 (95% CIϭϪ3.3, Ϫ1.9) for black–white RD; Ϫ4.2 (95% CIϭϪ5.3, Ϫ3.2) for Hispanic– white RR; and Ϫ5.5 (95% CIϭϪ6.5, Ϫ4.4) for
Hispanic–white RD. In the oldest age group, all relative measures suggest a decreasing trend in racial disparity in rates of AIDS diagnoses (pՅ0.03), while all absolute measures suggest no change (pϭ0.06) from 2000 to 2009.
The EAPC was Ϫ2.5 (95% CIϭϪ3.7, Ϫ1.3) for TI; Ϫ2.6
(95% CIϭϪ4.2, Ϫ0.9) for MLD; Ϫ3.1 (95% CIϭϪ5.0, Ϫ1.1) for black–white RR; and Ϫ4.9 (95% CIϭϪ9.0, Ϫ0.7) for
Hispanic–white RR.
To examine whether the racial disparity trend in the rates of AIDS diagnoses from 2000 to 2009 varied by region, the analyses were conducted by region also
(Northeast, Midwest, South, and West). Results showed a general decreasing trend in the overall racial/ethnic disparity, black–white disparity, and Hispanic–white disparity in all regions of the U.S. and an increasing trend in black–white disparity among those aged 13–24 years in all regions but west (data not shown).
To understand the disagreement in relative and absolute measures of racial disparity in rates of AIDS diagnoses during 2000 –2009 for those aged 13–24 years and those aged Ն65 years, a comparison was made of the race/ethnicity-specifıc rates of AIDS diagnoses for each age and gender group in 2000 and 2009. From 2000 to
2009, the rates of AIDS diagnoses increased by 38% in the group aged 13–24 years, decreased by 32% and 8% for those aged 25– 44 years and those aged 45– 64 years, respectively, and remained unchanged in the group aged
Ն65 years (Table 3). The increase in the rates of AIDS diagnoses among young people aged 13–24 years was attributable to the 90% increase among men/boys, from
4.1 per 100,000 in 2000 to 7.8 per 100,000 in 2009.

Among young men aged 13–24 years, the rates of AIDS diagnoses increased by 116% from 15.4 per 100,000 to
33.3 per 100,000 in blacks, by 35% from 6.3 per 100,000 to
8.5 per 100,000 in Hispanics, and by 50% from 1.2 per
100,000 to 1.8 per 100,000 in whites from 2000 to 2009.
For the group aged Ն65 years, although the overall rates of AIDS diagnoses remained unchanged, the rates of
AIDS diagnoses decreased in men from 3.8 per 100,000 in
2000 to 3.6 per 100,000 in 2009. Among the oldest men, the rates of AIDS diagnoses decreased from 26.1 to 21.3 per 100,000 (18.4%) in blacks and from 11.9 to 8.5 per
100,000 (28.6%) in Hispanics, but increased from 1.4 to
1.5 per 100,000 (7.1%) in whites from 2000 to 2009. In addition, to investigate the possibility that using standard age cut-points may have affected the results, a sensitivity analysis was conducted that demonstrated similar results when using fıner age strata by 5-year age groups (data not shown). Discussion
The results confırmed the hypotheses that from 2000 to
2009, the overall racial/ethnic disparity, black–white disparity, and Hispanic–white disparity in rates of AIDS diagnoses decreased in the U.S., with more pronounced decreasing trends among people aged 25– 64 years. The black–white and Hispanic–white disparity in rates of
AIDS diagnoses also decreased among men aged
Ն65 years; however, the black–white disparity increased signifıcantly among young men aged 13–24 years. To our knowledge, the current study is the fırst that comprehensively evaluates the racial/ethnic disparity trend in rates of AIDS diagnoses in the U.S. It is the fırst to apply summary measures, together with pair-wise measures of health disparity to comprehensively assess the racial/ethnic disparity trend in rates of AIDS diagnoses in a decade in the U.S.
These measures were chosen from a variety of health disparity measures8,9,14 –17 to assess changes in both absolute and relative measures. Because racial/ethnic groups are nominal, the three summary measures were considered the best for nominal groups.8 –11 Moreover, they are sensitive to both the sizes of population subgroups and the AIDS diagnosis rate of each racial/ethnic subgroup.8 –11 The results from using these measures were reliable and valid.
For the group aged 13–24 years, the increasing absolute disparity measures indicate that the racial disparity in rates of AIDS diagnoses increased during 2000 –2009.
The absolute increase and the percentage increase in rates of AIDS diagnoses were greater in black young men than white young men. Although the percentage increase was smaller in Hispanic young men than white young men, www.ajpmonline.org An et al / Am J Prev Med 2012;43(5):461– 466

465

Table 3. Estimated AIDS diagnosis rates for selected groups, U.S., 2000 and 2009
Non-Hispanic
blacks
Age groups (years)

Non-Hispanic whites Hispanics

Overall

2000

2009

2000

2009

2000

2009

2000

2009

All

15.5

22.1

4.8

5.5

0.9

1.2

3.7

5.1

Men

15.4

33.3

6.3

8.5

1.2

1.8

4.1

7.8

Women

15.6

10.5

3.1

2.2

0.7

0.5

3.3

2.3

All

123.5

78.7

44.9

27.0

14.0

9.4

32.0

21.8

Men

169.4

105.1

66.8

41.0

23.9

16.1

47.2

32.1

82.4

54.4

20.3

10.4

4.1

2.6

16.8

11.2

85.7

71.2

34.7

23.5

6.8

7.1

17.2

15.9

135.6

104.2

55.1

35.0

12.1

12.3

27.5

24.3

43.8

43.6

15.5

11.9

1.7

2.0

7.5

8.0

All

14.4

12.7

6.1

5.5

0.7

0.8

2.1

2.1

Men

26.1

21.3

11.9

8.5

1.4

1.5

3.8

3.6

7.1

7.4

1.9

3.2

0.2

0.2

0.9

1.1

13Ϫ24

25Ϫ44

Women
45Ϫ64
All
Men
Women
Ն65

Women

Note: Estimates of AIDS diagnoses are adjusted for reporting delay, but not complete reporting. Rate is per 100,000 people. Hispanics can be of any race.

the absolute increase was greater. As a result, the absolute difference between blacks and whites, and Hispanics and whites, increased from 2000 to 2009 among the group aged 13–24 years, and consequently there was an increase in the absolute summary measure of disparity, BGV. The results suggest that the racial disparity in rates of AIDS diagnoses increased signifıcantly in young men aged
13–24 years from 2000 to 2009, highlighting the increasing burden of HIV in young men, particularly black young men aged 13–24 years in the U.S., which is consistent with fındings from other studies.18,19
Among the groups aged 25– 44 years and 45– 64 years, the reason for the decreasing racial/ethnic disparity trend is that the overall rates of AIDS diagnoses decreased, and the rates decreased faster in blacks and Hispanics than in whites. Among the group aged Ն65 years, the decreasing black–white and Hispanic–white rate ratios indicate that the black–white and Hispanic–white racial disparity in rates of AIDS diagnoses decreased during 2000 –2009.
This was caused by the increasing rates in older white men, together with decreasing rates in black and Hispanic men in the same age group during 2000 –2009.
The disagreement between absolute and relative measures of racial disparity for those aged 13–24 years and
November 2012

those aged Ն65 years suggests that it is important to use the absolute and relative measures simultaneously when evaluating changes in racial disparity over time. When disease rates are increasing as in the group of those aged
13–24 years, a decreasing or stable relative disparity measure does not necessarily correspond to a reduction in the absolute disparity measure; therefore, it is not suffıcient to indicate any trend in the disparity between groups.
However, as shown by the declining disease rates in the black and Hispanic groups of those aged Ն65 years, a decrease in relative disparity measures does correspond to a reduction in the absolute disparity measures and is indicative of a decreasing trend in the disparity between groups.20 This analysis is affected by several limitations. First, the data represent people who have been diagnosed with
AIDS and were reported to the national HIV surveillance system. Studies indicate that the reporting of AIDS cases in most areas of the U.S. is more than 85% complete.21–24
If the percentage of undiagnosed or unreported cases were consistent across years, fındings from the present study should still hold. Additionally, race data were collected differently in 2000 –2002 versus post-2003. Race data collected in 2000 –2002 were mapped to the 2003

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An et al / Am J Prev Med 2012;43(5):461– 466

categories, affecting a small number of cases in the Asian and Native Hawaiian/other Pacifıc Islander categories; however, the impact of these cases should be small.
The current study assessed the racial/ethnic disparity trends in rates of AIDS diagnoses. The time of progression from initial HIV infection to AIDS varies across individuals, depending on factors such as one’s health status, timing of entry into HIV care, antiretroviral use and adherence, and presence of other medical conditions.25 Therefore, the racial/ethnic disparity trend in
AIDS diagnoses is the combination of the racial/ethnic disparity trend in HIV infection, diagnosis, and access to care. Also, decreasing racial/ethnic disparity in rates of
AIDS diagnoses does not imply a low rate. Recent data show that HIV prevalence is still disproportionately high among blacks.26
Results from this analysis show that the racial/ethnic disparity in rates of AIDS diagnoses decreased in the U.S. from 2000 to 2009 except among young men aged
13–24 years, for whom racial/ethnic disparities increased signifıcantly. Among young men aged 13–24 years, rates of AIDS diagnoses more than doubled in blacks compared with smaller increases in whites and Hispanics from 2000 to 2009. Such disparities indicate priorities for
HIV testing, prevention, treatment, and policy-making.
The fındings and conclusions are those of the authors and do not necessarily represent the views of the CDC.
No fınancial disclosures were reported by the authors of this paper. References
1. Joseph P, Song R, Hernandez A, et al. Estimated HIV Incidence in the
U.S., 2006 –2009. PLoS ONE 2011;6(8):e17502. doi:10.1371/journal. pone.0017502. 2. DHHS. Healthy People 2010: understanding and improving health.
2nd ed. Washington DC: U.S. GPO, 2000. www.healthypeople. gov/Document/pdf/uih/2010uih.pdf. 3. CDC. A heightened national response to the HIV/AIDS crisis among
African Americans. Revised June 2007. www.cdc.gov/hiv/topics/aa/ resources/reports/pdf/heightenedresponse.pdf. 4. CDC. HIV prevention strategic plan through 2005. January 2001. www.cdc.gov/hiv/resources/reports/psp/pdf/prev-strat-plan.pdf. 5. Drewette-Card JR, Landen GM. The disparity change score: a new methodology to examine health disparities in New Mexico. J Public
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7. CDC. Disparities in diagnoses of HIV infection between blacks/African Americans and other racial/ethnic populations—37 states, 2005–
2008. Morb Mortal Wkly Rep 2011;60:94 – 8.

8. Harper S, Lynch J. Methods for measuring cancer disparities: using data relevant to Healthy People 2010 cancer-related objectives. Washington
DC: National Cancer Institute, 2006. seer.cancer.gov/publications/ disparities/measuring_disparities.pdf. 9. Harper S, Lynch J, Meersman CS, Breen N, Davis WW, Reichman EM.
An overview of methods for monitoring social disparities in cancer with an example using trends in lung cancer incidence by areasocioeconomic position and race-ethnicity, 1992–2004. Am J Epidemiol 2009;167(8):889 –99.
10. Harper S, Lynch J, Meersman CS, et al. Respond to “Measuring Social
Disparities in Health.” Am J Epidemiol 2009;167(8):905–7.
11. Harper S, Lynch J, Meersman CS, Breen N, Davis WW, Reichman CM.
Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987–2005). Cancer Epidemiol
Biomarkers Prev 2009;18(1):121–31.
12. Green TA. Using surveillance data to monitor trends in the AIDS epidemic. Stat Med 1998;17:143–54.
13. U.S. Census Bureau. Population estimates: entire data set. July 1, 2009. www.census.gov/popest/estimates.php. 14. Pearcy NJ, Keppel GK. A summary measure of health disparity. Public
Health Rep 2002;117:273– 80.
15. Keppel KG, Pearcy JN, Klein RJ. Measuring progress in Healthy People
2010. Healthy People 2010. Stat Notes 2004:1–16.
16. Regidor E. Measures of health inequalities: part 1. J Epidemiol Community Health 2004;58:858 – 61.
17. Regidor E. Measures of health inequalities: part 2. J Epidemiol Community Health. 2004;58:900 –3.
18. CDC. Trends in HIV/AIDS diagnoses among men who have sex with men—33 states, 2001–2006. Morb Mortal Wkly Rep 57:681– 6.
19. Johnson SA, Hu X, Sharpe TT, Dean DH. Disparities in HIV/AIDS diagnoses among racial and ethnic minority youth. J Equity Health
2009;2(1):4 –17.
20. Hoover K, Bohm M, Keppel GK. Measuring disparities in the incidence of sexually transmitted diseases. Sex Transm Dis 2009;35(12S):
S40 –S44.
21. Hall HI, Song R, Gerstle JE III, Lee LM, on behalf of the HIV/AIDS
Reporting System Evaluation Group. Assessing the completeness of reporting of human immunodefıciency virus diagnoses in 2002–2003: capture-recapture methods. Am J Epidemiol 2007;164:391–7.
22. Schwarcz SK, Hsu LC, Parisi MK, Katz MH. The impact of the 1993
AIDS case defınition on the completeness and timeliness of AIDS surveillance. AIDS 1999;13:1109 –14.
23. Klevens RM, Fleming PL, Li J. The completeness, validity, and timeliness of AIDS surveillance data. Ann Epidemiol 2001;11:443–9.
24. Campsmith M, Rhodes P, Hall HI. Estimated prevalence of undiagnosed HIV infection in the U.S. at the end of 2006. Abstract #1036.
Presented at the 2009 Conference on Retroviruses and Opportunistic
Infections; Montreal, Canada, February 11, 2009.
25. CiChocki M. How long does it take for HIV to progress to AIDS? aids.about.com/cs/aidsfactsheets/f/blhowlong.htm. 26. CDC. HIV/AIDS Surveillance Report, 2009; Vol. 21. www.cdc. gov/hiv/surveillance/resources/reports/2009report/. Appendix
Supplementary data
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.amepre.2012.07.040.

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