Factors Associated with State Variation in Mortality Among Persons Living with Diagnosed HIV Infection

  • Amy L. KruegerEmail author
  • Michelle Van Handel
  • Patricia M. Dietz
  • Weston O. Williams
  • Anna Satcher Johnson
  • Pamela W. Klein
  • Stacy Cohen
  • Paul Mandsager
  • Laura W. Cheever
  • Philip Rhodes
  • David W. Purcell
Original Paper


In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age–group-specific models (24–34, 35–54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010–2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3–5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92–0.99 for 24–34 years, aRR: 0.97, 95%CI: 0.94–0.99 for 35–54 years, aRR: 0.96, 95%CI: 0.94–0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4–11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93–0.99 for 34–54 years; aRR: 0.89, 95%CI: 0.81–0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2–3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95–1.00 for 34–54 years; aRR: 0.97, 95%CI: 0.94–0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.


HIV/AIDS HIV testing Viral suppression Healthcare coverage Stigma 



Publication of this manuscript was made possible by the contributions of the state and territorial health departments and the HIV surveillance programs that provided surveillance data to CDC and the Ryan White HIV/AIDS Program grant recipients and subrecipients that provided data to HRSA.


The authors received no financial support for the research, authorship, and/or publication of this article.

Compliance with Ethical Standards

Conflicts of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplementary material

10900_2019_655_MOESM1_ESM.docx (46 kb)
Supplementary material 1 (DOCX 45 kb)


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Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  • Amy L. Krueger
    • 1
    • 2
    Email author
  • Michelle Van Handel
    • 1
  • Patricia M. Dietz
    • 1
  • Weston O. Williams
    • 1
    • 3
  • Anna Satcher Johnson
    • 1
  • Pamela W. Klein
    • 4
  • Stacy Cohen
    • 4
  • Paul Mandsager
    • 4
  • Laura W. Cheever
    • 4
  • Philip Rhodes
    • 1
  • David W. Purcell
    • 1
  1. 1.Division of HIV/AIDS PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDCAtlantaUSA
  2. 2.School of Health SciencesUniversity of TampereTampereFinland
  3. 3.Public Health Analytic Consulting Services, Inc.HillsboroughUSA
  4. 4.HIV/AIDS Bureau, Health Resources and Services AdministrationRockvilleUSA

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