aids mortality before and after the introduction of highly active antiretroviral

European Journal of Public Health, Vol. 16, No. 6, 601–608

� The Author 2006. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

doi:10.1093/eurpub/ckl062 Advance Access published on 12 May, 2006

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Infectious diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AIDS mortality before and after theintroduction of highly active antiretroviraltherapy: does it vary with socioeconomicgroup in a country with a NationalHealth System?

Carme Borrell, Maica Rodrıguez-Sanz, M. Isabel Pasarın, M. Teresa Brugal,Patricia Garcıa-de-Olalla, Marc Marı-Dell’Olmo, Joan Cayla

Background: The aim of this study is to determine whether socioeconomic AIDS mortality inequalitiesbefore and after the introduction of highly active antiretroviral therapy (HAART) have increased ordecreased in a Spanish city where HAART is free. Methods: The study used a trend design, includingall Barcelona residents older than 19 years of age. All AIDS deaths, which occurred among these residentsbetween 1991 and 2001 were included. The variables studied were age, sex, socioeconomic (SES) groupand HIV transmission group. AIDS age-standardized mortality rates for each year were estimated.Poisson regression models were fitted to obtain the relative risk (RR) of AIDS death for each socio-economic group with respect to the reference group. Results: AIDS mortality increased up until 1995and subsequently decreased due to the introduction of HAART. The increase in AIDS mortality wasgreater in the lowest SES group, which had higher rates and a RR of dying larger than that of the highestSES group, fact that remained fairly stable over the whole period. A similar pattern was observed inintravenous drug users. In the homosexual transmission group, rates for the lowest SES group werehigher for thewhole period and increased until 1996, while rates for the other SES groupswere lower anddecreased over the entire period. Conclusions: The fact that inequalities in AIDS mortality by SES groupremained fairly stable for thewhole period suggests that perhaps access to HAART, or adherence, is lowerthan desirable, in people of lower SES groups. These results ought to be taken into account whenimplementing treatment and prevention strategies.

Keywords: AIDS mortality, HAART therapy, socioeconomic inequalities, trends, urban area,Southern Europe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

T he pattern of AIDS mortality changed after 1996 in thedeveloped countries. Previously, it had been increasing

since the appearance of the disease, having become the leadingcause of death among young adults in Spain; after that year itstarted to decline.1–4 This change was due to the introduction ofhighly active antiretroviral therapy (HAART) and also to theutilization of preventive measures for opportunistic diseases.5–7

However, HAART did not only diminish mortality, it alsoimproved the survival and the quality of life of persons withAIDS as has been reported by several authors.8–10

HIV transmission and AIDS have been related to social andmaterial deprivation such as poverty, use of drugs, prostitutionand immigration.11,12 Nowadays, AIDS is concentrated in themost socially vulnerable groups and countries,13–17 inner cityurban areas generally having high incidence. It has been reportedthat in the city of Barcelona (Spain) there are social inequalitiesin the AIDS distribution among the neighbourhoods of thecity. The inequality pattern was different in the differenttransmission categories: material and social deprivation wasrelated with AIDS in intravenous drug users (IDUs) and het-

erosexual contacts, but inversely related in the case ofhomosexual contacts.18

Several studies have shown that, prior to the introduction ofHAART, AIDS mortality was increasing more in areas withgreater deprivation than in other areas.19,20 Furthermore,some authors have reported that AIDS survival was longerfor people having a higher socioeconomic status,21,22 althoughother studies have not found any differences.23 However,relatively few studies have tried to assess the effect on socialinequalities of the introduction of this therapy.24,25

In Spain HAART was introduced in 1996 and its effectivenesshas increased with the introduction of new drugs in thetherapy.10 HAART is free of charge for all patients due to theexistence of a National Health System. For this reason we mayhypothesize that AIDS mortality inequalities after the intro-duction of HAART should narrow. Therefore, our aim is todetermine whether socioeconomic AIDS mortality inequalitiesbefore and after the introduction of HAART have increased ordecreased in a Spanish city.

Methods

Design and study population

Barcelona, the second largest city in Spain (1 508 805 inhabitantsin 1996), is located on the north eastern coast. The study useda trend design, including all Barcelona residents older than

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Agencia de Salut Publica de Barcelona, Red de Centros deEpidemiologıa y Salud Publica (RCESP), Barcelona, Spain

Correspondence: Carme Borrell, Agencia de Salut Publica deBarcelona, Pl. Lesseps 1, 08023 Barcelona, Spain, tel: þ34-93-2384545, fax: þ34-93-2173197, e-mail: [email protected]

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19 years of age. All AIDS-related deaths in the mortality register,which occurred among these residents between 1991 and 2001were included. The underlying causes of death were coded usingthe International Classification of Diseases (ICD) 9th revisionuntil 1999, the codes attributed to AIDS/HIV in Spain being:279.5 (AIDS) and 795.8 (HIV without other specified causes).After 1999 the codes used were B20–B24 of the ICD-10.

The educational level and the neighbourhood of the deceasedwere obtained through a record linkage between the mortalityregister and the municipal census (87.4% of cases were linked),and transmission group was obtained through a record linkagewith the AIDS cases register of Barcelona (85.6% of caseswere linked). These are confidential probabilistic linkagesbased on the name and the surname and date of birth of thedeceased.26

Information on the population at risk, including age, sex, thehighest completed level of education and neighbourhood ofresidence comes from the 1991 and 1996 Municipal Census,an administrative register not subject to statistical secrecy; wedid not have data of the census by educational level for other

years. Every resident in Barcelona is registered in the municipalcensus. This census is continually updated to incorporate dataon migration, births and deaths. For the years between the twocensuses an estimate of the intercensal population was obtainedbased on a geometric curve. The denominators for the years1997–2001 were based on the 1996 census.

Variables and indicators analysed

The variables studied were age, sex, highest level of educationcompleted (educational level), neighbourhood of residence, andHIV transmission group.

Educational level was categorized in two groups: (i) Loweducational level: includes illiterate, people with no education(no schooling) who have 0–4 years of schooling and people withprimary studies not finished (5–6 years of schooling) and(ii) High educational level: includes people with more thanprimary studies ($7 years of schooling). These two groupswere chosen after inspecting the distribution of AIDS mortalityrates in five educational levels (illiterate and no education,

Table 1 Distribution of AIDS deaths by year of death, HIV transmission group, socioeconomic group and age-group. Menand women, Barcelona 1991–2001

Men Women

N % N %

Year of death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 192 9.2 32 6.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1992 242 11.6 51 10.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 270 12.9 68 13.9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1994 304 14.6 87 17.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 344 16.5 74 15.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 317 15.2 67 13.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1997 121 5.8 31 6.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 78 3.7 23 4.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1999 66 3.2 16 3.3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 82 3.9 17 3.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2001 71 3.4 22 4.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HIV transmission group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intravenous drug user 947 45.4 261 53.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Homosexual 636 30.5 – –. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heterosexual 205 9.8 155 31.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Missing data 299 14.3 72 14.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Socio-economic group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Non-deprived neighbourhood and high educational level 442 21.2 131 26.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Non-deprived neighbourhood and low educational level 419 20.1 112 23.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Deprived neighbourhood and high educational level 255 12.2 57 11.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Deprived neighbourhood and low educational level 694 33.3 140 28.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Missing data 277 13.2 48 9.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Age-group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20–34 years 883 42.3 311 63.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$35 years 1204 57.7 177 36.3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total 2087 100.0 488 100.0

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primary not finished, primary finished, secondary and univer-sity studies), it being found that AIDS rates in the first twogroups were similar and likewise the rates in the other threegroups.

Barcelona has 38 neighbourhoods, their populationsvarying, in 1996, between 1081 and 95 382 inhabitants (mean:39 705 inhabitants per neighbourhood). We grouped theneighbourhoods following our prior analysis that dividedthem in two groups20: one group contained the low socioeco-nomic (SES) neighbourhoods while the other included allremaining neighbourhoods. The method employed was clusteranalysis using SES variables (unemployment and illiteracy)obtained from local censuses corresponding to the years1981, 1986 and 1991. Neighbourhoods were divided in twogroups due to the small numbers of deaths in each neighbour-hood, and also to the fact that there is an important degree ofhomogeneity in the group of neighbourhoods with high SESlevel, both in terms of SES indicators and in terms of mortality .The grouping involved 11 deprived neighbourhoods with highunemployment and illiteracy (and a population of 262 921inhabitants in 1996), and included the older inner-city neigh-bourhoods, as well as a few new peripheral neighbourhoods; theother group consisted of 27 neighbourhoods, with a total popu-lation of 1 245 884 inhabitants in 1996 with lower values of theSES indicators (unemployment and illiteracy).

Using the two educational levels and the two groups ofneighbourhoods we obtained 4 SES groups, hence subjectswere classified as: (i) Living in a non-deprived neighbourhoodand having a high educational level, (ii) Living in a non-deprived neighbourhood and having a low educational level,(iii) Living in a deprived neighbourhood and having a higheducational level, (iv) Living in a deprived neighbourhoodand having a low educational level.

Three HIV transmission groups were studied: homosexualsand bisexuals who were not IDUs, heterosexuals who were notIDUs and IDUs (i.e. includes homosexuals, bisexuals andheterosexuals who were IDUs).

Data analysis

All the analyses were performed for each sex and transmissiongroup. Age-standardized AIDS mortality rates for each year,

standardized through the direct method, were estimatedusing the 1996 population of Barcelona as the referencepopulation. For IDUs we calculated the standardized rates forthe 20–49 age-group because there were almost no cases olderthan 49 years.

Poisson regression models27 were fitted to obtain the relativerisk (RR) of AIDS death for each SES group with respect to thereference group (living in a non-deprived neighbourhood andhaving a high educational level), adjusted for age for the years1991, 1993, 1995, 1996, 1998 and 2000. The dependent variablewas the logarithm of the AIDS mortality rate, and the independ-ent variables were SES group and age (grouped as: 20–34 yearsand $35 years). For IDUs the models were estimated for the20–49 age-group.

Results

We included 2087 cases of male AIDS death, and 488 female.Table 1 shows the distribution of these cases of death by year,transmission group, SES group and age-group. The majority ofAIDS deaths occurred in the IDUs group, followed by the malehomosexual transmission group.

Figure 1 shows total age-standardized AIDS mortality ratesduring the whole study period by sex. For men, the increaseuntil 1995 was higher among those living in deprived neigh-bourhoods; both these SES groups experienced a decreasewhich ended in 1998, after which rates either increased againor remained stable. For women, the pattern was similar. After1998 the rates among women living in deprived neighbour-hoods increased again, showing a different pattern comparedto women living in non-deprived neighbourhoods.

Tables 2 and 3 show, for men and women, the RR of dying ofeach SES group comparing with the most privileged one, for thedifferent years and for the different transmission groups. Fortotal AIDS mortality, it is possible to observe how the RRincrease mainly in the lowest SES in both sexes for the wholeperiod: the RR were higher in 1995, 1998 and 2000 for men andin 1991, 1993 and 2000 for women, although the confidenceintervals are wide. But it has to be mentioned that absolutedifferences are higher in 1995 than in the other years, mainly

0

60

120

180

240

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

0

60

120

180

240

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

MenMen WomenWomen

Low educational level and deprived neighborhood

Low educational level and the rest of neighborhoods

High educational level and deprived neighborhood

High educational level and the rest of neighborhoods

Figure 1 Age-standardized AIDS mortality rate per 100000 inhabitants aged $20 years by socioeconomic group. Barcelona,men and women, 1991–2001

AIDS mortality before and after the introduction of highly active antiretroviral therapy 603

by AN

A B

ringeL on A


Dow

nloaded from


due to the higher rates. For example, the absolute difference formen between the lowest SES group and the highest in 1995 is200.04 per 100 000 inhabitants and in 2000 is 59.9, for womenthese differences are 51.4 and 21.7.

Figure 2a shows the pattern of the evolution of agestandardized AIDS mortality rates in IDUs. The patternis very similar to that for all deaths, increasing until 1995,decreasing to 1998 and then increasing again mainly in peopleliving in deprived neighbourhoods. RR are higher than fordeaths due to all causes, mainly in the lowest SES group

all over the years, although in the years 1995 and 2000 theRR are higher for men and in 2000 for women (tables 2and 3). Again, the absolute differences are higher in 1995(figure 2a).

In the homosexual transmission group, the trends in menare quite different from the trends in total AIDS mortality(figure 2b). Rates for the lowest SES group increased until1996, while rates for the other SES groups decreased over theentire period. Table 2 shows the higher RR for the lowest SESgroup, with a peak in 1998.

Table 2 Relative risk of dying of AIDS by socioeconomic group. Different transmission groups in men aged $20 years.Barcelona, 1991–2000

Transmissiongroup and year

Socioeconomic group

Non deprived neighbourhood Deprived neighbourhood

High educationallevel

Low educationallevel



RR RR 95% CI RR 95% CI RR 95% CI

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 1.9 1.2–2.8 1.3 0.7–2.3 3.7 2.4–5.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 1.3 0.9–1.8 1.4 0.9–2.2 2.6 1.8–3.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 1.6 1.2–2.3 2.4 1.7–3.4 5.7 4.2–7.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 1.4 1.0–1.9 2.4 1.7–3.5 3.2 2.3–4.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 2.0 1.0–3.8 3.9 1.9–8.0 6.6 3.5–12.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 2.9 1.4–5.9 6.3 2.9–13.9 10.0 5.0–20.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intravenous drug usera. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 4.6 2.5–8.5 1.4 0.6–3.4 9.6 5.1–18.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 2.6 1.5–4.4 1.4 0.7–2.7 5.5 3.2–9.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 4.1 2.7–6.4 3.4 2.1–5.5 13.3 8.9–19.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 4.4 2.8–6.7 3.9 2.4–6.2 8.7 5.6–13.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 4.6 1.8–11.6 4.0 1.4–11.4 7.8 2.9–21.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 4.8 1.6–14.3 4.4 1.2–15.5 15.1 5.5–41.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Homosexual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 1.0 0.5–1.7 1.2 0.5–3.1 0.9 0.4–2.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 0.8 0.5–1.5 1.2 0.5–2.6 1.4 0.7–2.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 0.6 0.4–1.2 1.8 0.9–3.5 2.0 1.2–3.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 0.7 0.4–1.2 1.9 1.0–3.8 2.0 1.1–3.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 1.7 0.3–8.5 5.0 0.8–30.2 7.9 1.8–33.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 0.9 0.2–3.8 3.3 0.6–16.9 1.7 0.3–8.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heterosexual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 0.9 0.2–5.0 1.8 0.2–16.4 3.7 0.8–17.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 1.0 0.4–2.8 2.3 0.6–8.3 2.8 1.0–7.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 1.0 0.3–3.0 1.8 0.5–6.3 5.0 2.0–12.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 0.6 0.3–1.5 1.0 0.2–4.1 1.0 0.3–3.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 0.6 0.1–3.1 1.6 0.2–14.0 4.3 1.2–15.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 0b 0–1b 8.8 0.6–140.9 7.9 0.7–86.6

RR: Age-adjusted relative risk; 95% CI: 95% confidence interval of RRa: For intravenous drug users it refers to 20–49 age-groupb: The number of cases in this socio-economic group is 0


by AN

A B

ringeL on A


Dow

nloaded from


Figure 2c shows trends in the heterosexual transmissiongroup: for the lowest SES group, rates are higher and increasemore for women than for men. For men, RR across SES groupsare statistically significant particularly for the lowest SES groupfor almost all the years (table 2). For women, the small numberof cases in this group makes the estimations difficult, but thelowest SES had high RR mainly in the first period (1991 and1993) (table 3).

Discussion

These results show how AIDS mortality rates which wereincreasing prior to the introduction of HAART in 1996decreased after that year. They also show that although theevolution of AIDS mortality for different SES groups, sexesand transmission groups was slightly different, AIDS mortalityinequalities by SES group remained quite stable, in the sensethat lower SES groups had higher mortality than the moreprivileged one’s, and inequalities did not narrow after theintroduction of HAART as we had hypothesized. These results

refer to a Southern European urban area, in a country witha National Health System where HAART therapy is free andtherefore accessible to everyone. To our knowledge thisrelationship has not been described before in any SouthernEuropean country, despite being the region where the highestAIDS rates among developed countries have been experienced.

The pattern of trends in AIDS mortality overall is very similarto that observed in IDUs, with rates being higher in males andin deprived neighbourhoods. In IDUs, mortality rates hadalready begun to decrease before the introduction of theHAART therapy in the majority of SES groups, probablydue to the intervention programs in the AIDS field addressedto this group of people.28 These programs were designed to assistdrug users, dealing not only with specific health problems(infectious disease, mental health. . .) but also with practicalneeds (housing, food. . .). Moreover, the harm reductionprograms include active case-finding and treatment of organicproblems (such as tuberculosis), methadone maintenanceprograms,29 syringe exchange, outreach programs, legal andoccupational support. At the end of the period rates in

Table 3 Relative risk of dying of AIDS by socioeconomic group. Different transmission groups in women aged $20 years.Barcelona, 1991–2000

Transmissiongroup and year

Socioeconomic group

Non deprived neighbourhood Deprived neighbourhood





RR RR 95% CI RR 95% CI RR 95% CI

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 6.3 2.3–17.3 1.3 0.3–6.3 13.1 4.7–36.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 4.2 2.0–8.7 3.1 1.4–7.1 12.1 6.0–24.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 1.7 0.9–3.6 1.9 0.8–4.1 7.4 4.0–13.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 2.0 1.0–4.1 2.1 0.9–4.6 6.2 3.2–12.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 2.6 0.8–8.4 0.9 0.1–7.0 5.7 1.7–19.4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 4.0 0.9–18.7 2.0 0.2–19.5 20.2 5.0–81.9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intravenous drug usera. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 7.9 2.3–27.1 2.1 0.4–11.0 13.6 3.7–50.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 4.6 1.7–12.1 2.8 0.9–8.1 13.4 5.4–33.1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 5.6 2.3–13.6 2.3 0.7–7.4 18.6 8.2–42.2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 2.7 1.1–6.9 2.8 1.1–4.3 9.4 4.1–21.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 3.1 0.5–19.5 2.1 0.2–20.0 11.6 2.3–59.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 4.6 0.3–75.4 6.3 0.4–100.8 56.9 6.5–497.9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heterosexual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1991 1 3.4 0.4–28.5 0b 0–1b 14.9 2.3–98.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1993 1 5.6 1.5–21.4 2.9 0.5–15.8 11.8 3.0–46.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1995 1 0.7 0.2–2.2 0.9 0.2–3.8 3.2 1.1–8.8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1996 1 2.1 0.7–6.2 0.8 0.1–6.4 4.7 1.5–14.5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1998 1 4.5 0.8–25.9 0b 0–1b 4.0 0.4–40.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2000 1 1c 0–1c 1c 0–1c 1c 0–1c

RR: Age-adjusted relative risk; 95%CI: 95% confidence interval of RRa: For intravenous drug users it refers to 20–49 age-groupb: The number of cases in this socioeconomic group is 0c: The number of cases in the reference group is 0


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IDUs tended to increase again, mainly those of the deprivedneighbourhoods.

In the homosexual and heterosexual transmissiongroups, rates were higher in the lowest SES group. AIDSmortality trends in these groups have tended to decreasesince 1996.

Other papers have reported AIDS evolution in terms ofSES groups using both individual and aggregated data. Rapitiet al.30 studied AIDS survival by neighbourhood SES statusbefore (1993–1995) and after (1996–1997) the introductionof HAART therapy in Rome in a retrospective cohort ofAIDS cases. For persons with AIDS diagnosed in the 1993–1995 period they found little difference in the risk of deathby neighbourhood SES status; but for 1996–1997, the risk of

death was greater for persons with lower neighbourhood SESstatus, after having adjusted for age, sex, intravenous drug use,CD4 cell count diagnosis, AIDS defining disease and hospitaldiagnosis. The authors discuss the roles which health-careaccess, medical management, or poor adherence to treatmentmay play in explaining these inequalities.

Several studies, in American countries, have shown howcertain trends in inequalities are related to the lack of accessto HAART therapy. Wallace24 showed that decreases in AIDSmortality in areas of New York (USA), defined by zip code,were related to an array of SES and community stress variables,the areas with indicators of less deprivation (white population,college degree, higher income) having a greater decrease, whilemore deprived areas had a lower decrease. In San Franciso

0

50

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 20010

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

MenMen

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 0

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1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Low educational level and deprived neighborhood

Low educational level and the rest of neighborhoods

High educational level and deprived neighborhood

High educational level and the rest of neighborhoods

(a)

(b)

(c)

Figure 2 Age-standardized AIDS mortality rate per 100 000 inhabitants aged $20 years by socioeconomic group andtransmission group. Barcelona, men and women, 1991–2001. (a) Intravenous drug users (20–49 age-group) (b) Homosexualmen (c) Heterosexual


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(USA), persons living in poorer neighbourhoods were lesslikely to have undergone HAART at any time in the past com-pared with persons in wealthier neighbourhoods, leading topoorer AIDS survival for people living in deprived areas.25

Blair et al.31 examined the evolution of AIDS mortality inmen who have sex with men in the USA by racial/ethnicgroup: blacks and Hispanics had higher rates and smallerdeclines than whites. However one study, in Sao Paolo (Brasil),which found no relation between the decline of AIDS mortalityrates and deprivation of the neighbourhoods, the authorshypothesize that this may be due to programs of free treatmentand prevention.32

In the present study it was not possible to investigatedifferences in plasma viral load, CD4 cell count, comorbidity,resistance to treatment or behaviours related to AIDS (such assyringe sharing or risky sexual behaviour) between differentSES groups. We only can say that late diagnosis of AIDS(which can be a proxy of CD4 cell counts) was not differentamong SES groups in the AIDS death cases where we hadthis variable available through the record linkage with theAIDS cases register (88.4% of death cases). One study conductedin British Columbia (Canada) where HAART therapy isalso free, found that, after adjusting for all the factorsmentioned above (except behaviours), individuals of lowerSES groups had higher mortality and were less likely to receivetriple therapy.33

The persistence of SES-group related mortality inequalitiesin Barcelona following the introduction of HAART may beexplained by different factors.16 First of all, factors related tohealth care such as lack of access to treatment for people inthe lowest SES groups,34 even though Spain has a NationalHealth System and the therapy is free. In this sense, one Spanishstudy has reported that 8.4% of IDUs have not had an HIV test,which probably leads to a late diagnosis of AIDS and late treat-ment. The same study also reports that 36.8% of IDUs whoare HIV positive have never taken HAART therapy.35 Otherstudies in Spain have found social class inequalities in accessto preventive practices related to cancer (mammography, cyto-logy, etc.) despite their being free; people of advantaged classesundertake these practices more frequently.36 Another explana-tion may involve differences in adherence to treatments becauseHAART is a long and complex treatment; people of low SESmay have more difficulties in following it.16 Also, comorbiditymay play a role: the presence of other diseases mainly in thelowest SES groups, such as hepatitis C, pulmonary infections,tuberculosis, etc. may affect HIV prognosis. Finally, differencesin living conditions, life style and health behaviours may haveconsequences that affect the course of HIV infection.16

One of the limitations of the present study is that we onlyincluded death cases having AIDS as the underlying cause ofdeath in the mortality register. In the pre-HAART era themajority of deaths in people with AIDS were AIDS-related,this cause of death having high validity,37 but after theintroduction of HAART the causes of death probably changedamong HIV infected individuals, diminishing the AIDS-relateddeaths as has been described by other authors.38 We have to takeinto account that this study did not collect the deaths due toother causes. Another limitation could be the small numbers ofAIDS death cases for the heterosexual transmission group, par-ticularly women in the last few years. Finally, we have to recog-nize the presence of some missing values in our variables (seetable 1), these missing values were not however related to theother variables, except in the HIV transmission group which hadmore missing values for the years 2000 and 2001.

This study has described how SES group relatedinequalities in AIDS mortality did not narrow after the intro-duction of HAART, possibly suggesting that access, or adher-ence, to HAART among people in low SES groups is rather lessthan desirable. These SES inequalities must be considered when

prevention and treatment strategies are implemented,39,40 tak-ing into account that some studies have shown that it is possibleto administer the HAART therapy to poor populations.41,42

Key points

� This study pretends to determine whether socio-economic AIDS mortality inequalities before andafter the introduction of highly active antiretroviraltherapy (HAART) have increased or decreased inBarcelona.

� The evolution of AIDS mortality for different socio-economic (SES) groups, sexes and transmission groupswas slightly different.

� AIDS mortality inequalities by SES group remainedquite stable, therefore inequalities did not narrowafter the introduction of HAART. A similar patternwas observed in intravenous drug users.

� These results ought to be taken into account whenimplementing treatment and prevention strategies ina country where HAART therapy is free.

Acknowledgements

This study was made possible by financial support fromFIPSE (grant number 2425/01) and FISS C03/09, G03/05(Cooperative Investigation Networks).

References

1 Palella FJ, Delaney K, Moorman A, et al. Declining morbidity and

mortality among patients with advanced human immunodeficiency virus

infection. N Eng J Med 1998;338:853–60.

2 Macroft A, Ledergerber B, Katlama C, et al. Decline in the AIDS and death

rates in the EuroSIDA study: observational study. Lancet 2003;

362:22–9.

3 Castilla J, De la Fuente L. Evolucion del numero de personas infectadas por

el virus de la inmunodeficiencia humana y de los casos de sida en Espana:

1980–1998. Med Clin (Barc) 2000;115:85–9.

4 Borrell C, Pasarın MI, Cirera E, Plasencia A. Trends in young adult AIDS

mortality in Barcelona, 1986–1999. J Epidemiol Comm Health

2001;55:577–82.

5 Fauci AS. The AIDS epidemic. Considerations for the 21st Century. N Eng

J Med 1999;341:1046–50.

6 Garcıa de Olalla P, Cayla JA, Brugal MT, et al. Evolucion de la mortalidad y

supervivencia del sida en Barcelona (1981–1997). Med Clin (Barc)

1999;113:169–70.

7 Messeri P, Lee G, Abramson DM, et al. Antiretroviral therapy and declining

AIDS mortality in New York city. Med Care 2003;41:512–21.

8 Li Y, McDonald AM, Dore GJ, et al. Improving survival following AIDS in

Australia, 1991–1996. AIDS 2000;14:2349–54.

9 Dore GJ, Li Y, McDonald A, et al. Impact of highly active antiretroviral

therapy on individual AIDS-defining illness incidence and survival in

Australia. J Acquir Immune Defic Syndr 2002;29:388–95.

10 Garcıa de Olalla P, Knobel H, Carmona A, et al. Impact of adherence and

highly active antiretroviral therapy on survival in HIV-infected patients.

J Acquir Immune Defic Syndr 2002;30:105–10.

11 Wallace R, Fullilove M, Fullilove R, et al. Will AIDS be contained within

US minority urban populations? Soc Sci Med 1994;39:1051–62.

12 Fournier AM, Carmichael C. Socioeconomic influences on the transmission

of Human Immunodeficiency Virus Infection. The Hidden risk. Arch Fam

Med 1998;7:214–17.

13 Benatar SR. AIDS in the 21st Century (letter). N Engl J Med

2000;342:515–16.

14 Levi J. The public health challenges of the HIV epidemic (editorial).

Am J Public Health 2000;90:1023–4.


by AN

A B

ringeL on A


Dow

nloaded from


15 Moatti JP, Souteyrand Y. AIDS social and behavioral research: past advances

and thoughts about the future (Editorial). Soc Sci Med 2000;50:

1519–32.

16 Dray-Spira R. Social health inequalities during the course of chronic HIV

disease in the era of highly active antiretroviral therapy. AIDS

2003;17:283–390.

17 Poundstone KE, Strathdee SA, Celentano DD. The social epidemiology of

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome.

Epidem Rev 2004;26:22–35.

18 Brugal MT, Borrell C, Diaz de Quijano E, et al. Deprivation and AIDS in a

Southern European city: different patterns across transmission group.

Eur J Public Health 2003;13:259–61.

19 Zierler S, Krieger N, Tang Y, et al. Economic deprivation and AIDS

incidence in Massachusetts. Am J Public Health 2000;90:1064–73.

20 Borrell C, Pasarın MI, Plasencia A, Ortun V. Widening inequalities in

mortality: the case of a southern European city (Barcelona). J Epidemiol

Community Health 1997;51:659–67.

21 Schechter MT, Hogg RS, Aylward B, et al. Higher socioeconomic status is

associated with slower progression of HIV infection independent of access to

health care. J Clin Epidemiol 1994;47:59–67.

22 Hogg RS, Strathdee SA, Craib KJP, et al. Lower socio-economic status and

shorter survival following HIV infection. Lancet 1994;344:1120–4.

23 Katz MH, Hsu L, Lingo M, et al. Impact of socio-economic status on

survival with AIDS. Am J Epidemiol 1998;148:282–91.

24 Wallace RG. AIDS in the HAART era: New York’s heterogeneous geography.

Soc Sci Med 2003;56:1155–71.

25 McFarland W, Chen S, Hsu L, et al. Low socio-economic status is

associated with a higher rate of death in the era of highly active antiretroviral

therapy, San Francisco. J Acquir Immune Defic Syndr 2003;33:96–103.

26 Arribas P, Cirera E, Tristan M. Buscando una aguja en un pajar: las tecnicas

de conexion de registros en los sistemas de informacion sanitaria.

Med Clin (Barc) 2004;122 (Suppl 1):16–20.

27 Breslow NE, Day NE. Statistical Methods in Cancer Research. Volume II:

The Design and Analysis of Cohort Studies. Lyon: International Agency for

Research in Cancer, 1987.

28 Manzanera R, Torralba Ll, Brugal MT, et al. Afrontar los estragos de la

heroına: diez anos del Plan de Accion sobre Drogas de Barcelona. Gac Sanit

2000;14:58–66.

29 Brugal MT, Domingo-Salvany A, Puig R, et al. Evaluating the impact

of methadone maintenance programmes on mortality due to overdose and

AIDS in a cohort of heroin users in Spain. Addiction 2005;100:981–9.

30 Rapiti E, Porta D, Forastiere F, et al. Socio-economic status and survival of

persons with AIDS before and after the introduction of highly active

antiretroviral therapy. Epidemiology 2000;11:496–501.

31 Blair JM, Fleming PL, Karon JM. Trends in AIDS incidence and survival

among racial/ethnic minority men who have sex with men, United States,

1990–1999. J Acquir Immune Defic Syndr 2002;31:339–47.

32 Antunes JLF, Waldman EA, Borrell C. Is it possible to reduce AIDS deaths

without reinforcing socioeconomic inequalities in health? Int J Epidemiol

2005;34:586–92.

33 Wood E, Montaner JSG, Chan K, et al. Socio-economic status, access to tripe

therapy and survival from HIV-disease since 1996. AIDS 2002;16:2065–72.

34 Wood E, Montaner JSG, Tyndall MW, et al. Prevalence and correlates of

untreated Human Immunodeficiency Virus Type 1 Infection among persons

who have died in the era of modern antiretroviral therapy. J Infect Dis

2003;188:1164–70.

35 Bravo MJ, Royuela L, Barrio G, Rodrıguez MA, de la Fuente L, Grupo de

trabajo de Medicos del Mundo para el control de la infeccion por VIH y las

practicas de riesgo en inyectores de drogas. Prevalencia de practicas

indirectas de compartir material para inyectarse drogas en Galicia, Madrid,

Sevilla y Valencia. Gac Sanit 2004;18:472–8.

36 Borrell C, Fernandez E, Schiaffino A, et al. Social class inequalities in the use

of and access to health services in Catalonia (Spain): what is the influence

of a supplemental private health insurance? Int J Qual Health Care

2001;13:117–25.

37 Montella N, Ricart I, Borrell C, et al. Comparacion de las defunciones del

registro de casos de sida y de las defunciones por sida del registro de

mortalidad. Barcelona 1991–1992. Rev San Hig Pub 1995;69:49–57.

38 Krentz HB, Kliewer G, Gill MJ. Changing mortality rates and causes of death

for HIV-infected individuals living in Southern Alberta. Canada from

1984 to 2003. HIV Med 2005;6:99–106.

39 Auerbach JD, Coates TJ. HIV prevention research: accomplishments and

challenges for the third decade of AIDS. Am J Public Health

2000;90:1029–32.

40 Wolffers I. Biomedical and development paradigms in AIDS prevention.

Bull World Health Organ 2000;76:267–73.

41 Bamberger JD, Unick J, Klein P, et al. Helping the urban poor stay with

antiretroviral HIV drug therapy. Am J Public Health 2000;90:699–701.

42 Farmer P, Leandre F, Mukherjee JS, et al. Community-based approaches to

HIV treatment in resource-poor settings. Lancet 2001;358:404–9.

Received 20 June 2005, accepted 4 April 2006


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