Identifying disparities at the intersection of race and HIV in patients with sepsis and pneumonia.

Background: Pneumonia and sepsis remain leading causes of hospitalization and death among people with HIV (PWH) despite widespread antiretroviral therapy. Although disparities in critical illness have been described, it remains unclear whether the association between HIV status and mortality differs across racial groups. Setting: Retrospective cohort study of adults hospitalized with pneumonia and/or sepsis using the Healthcare Cost and Utilization Project State Inpatient Databases from seven U.S. states (2018–2021). Methods: We compared crude in-hospital mortality by HIV status and race. Multilevel logistic regression models adjusted for demographics, comorbidities, acute organ failures present on admission, do-not-resuscitate status, surgical status, and hospital-level clustering. We evaluated race as an effect modifier using an HIV × race interaction model to estimate race-specific adjusted odds ratios. Complementary analyses evaluated racial disparities separately among patients with and without HIV. Results: Among 3,949,906 hospitalizations, PWH had lower crude mortality than patients without HIV (8.4% vs. 10.2%; absolute risk difference, 1.8%, 95% CI, 1.6–2.0). A significant HIV × race interaction was observed (P=0.0033). HIV infection was associated with increased mortality among patients identified as White (aOR, 1.09; 95% CI, 1.03–1.16) and Asian (aOR, 1.53; 95% CI, 1.13–2.08), but not among patients identified as Black or Other race. Racial disparities also differed according to HIV status. Conclusions: The association between HIV infection and pneumonia- and sepsis-related mortality differs across racial groups, indicating important heterogeneity masked by average population estimates. An intersectionality framework may provide insight into structural mechanisms underlying disparities in critical illness among PWH.