---
title: "COVID-19 mortality among people with HIV in Florida before and after COVID-19 vaccine availability"
id: "plos-one-13-covid-19-mortality-risk-among-people-with-hiv-in-florida-before-and-after-the"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-13-covid-19-mortality-risk-among-people-with-hiv-in-florida-before-and-after-the"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358543"
published_at: "2026-09-18T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# COVID-19 mortality among people with HIV in Florida before and after COVID-19 vaccine availability
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-13-covid-19-mortality-risk-among-people-with-hiv-in-florida-before-and-after-the
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358543)
- **Published At:** 2026-09-18T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This population-based retrospective cohort used Florida Department of Health enhanced HIV/AIDS Reporting System (eHARS) data to examine COVID-19 mortality among **people with HIV (PWH)** from March 1, 2020 to December 31, 2021, comparing periods before (3/1/2020–4/30/2021) and during (5/1/2021–12/31/2021) COVID-19 vaccine availability. - The analytic cohort comprised 122,527 PWH after exclusions from an initial dataset of 129,770; linkage to Vital Records, the Social Security Death Master File, and the National Death Index provided death verification. - Community-level measures included ZIP Code Tabulation Area linkage to the **Social Vulnerability Index (SVI)** and Rural-Urban Commuting Area (RUCA) codes; SVI high vs low was examined as a predictor. - Overall COVID-19 mortality rates increased from 22.3 to 27.5 per 100,000 person-months in the vaccine availability period, a trend partly attributed to the mid-to-late 2021 **Delta variant** surge. - Racial/ethnic disparities persisted: Non-Hispanic Black (NHB) PWH had elevated adjusted COVID-19 mortality hazards versus Non-Hispanic White (NHW) PWH both before (HR 2.06, 95% CI 1.45–2.91) and during (HR 1.60, 95% CI 1.13–2.27) vaccine availability. - Hispanic PWH showed an elevated hazard relative to NHW before vaccine availability (HR 2.24, 95% CI 1.55–3.23) that attenuated during vaccine availability (HR 1.03, 95% CI 0.68–1.57). - Living in ZIP Code-level areas of high social vulnerability was associated with higher COVID-19 mortality hazard during vaccine availability (HR 1.75, 95% CI 1.04–2.97) in the final adjusted model. - The authors note these are observational comparisons and do not estimate causal effects of **vaccination uptake**; they highlight the need for tailored vaccination strategies and structural interventions to reduce inequities among PWH.
## Clinical Analysis & Structured Key Points
COVID-19 mortality risk among people with HIV in Florida before and after the introduction of COVID-19 vaccines: A population-based study | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Objective Assess associations between COVID-19 vaccine availability and differences in COVID-19 mortality risk across subgroups among 122,527 people with HIV (PWH) in Florida. Methods Analyzed HIV surveillance data, Social Vulnerability Index (SVI), and Rural-Urban Commuting Area Codes using a competing risks model to compare COVID-19 mortality among PWH before (3/1/2020–4/30/2021) and during (5/1/2021–12/31/2021) vaccine availability. Results Overall COVID-19 mortality rates increased from before to during the vaccine availability period (22.3 vs. 27.5 per 100,000 person-months), driven in part by the Delta variant surge in mid-to-late 2021. Compared to Non-Hispanic White (NHW) PWH, adjusted COVID-19 mortality hazards remained elevated for Non-Hispanic Black (NHB) PWH both before (HR 2.06, 95% CI 1.45–2.91) and during (HR 1.60, 95% CI 1.13–2.27) vaccine availability. For Hispanic PWH, the relative hazard compared to NHW was elevated before (HR 2.24, 95% CI 1.55–3.23) and attenuated during vaccine availability (HR 1.03, 95% CI 0.68–1.57). In the final model, living in ZIP Code-level areas of high social vulnerability (overall SVI high vs. low) was associated with elevated hazard during vaccine availability (HR 1.75, 95% CI 1.04–2.97). Conclusions Overall COVID-19 mortality rates were higher during the vaccine availability period (27.5 vs. 22.3 per 100,000 person-months); however, subgroup patterns varied substantially. Inequities persisted in key subgroups and were most pronounced among PWH living in more socially vulnerable areas. These observational comparisons do not estimate the causal effect of vaccination uptake. Public health implications Tailored vaccination strategies and structural interventions remain essential to advancing equity in pandemic response among PWH. Citation: Gwanzura TN, Trepka MJ, Li T, Juhasz L, Barreto GA, Burchfield S, et al. (2026) COVID-19 mortality risk among people with HIV in Florida before and after the introduction of COVID-19 vaccines: A population-based study. PLoS One 21(9): e0358543. https://doi.org/10.1371/journal.pone.0358543 Editor: Kuo-Cherh Huang, Taipei Medical University, TAIWAN Received: January 18, 2026; Accepted: September 2, 2026; Published: September 18, 2026 Copyright: © 2026 Gwanzura et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: This study used de-identified person-level HIV surveillance data from the Florida Department of Health (FDOH) Enhanced HIV/AIDS Reporting System (eHARS). Public sharing of individual-level data is restricted under Florida law and the executed Data Use Agreement (DUA) with FDOH, which prohibit release of records that could be used to re-identify individuals living with HIV. Researchers seeking access should email a brief project summary to DCHPDataRequest@FLHealth.gov ; if approved, the FDOH Bureau of Epidemiology will work with the requester to complete a Data Use Agreement. This is the single point of contact for data requests — researchers do not need to submit requests through any additional website. Aggregate supporting data include the American Community Survey (ACS) 5-Year Estimates (2016–2020), available from the U.S. Census Bureau ( https://www.census.gov/programs-surveys/acs/ ), and Rural-Urban Commuting Area (RUCA) Codes Version 3.10 (2010), available from the USDA Economic Research Service ( https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/ ). Analysis code (SAS programs) and variable definitions are publicly available at https://github.com/GwanzuraT/HIV-COVID19-Mortality-Florida (DOI: https://doi.org/10.5281/zenodo.19493424 ). The GitHub and Zenodo repositories contain identical content — Zenodo provides a permanent archived version with a citable DOI. Funding: This work was supported by the NIH National Institute on Minority Health and Health Disparities (T.G.: F31MD018550). There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction COVID-19 emerged as the third leading cause of death in the United States (US) between 2020 and 2021, with 767,724 fatalities [ 1 – 3 ]. Studies indicate mixed results on COVID-19 mortality among people with HIV (PWH). One meta-analysis found higher mortality among PWH than among people without HIV [ 4 ], while another found no statistically significant increase in COVID-19 mortality associated with HIV [ 5 ]. A pooled analysis conducted as part of a scoping review identified COVID-19 mortality differences among PWH related to age, sex, race, injection drug use, comorbidities, smoking, and CD4 count [ 6 ]. Specifically, those aged 70 years or older had a higher case fatality rate of 41.8% compared to 1.2% among those under 40 years of age [ 6 ]. Additionally, the pooled case fatality rate for males was approximately twice that of females [ 6 ]. Notably, Black PWH had a higher case fatality rate (12.9%), than Hispanics (10.3%) and White PWH (10.0%) [ 6 ]. Those reporting injection drug use, smoking, and having a CD4 cell count below 200 had higher pooled case-fatality rates [ 6 ]. A study of US counties found that mortality risk was also higher in counties with a higher percentage of the Black population, in both rural and urban settings [ 7 ]. Although few studies have examined COVID-19 outcomes among PWH in the context of community vulnerability, one study in Florida’s general population found that counties with a high Social Vulnerability Index (SVI) had a 19.4% higher COVID-19 mortality rate than the national average [ 8 ]. This suggests that structural factors—like poverty, crowding, and transportation access—may also shape mortality patterns among PWH. The advent and widespread distribution of COVID-19 vaccines represented a critical milestone in mitigating mortality rates [ 9 , 10 ]. Notable differences in COVID-19 mortality persisted after vaccine introduction, with disparities particularly pronounced among racial/ethnic minorities and older adults [ 3 , 11 ]. In a community-based Connecticut sample surveyed before vaccine availability, vaccine hesitancy was identified as a contributing factor, with higher hesitancy observed among Black and Hispanic communities compared to non-Hispanic White/other communities [ 12 ]. Counties with 80% or more vaccination coverage saw 46% lower COVID-19 mortality rates compared to those with less than 50% coverage [ 13 ]. Additionally, counties with 70–79% and those with 60–69% vaccination rates had a 35% and 20% reduction in mortality rates, respectively [ 13 ]. A statewide spatial analysis in Florida found that vaccination sites were concentrated in urban counties, with rural counties having fewer sites and longer travel times to nearest vaccination sites [ 14 ]. Additionally, research conducted in New York showed that 63.5% of PWH had completed a primary COVID-19 vaccination regimen compared to 75.0% in the general population [ 15 ]. These differences suggest that improving vaccine accessibility is key to ensuring equitable health outcomes and reducing mortality. Despite the extensive research on differences in COVID-19 mortality among the general population, limited data exist on how vaccine availability influenced mortality differences among PWH [ 6 ]. To address this gap, we evaluated the effect of COVID-19 vaccine availability on COVID-19 mortality across socio-demographic and community-level factors among PWH in Florida. Methods Study population and data sources We conducted a retrospective cohort study of 129,770 PWH residing in Florida, followed from March 1, 2020, to December 31, 2021, using data from the Florida Department of Health’s (FDOH) enhanced HIV/AIDS Reporting System (eHARS). This dataset includes demographics (age, sex, race/ethnicity), place of birth, HIV transmission mode, viral suppression status, vital status, underlying cause of death, and ZIP Code Tabulation Areas (ZCTAs) for residence during life and at death. ZCTAs are generalized representations of US postal ZIP Codes created by the US Census Bureau for statistical purposes, approximating the geographic areas covered by ZIP Codes but aligned with census boundaries [ 16 ]. Vital status and cause of death were verified through routine linkages to FDOH Vital Records, the Social Security Administration’s Death Master File, and the National Death Index. We used a deidentified dataset linked in June 2022. Inclusion and exclusion criteria Of the 129,770 PWH in the dataset, 122,527 (94.4%) individuals met the inclusion criteria. We included PWH aged 18 years or older residing in Florida by December 31, 2019, and alive during the study period or until death. We excluded 131 (0.1%) individuals over the age of 90 due to potential data quality issues such as records misclassifying deceased individuals. After linking community-level social vulnerability data, 4,340 individuals were removed due to lack of valid or missing ZCTA. Among those who died during the study period, we additionally excluded 2,682 individuals who either died outside Florida or lacked a valid ZCTA at the time of death, including three COVID-19 deaths with no recorded ZCTA or state of residence at death. For PWH missing a ZCTA at the end of 2021 but recorded as alive and residing in Florida, their 2020 ZCTA was used. Of the 122,527 individuals in the final analytic cohort, 3,359 (2.7%) had an unknown place of birth and were retained in the descriptive analyses but excluded from multivariable regression models due to inability to classify US birth status; the final regression model included 119,168 (97.3%) PWH. COVID-19 vaccine availability In the US, the first doses of COVID-19 vaccine were administered on December 14, 2020 [ 17 ]. The Advisory Committee on Immunization Practices (ACIP) recommended that adults aged 16–64 years with high-risk medical conditions be offered COVID-19 vaccination during Phase 1c [ 18 ]. As vaccine eligibility and supply expanded nationally beginning in late March 2021 [ 17 ], the period of vaccine availability for this analysis was defined as starting May 1, 2021, approximately six weeks later. This date coincided with 8.87 million Florida residents having received at least one COVID-19 vaccine dose, including 6.28 million who had completed a vaccine series, as of April 30, 2021, according to the Florida Department of Health COVID-19 Vaccine Summary [ 19 ]. Outcome definition The primary outcome was COVID-19–related death, classified using International Classification of Diseases 10 (ICD-10 code U07.1). All other deaths were treated as competing events. Covariates Individual and community factors of interest were determined from the literature [ 5 – 8 ]. Individual factors included age, sex, place of birth (US or foreign), and HIV transmission category (injection drug use [IDU]—including men who have sex with men [MSM] who also had the IDU category, MSM, heterosexual transmission, and ‘other’ categories like perinatal transmission, unknown, and blood transfusion). Additional factors included viral suppression status and race/ethnicity (Hispanic, of all races; Non-Hispanic Black [NHB]; Non-Hispanic White [NHW]; and other races including multiple races, Asian, Native American, and Pacific Islander). Community factors were social vulnerability and rurality at the ZCTA level, and county-level vaccination rates by December 31, 2021. Social vulnerability was assessed at the ZIP Code-level modeling the CDC’s Social Vulnerability Index (SVI), ranking ZCTAs in Florida based on four themes: socioeconomic status, household characteristics, racial/ethnic minority status/language, and housing type/transportation [ 20 ]. Because the CDC provides SVI scores at the census tract and county levels but not at the ZCTA level, we replicated the methods for calculating social vulnerability using data from the 2020 5-year American Community Survey (ACS) at the ZCTA level [ 21 ]. Each theme was individually scored and combined to create an overall SVI score and theme scores. Subsequently, scores were ranked from 0 to 1 and categorized into tertiles: low (0–0.333), moderate (0.334–0.666), and high (0.667–1), with higher values indicating greater social vulnerability. Rural-urban classifications were determined using Rural-Urban Commuting Area (RUCA) codes [ 22 ]. Neighborhood ZCTA-level data were linked with individual-level eHARS data using the ZCTA of residence recorded at death or the most recent ZCTA if the individual did not die. Statistical analysis At-risk time origin: We defined the analytic at-risk period to begin March 1, 2020. Individuals with competing (non-COVID) deaths in January–February 2020 were excluded from the risk set; for all others, time was rebased so that month 0 corresponds to March 2020. Total person-time, measured in months, was calculated for two groups: before vaccine (deaths from March 1, 2020, to April 30, 2021) and during vaccine availability (deaths from May 1, 2021, to December 31, 2021), from the group start date to the COVID-19 death or end date, with mortality rates calculated as the number of deaths divided by the total person-time in months, multiplied by 100,000. We first used a multilevel cause-specific hazard model to estimate the intraclass correlation at the ZIP Code and county levels, but findings showed minimal clustering. As such, we applied a Fine-Gray proportional sub-distribution hazard model without random effects to estimate the cumulative incidence function (CIF) for COVID-19 deaths, accounting for competing risks among PWH in Florida before and during vaccine availability. Gray’s test was used to assess differences in CIF curves across subgroups. We estimated adjusted sub-distribution hazard ratios (HR) and 95% confidence intervals (CIs) for both periods, controlling for covariates significant in univariate CIF analyses. Statistical significance was set at P < 0.05. We conducted analyses in SAS version 9.4 (SAS Institute, Cary, NC). Ethics statement This study was reviewed by the Florida International University Office of Research Integrity and deemed exempt from human subjects review via the Exempt Review process (IRB Protocol Exemption #IRB-22-0517; Exemption Date: 12/08/2022; TOPAZ Reference #113536) and Florida Department of Health (2021-491). The study used de-identified surveillance data provided by the Florida Department of Health, and no informed consent was required. Results The overall COVID-19 mortality rate increased from before to during vaccine availability (22.3 vs. 27.5 deaths per 100,000 person-months), a pattern consistent with the Delta variant surge observed in mid-to-late 2021. Stratified rates revealed demographic and structural differences. Mortality rates among PWH aged 65 and older were similarly elevated before and during vaccine availability (66.0 and 65.6 deaths per 100,000 person-months), whereas rates among those aged 18–34 increased from 4.0 to 8.0 deaths per 100,000 person-months. NHB PWH had the highest mortality rates in both periods, with rates increasing from 28.2 to 37.8 deaths per 100,000 person-months, whereas Hispanics had a notable reduction (21.2 to 16.8 deaths per 100,000 person-months). Heterosexual PWH had the highest increase in rates across transmission categories (30.7 to 40.2 deaths per 100,000 person-months), while those with IDU had similar rates before and during vaccine availability (34.7 and 37.0 deaths per 100,000 person-months, respectively). Rates were similar between PWH with and without viral suppression before vaccine availability (22.2 and 22.4 deaths per 100,000 person-months, respectively), but diverged sharply during vaccine availability, with PWH without viral suppression having a markedly higher rate (38.1 vs. 22.6 deaths per 100,000 person-months). Rural mortality rates decreased (23.2 to 15.2 deaths per 100,000 person-months), while urban rates increased (22.3 to 27.8 deaths per 100,000 person-months). Rates remained highest in ZIP Codes with high social vulnerability during both time periods (25.0 and 30.6 deaths per 100,000 person-months) ( Table 1 ). Download: PNG larger image TIFF original image Table 1. Comparison of COVID-19 mortality rates and person-time among people with HIV before (March 2020 – April 2021) and during vaccine availability (May 2021 – December 2021), Florida. https://doi.org/10.1371/journal.pone.0358543.t001 Significant crude differences ( P < 0.05) in the CIF for death curves were found across age, race/ethnicity, HIV transmission category, viral suppression, and SVI subgroups before and during vaccine availability. The CIF curves for birth sex were significant only during vaccine availability ( P = 0.04). There were no significant differences by US-born status or rurality ( Figs 1 – 3 ). Download: PNG larger image TIFF original image Fig 1. Cumulative incidence of COVID-19 deaths among people with HIV by race/ethnicity before and during vaccine availability, Florida, 2020–2021. Cumulative incidence estimates are shown for Hispanic, non-Hispanic Black (NHB), non-Hispanic White (NHW), and Other race/ethnicity. Solid lines represent the period before vaccine availability (0–13 months since March 2020) and dashed lines represent the period during vaccine availability (14–22 months since March 2020). https://doi.org/10.1371/journal.pone.0358543.g001 Download: PNG larger image TIFF original image Fig 2. Cumulative incidence of COVID-19 deaths among people with HIV by viral suppression, rurality and social vulnerability index before and during vaccine availability, Florida, 2020–2021. Cumulative incidence of COVID-19 deaths among people with HIV by structural and community characteristics before and during COVID-19 vaccine availability, Florida, 2020–2021. Panels display viral suppression status, rural-urban residence classification, and Social Vulnerability Index (SVI) tertiles. https://doi.org/10.1371/journal.pone.0358543.g002 Download: PNG larger image TIFF original image Fig 3. Cumulative incidence of COVID-19 deaths among people with HIV by age, US birth status, sex and transmission category before and during vaccine availability, Florida, 2020–2021. Cumulative incidence estimates are shown by individual characteristics. Panels display age group, sex, US birth status, and HIV transmission category. Solid lines represent the period before vaccine availability (March 1, 2020–April 30, 2021); dashed lines represent the period during vaccine availability (May 1, 2021–December 31, 2021). https://doi.org/10.1371/journal.pone.0358543.g003 In the final proportional sub-distribution hazard model, the adjusted hazards for COVID-19 mortality relative to those aged 18–34 were higher for individuals aged 50–64 (during: HR 4.18, 95% CI 2.21–7.91; before: HR 5.43, 95% CI 2.68–11.03) and those ≥65 years (during: HR 9.13, 95% CI 4.78–17.41; before: HR 16.78, 95% CI 8.24–34.13) ( Table 2 ). Download: PNG larger image TIFF original image Table 2. Adjusted sub-distribution hazard ratios of COVID-19 deaths among people with HIV before (March 1, 2020 – April 30, 2021) and during (May 1, 2021 – December 31, 2021) vaccine availability in Florida. https://doi.org/10.1371/journal.pone.0358543.t002 During the vaccine period, elevated hazard of COVID-19
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