COVID-19 mortality risk among people with HIV in Florida before and after the introduction of COVID-19 vaccines: A population-based study

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.