The relationship between adverse neighborhood socioeconomic context and HIV continuum of care outcomes in a diverse HIV clinic cohort in the Southern United States

Insights on HIV Care Engagement Strategies from Seven Interventions Serving Key Populations in the United States: A Qualitative Study

As HIV diagnoses continue to decrease and rates of viral suppression increase in the United States, key populations of underserved individuals represent a disproportionate share of those left undiagnosed, unengaged in care, and not virally suppressed. In 2021, the Health Resources and Services Administration's HIV/AIDS Bureau funded 20 HIV care organizations across the United States to implement seven innovative evidence-based interventions to engage individuals in the following four focus areas: LGBTQ+ youth, people with substance-use disorder, individuals with incarceration experience, and those for whom telehealth may reduce barriers to care. This article explores themes of implementer experiences common across interventions serving the four focus areas. Data sources include key informant interviews (n = 94) with members of the implementation teams, observation, and document review. Thematic analytic methods were first inductive, identifying semantic themes from observation and document review, then deductive, selecting coded interview data for analysis of latent themes present and salient across focus areas. We identified three main themes as follows: (1) challenging by design, (2) enhanced client-centered care, and (3) leveraging relationships. We present these themes as distinct concepts and discuss how they operate in relation to one another using the Exploration, Preparation, Implementation, Sustainment framework. Teams implementing interventions to engage people with HIV who remain out of care may benefit from adopting the following: an enhanced client-centered orientation with a focus on understanding the context of clients' lives; a high level of organizational and programmatic flexibility; an individualized, trauma-informed approach to enrollment and intervention delivery; and thoughtfully cultivated relationships among implementers, clients, and organizational partners.

Drive time to care and retention in HIV care: Rural-urban differences among Medicaid enrollees in the United States South

PURPOSE

Less than 50% of people with HIV (PWH) in the United States are retained in care, a key step along the HIV care continuum. We examined the impact of geographic access to care on retention in care for urban and rural PWH.

METHODS

We used Medicaid claims and clinician data (Medicaid Analytic eXtract and MAX Provider Characteristics, 2009-2012) for 13 Southern states plus the District of Columbia. We calculated drive time from the enrollees' ZIP Code Tabulation Area to their usual source of care. We used generalized estimating equations to examine the association between drive time to care >30 min (versus ≤30 min) and retention in care, overall and stratified by rurality. In sensitivity analysis, we examined the definition of retention in care, states included in the analysis, and enrollee- and care-related characteristics.

FINDINGS

The sample included 49,596 PWH. Overall, the association between drive time >30 min and retention was significant, but small (adjusted odds ratio [aOR] 1.01, 95% confidence interval [CI] 1.00, 1.01) and was not significant in urban areas; however, the significance and direction of the association differed in sensitivity analysis. In rural areas, driving >30 min to care was associated with 7% higher odds of retention in care (aOR 1.07, 95% CI 1.05, 1.08) and this association remained significant and positive in nearly all sensitivity analyses.

CONCLUSIONS

For PWH in rural areas, greater drive time is consistently associated with greater retention in care. Disentangling the mechanisms of this relationship is a future research priority.

Spatial and temporal analysis of HIV clinical outcomes in Florida reveals counties with persistent racial and ethnic disparities during 2012-2019

BACKGROUND

Racial/ethnic disparities in the HIV care continuum have been well documented in the US, with especially striking inequalities in viral suppression rates between White and Black persons with HIV (PWH). The South is considered an epicenter of the HIV epidemic in the US, with the largest population of PWH living in Florida. It is unclear whether any disparities in viral suppression or immune reconstitution-a clinical outcome highly correlated with overall prognosis-have changed over time or are homogenous geographically. In this analysis, we 1) investigate longitudinal trends in viral suppression and immune reconstitution among PWH in Florida, 2) examine the impact of socio-ecological factors on the association between race/ethnicity and clinical outcomes, 3) explore spatial and temporal variations in disparities in clinical outcomes.

METHODS

Data were obtained from the Florida Department of Health for 42,369 PWH enrolled in the Ryan White program during 2008-2020. We linked the data to county-level socio-ecological variables available from County Health Rankings. GEE models were fit to assess the effect of race/ethnicity on immune reconstitution and viral suppression longitudinally. Poisson Bayesian hierarchical models were fit to analyze geographic variations in racial/ethnic disparities while adjusting for socio-ecological factors.

RESULTS

Proportions of PWH who experienced viral suppression and immune reconstitution rose by 60% and 45%, respectively, from 2008-2020. Odds of immune reconstitution and viral suppression were significantly higher among White [odds ratio =2.34, 95% credible interval=2.14-2.56; 1.95 (1.85-2.05)], and Hispanic [1.70 (1.54-1.87); 2.18(2.07-2.31)] PWH, compared with Black PWH. These findings remained unchanged after accounting for socio-ecological factors. Rural and urban counties in north-central Florida saw the largest racial/ethnic disparities.

CONCLUSIONS

There is persistent, spatially heterogeneous, racial/ethnic disparity in HIV clinical outcomes in Florida. This disparity could not be explained by socio-ecological factors, suggesting that further research on modifiable factors that can improve HIV outcomes among Black and Hispanic PWH in Florida is needed.

Characterizing residential mobility among people with HIV in Tennessee and its impact on HIV care outcomes

OBJECTIVE

Our objective was to assess the prevalence and patterns of mobility among people with HIV (PWH) in Tennessee and its impact on HIV care outcomes.

DESIGN

Retrospective cohort study.

METHODS

We combined residential address and HIV surveillance data from PWH in Tennessee from 2016 to 2018. Using Poisson regression, we estimated associations between in-state mobility (change in address or total miles moved) in 1 year and outcomes in the subsequent year; retention: having two CD4 + /HIV RNA values (labs) in a calendar year at least 3 months apart, loss to follow-up (LTFU): having labs at baseline but not the subsequent year, and viral suppression: HIV RNA less than 200 copies/ml. We applied a kernel density estimator to origin-destination address lines to visualize mobility patterns across demographic subgroups.

RESULTS

Among 17 428 PWH [median age 45 years (interquartile range; IQR 34-53)], 6564 (38%) had at least one move. Median miles moved was 8.9 (IQR 2.6-143.4)). We observed in-state movement between major cities (Chattanooga, Knoxville, Memphis and Nashville) and out-of-state movement to and from Georgia and Florida. Having at least one in-state move was associated with a decreased likelihood of retention [adjusted relative risk (aRR) = 0.91; 95% confidence interval (CI) 0.88-0.95], and an increased risk of LTFU (aRR = 1.17; 95% CI 1.04-1.31, two to three moves vs. none). Greater distance moved in-state was associated with decreased retention and increased LTFU (aRR = 0.53; 95% CI 0.49-0.58, aRR = 2.52; 95% CI 2.25-2.83, respectively for 1000 vs. 0 miles). There was no association between mobility and viral suppression.

CONCLUSION

Mobility is common among PWH in Tennessee and is associated with initial poor engagement in HIV care.

Neighborhood characteristics and HIV treatment outcomes: A scoping review

Recognizing challenges faced by people living with HIV is vital for improving their HIV treatment outcomes. While individual-level interventions play a crucial role, community factors can shape the impact of individual interventions on treatment outcomes. Understanding neighborhood characteristics' association with HIV treatment outcomes is crucial for optimizing effectiveness. This review aims to summarize the research scope on the association between neighborhood characteristics and HIV treatment outcomes. The databases PubMed, CINAHL (EBSCOhost), Embase (Elsevier), and PsychINFO (EBSCOhost) were searched from the start of each database to Nov 21, 2022. Screening was performed by three independent reviewers. Full-text publications of all study design meeting inclusion criteria were included in the review. There were no language or geographical limitations. Conference proceedings, abstract only, and opinion reports were excluded from the review. The search yielded 7,822 publications, 35 of which met the criteria for inclusion in the review. Studies assessed the relationship between neighborhood-level disadvantage (n = 24), composition and interaction (n = 17), social-economic status (n = 18), deprivation (n = 16), disorder (n = 8), and rural-urban status (n = 7) and HIV treatment outcomes. The relationship between all neighborhood characteristics and HIV treatment outcomes was not consistent across studies. Only 7 studies found deprivation had a negative association with HIV treatment outcomes; 6 found that areas with specific racial/ethnic densities were associated with poor HIV treatment outcomes, and 5 showed that disorder was associated with poor HIV treatment outcomes. Three studies showed that rural residence was associated with improved HIV treatment outcomes. There were inconsistent findings regarding the association between neighborhood characteristics and HIV treatment outcomes. While the impact of neighborhood characteristics on disease outcomes is highly recognized, there is a paucity of standardized definitions and metrics for community characteristics to support a robust assessment of this hypothesis. Comparative studies that define and assess how specific neighborhood indicators independently or jointly affect HIV treatment outcomes are highly needed.

Multilevel Resilience and HIV Virologic Suppression Among African American/Black Adults in the Southeastern United States

OBJECTIVE

To assess overall and by neighborhood risk environments whether multilevel resilience resources were associated with HIV virologic suppression among African American/Black adults in the Southeastern United States.

SETTING AND METHODS

This clinical cohort sub-study included 436 African American/Black participants enrolled in two parent HIV clinical cohorts. Resilience was assessed using the Multilevel Resilience Resource Measure (MRM) for African American/Black adults living with HIV, where endorsement of a MRM statement indicated agreement that a resilience resource helped a participant continue HIV care despite challenges or was present in a participant's neighborhood. Modified Poisson regression models estimated adjusted prevalence ratios (aPRs) for virologic suppression as a function of categorical MRM scores, controlling for demographic, clinical, and behavioral characteristics at or prior to sub-study enrollment. We assessed for effect measure modification (EMM) by neighborhood risk environments.

RESULTS

Compared to participants with lesser endorsement of multilevel resilience resources, aPRs for virologic suppression among those with greater or moderate endorsement were 1.03 (95% confidence interval: 0.96-1.11) and 1.03 (0.96-1.11), respectively. Regarding multilevel resilience resource endorsement, there was no strong evidence for EMM by levels of neighborhood risk environments.

CONCLUSIONS

Modest positive associations between higher multilevel resilience resource endorsement and virologic suppression were at times most compatible with the data. However, null findings were also compatible. There was no strong evidence for EMM concerning multilevel resilience resource endorsement, which could have been due to random error. Prospective studies assessing EMM by levels of the neighborhood risk environment with larger sample sizes are needed.

Systematic Review of Neighborhood Factors Impacting HIV Care Continuum Participation in the United States

Social determinants have been increasingly implicated in accelerating HIV vulnerability, particularly for disenfranchised communities. Among these determinants, neighborhood factors play an important role in undermining HIV prevention. However, there has been little research comprehensively examining the impact of neighborhood factors on HIV care continuum participation in the US. To address this, we conducted a systematic review (PROSPERO registration number CRD42022359787) to determine neighborhood factors most frequently associated with diminished HIV care continuum participation. Peer-reviewed studies were included if published between 2013 - 2022, centralized in the US, and analyzed a neighborhood factor with at least one aspect of the HIV care continuum. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Study quality was guided by LEGEND (Let Evidence Guide Every New Decision) evaluation guidelines. Systematic review analysis was conducted using Covidence software. There were 3,192 studies identified for initial screening. Forty-four were included for review after eliminating duplicates, title/abstract screening, and eligibility assessment. Social and economic disenfranchisement of neighborhoods negatively impacts HIV care continuum participation among persons living with HIV. In particular, five key neighborhood factors (socioeconomic status, segregation, social disorder, stigma, and care access) were associated with challenged HIV care continuum participation. Race moderated relationships between neighborhood quality and HIV care continuum participation. Structural interventions addressing neighborhood social and economic challenges may have favorable downstream effects for improving HIV care continuum participation.

Estimation of place-based vulnerability scores for HIV viral non-suppression: an application leveraging data from a cohort of people with histories of using drugs

The relationships between place (e.g., neighborhood) and HIV are commonly investigated. As measurements of place are multivariate, most studies apply some dimension reduction, resulting in one variable (or a small number of variables), which is then used to characterize place. Typical dimension reduction methods seek to capture the most variance of the raw items, resulting in a type of summary variable we call "disadvantage score". We propose to add a different type of summary variable, the "vulnerability score," to the toolbox of the researchers doing place and HIV research. The vulnerability score measures how place, as known through the raw measurements, is predictive of an outcome. It captures variation in place characteristics that matters most for the particular outcome. We demonstrate the estimation and utility of place-based vulnerability scores for HIV viral non-suppression, using data with complicated clustering from a cohort of people with histories of injecting drugs.

Misclassification of Loss to Care Among Persons With Human Immunodeficiency Virus: Improved Capture of Silent Transfers Through Surveillance Linkage Using Statewide Mandatorily Reported Laboratory Measures

Human Immunodeficiency Virus (HIV)-positive individuals lost to follow-up from particular clinics may not be lost to care (LTC). After linking Vanderbilt's Comprehensive Care Clinic cohort to Tennessee's statewide HIV surveillance database, LTC decreased from 48.4% to 35.0% at 10 years. Routine surveillance linkage by domestic HIV clinics would improve LTC and retention measure accuracy.

A Census Tract-Level Examination of HIV Care Outcomes and Social Vulnerability Among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, 2018

We examined the association between social vulnerability and HIV diagnoses, linkage to HIV medical care, and viral suppression among adults in the Southern U.S. Data from CDC's National HIV Surveillance System (NHSS) were used to determine census tract-level HIV diagnosis rates and percentages of persons linked to care within one month and with viral suppression within six months of diagnosis among Black/African American, Hispanic/Latino, and White adults aged ≥ 18 years residing in the Southern U.S. in 2018. Census tract-level social vulnerability data were obtained from the 2018 CDC Social Vulnerability Index (SVI). Rate and proportion ratios were used to determine the difference between the lowest quartile of SVI scores (Q1) and the highest quartile (Q4) by age group, transmission category, and region of residence and stratified by sex assigned at birth. Areas with the highest social vulnerability (Q4) had the highest rates of HIV diagnoses (Black: 56.5, Hispanic/Latino: 27.2, and White: 10.3). Those in Q4 also had the lowest percentages of adults linked to care (Black: 76.1%, Hispanic/Latino: 81.2%, and White: 77.8%), and the lowest percentages of adults with viral suppression (Black: 59.8%, Hispanic/Latino: 68.4%, and White: 65.7%). This ecological study found an association between social vulnerability, HIV diagnoses, and poorer care outcomes among Black/African American, Hispanic/Latino, and White adults. Tailoring interventions and improving access for persons residing in areas with the highest social vulnerability is necessary to reduce HIV transmission and improve health outcomes in the Southern U.S.

Association of Neighborhood Deprivation With Healthcare Utilization Among Persons With Human Immunodeficiency Virus: A Latent Class Analysis

Background

We previously identified 3 latent classes of healthcare utilization among people with human immunodeficiency virus (PWH): adherent, nonadherent, and sick. Although membership in the "nonadherent" group was associated with subsequent disengagement from human immunodeficiency virus (HIV) care, socioeconomic predictors of class membership remain unexplored.

Methods

We validated our healthcare utilization-based latent class model of PWH receiving care at Duke University (Durham, North Carolina) using patient-level data from 2015 to 2018. SDI scores were assigned to cohort members based on residential addresses. Associations of patient-level covariates with class membership were estimated using multivariable logistic regression and movement between classes was estimated using latent transition analysis.

Results

A total of 1443 unique patients (median age of 50 years, 28% female sex at birth, 57% Black) were included in the analysis. PWH in the most disadvantaged (highest) SDI decile were more likely to be in the "nonadherent" class than the remainder of the cohort (odds ratio [OR], 1.58 [95% confidence interval {CI}, .95-2.63]) and were significantly more likely to be in the "sick" class (OR, 2.65 [95% CI, 2.13-3.30]). PWH in the highest SDI decile were also more likely to transition into and less likely to transition out of the "sick" class.

Conclusions

PWH who resided in neighborhoods with high levels of social deprivation were more likely to have latent class membership in suboptimal healthcare utilization groupings, and membership persisted over time. Risk stratification models based on healthcare utilization may be useful tools in the early identification of persons at risk for suboptimal HIV care engagement.

Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol

BACKGROUND

In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites.

METHOD

The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients.

DISCUSSION

This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.

Factors Associated with Geographic Patterns of Poor Sustained Viral Suppression in Miami-Dade County Florida, 2017

BACKGROUND

Identifying geographic locations most affected by the HIV epidemic is essential to addressing disparities that impact people living with HIV. This study sought to identify individual and neighborhood-level factors that are associated with residing in geographic hotspots of poor sustained HIV viral suppression.

METHODS

Using data from the Miami-Dade County Ryan White HIV/AIDS program, spatial autocorrelation of poor sustained viral suppression (at least 1 laboratory test ≥ 200 copies/ml in 2017) was investigated using Global Moran's I followed by Local Moran's I and Getis Ord Gi* statistics by ZIP code tabulation areas (ZCTAs). Subsequently, multivariable logistic regression analysis was conducted to identify factors associated with residing in geographic hotspots of poor sustained viral suppression.

RESULTS

Several ZCTAs in the northern part of the county, accounting for 1/3 of the Ryan White program clients, had significantly higher clustering of poor sustained viral suppression. Client-level sociodemographic characteristics such as race/ethnicity, age, and poverty, and neighborhood-level characteristics (socioeconomic disadvantage index, residential instability index, and racial/language homogeneity index) were significantly associated with living in a hotspot of poor sustained viral suppression.

CONCLUSION

These findings highlight that spatial variation in sustained viral suppression exists within the county. Targeted strategies that address structural factors and the needs of people with HIV living in specified geographic areas may improve their HIV health outcomes and contribute towards local, regional, and national goals of ending the HIV epidemic.

HIV Care Outcomes in Relation to Racial Redlining and Structural Factors Affecting Medical Care Access Among Black and White Persons with Diagnosed HIV-United States, 2017

Black/African American (Black) versus White persons are unequally burdened by human immunodeficiency virus (HIV) in the United States. Structural factors can influence social determinants of health, key components in reducing HIV-related health inequality by race. This analysis examined HIV care outcomes among Black and White persons with diagnosed HIV (PWDH) in relation to three structural factors: racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program (RWHAP) use. Using National HIV Surveillance System, U.S. Census, and Home Mortgage Disclosure Act data, we examined linkage to HIV care and viral suppression (i.e., viral load < 200 copies/mL) in relation to the structural factors among 12,996 Black and White PWDH with HIV diagnosed in 2017/alive at year-end 2018, aged ≥ 18 years, and residing in 38 U.S. jurisdictions with complete laboratory data, geocoding, and census tract-level redlining indexes. Compared to White PWDH, a lower proportion of Black PWDH were linked to HIV care within 1 month after diagnosis and were virally suppressed in 2018. Redlining was not associated with the HIV care outcomes. A higher prevalence of PWDH residing (v. not residing) in states with Medicaid expansion were linked to HIV care ≤ 1 month after diagnosis. A higher prevalence of those residing (v. not residing) in states with > 50% of PWDH in RWHAP had viral suppression. Direct exposure to redlining was not associated with poor HIV care outcomes. Structural factors that reduce the financial burden of HIV care and improve care access like Medicaid expansion and RWHAP might improve HIV care outcomes of PWDH.

Socio-Ecological Influences on HIV Care Engagement: Perspectives of Young Black Men Who Have Sex with Men Living with HIV in the Southern US

Young Black men who have sex with men (MSM) living with HIV evidence the lowest rates of linkage to care and viral suppression of all US MSM. Kentucky, identified by the US Department of Health and Human Services as a "hot spot" state with elevated HIV incidence compared to the rest of the country, exhibits similar racialized outcomes. Structural, interpersonal, and individual drivers of engagement along the HIV care continuum among people living with HIV have been identified, primarily through quantitative designs. However, the mechanisms by which these factors shape HIV care engagement, and the ways they may combine or reinforce each other, as well as from the lived experience of young Black MSM living with HIV, have been studied to a lesser extent. In this study, a purposive sample of n = 29 HIV-positive young Black MSM (age M = 25 years old; 38% retained in care) residing in Kentucky participated in in-depth interviews. Factors that were most influential on engagement varied along the continuum, with health insurance status and knowledge of HIV being relatively more influential to diagnosis, and housing stability, psychological processes, and interpersonal relationships being more influential on retention. For some participants, barriers to care at multiple levels had a mutually influencing and intensifying impact on care engagement. Additional efforts to center the voices of young Black MSM living with HIV will help illuminate acceptable and sustainable interventions for increasing their care engagement and narrowing persistent racial disparities in HIV morbidity and mortality.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

Individual, community, and structural factors associated with linkage to HIV care among people diagnosed with HIV in Tennessee

OBJECTIVE

We assessed trends and identified individual- and county-level factors associated with individual linkage to HIV care in Tennessee (TN).

METHODS

TN residents diagnosed with HIV from 2012-2016 were included in the analysis (n = 3,751). Individuals were assigned county-level factors based on county of residence at the time of diagnosis. Linkage was defined by the first CD4 or HIV RNA test date after HIV diagnosis. We used modified Poisson regression to estimate probability of 30-day linkage to care at the individual-level and the contribution of individual and county-level factors to this outcome.

RESULTS

Both MSM (aRR 1.23, 95%CI 0.98-1.55) and women who reported heterosexual sex risk factors (aRR 1.39, 95%CI 1.18-1.65) were more likely to link to care within 30-days than heterosexual males. Non-Hispanic Black individuals had poorer linkage than White individuals (aRR 0.77, 95%CI 0.71-0.83). County-level mentally unhealthy days were negatively associated with linkage (aRR 0.63, 95%CI: 0.40-0.99).

CONCLUSIONS

Racial disparities in linkage to care persist at both individual and county levels, even when adjusting for county-level social determinants of health. These findings suggest a need for structural interventions to address both structural racism and mental health needs to improve linkage to care and minimize racial disparities in HIV outcomes.

Multilevel Analysis of Individual and Neighborhood Characteristics Associated with Viral Suppression Among Adults with HIV in Rio de Janeiro, Brazil

Understanding the impact of neighborhood context on viral suppression outcomes may help explain health disparities and identify future interventions. We assessed the relationship between individual characteristics, neighborhood socioeconomic context, and viral suppression using multilevel logistic regression models. Adults with HIV initiating antiretroviral therapy (ART) between 2000 and 2017, who resided in Rio de Janeiro and had an HIV-1 RNA level (viral load) measured 90-270 days after ART initiation were included. Overall, 83.9% achieved viral suppression. Participants who were older, had a higher level of education, and identified as heterosexual cisgender men and cisgender men-who-have-sex-with-men had increased odds of viral suppression. Later calendar year of ART initiation carried the strongest association with viral suppression, reflecting the increased effectiveness and tolerability of ART over time. Neighborhood socioeconomic indicators did not predict viral suppression in unadjusted or adjusted analyses, which may result from the integrated care provided in our health care facility together with Brazil's universal treatment.

Neighbourhood-level material deprivation and response to combination antiretroviral therapy in the Canadian Observational Cohort (CANOC): a longitudinal cohort study

BACKGROUND

Socioeconomic status has been associated with higher viral loads and lower CD4 cell counts among people living with HIV. The objective of this study was to evaluate the relation between neighbourhood-level material deprivation and immunologic and virologic response to combination antiretroviral therapy (ART) among people living with HIV in Canada.

METHODS

The Canadian Observational Cohort (CANOC) is a longitudinal cohort of people living with HIV, containing data from 2000-2016 from 5 Canadian provinces. We defined response to combination ART as positive if the CD4 cell count increased by 50 cells/mm³ (0.05 cells × 10⁹/L) or more (CD4+) and viral load decreased to 50 copies/mL or less (VL+) within 6 months of treatment initiation. We further categorized response to therapy as concordant positive (CD4+/VL+), concordant negative (CD4-/VL-) or discordant (CD4+/VL- or CD4-/VL+). We used adjusted multinomial logistic regression to quantify the relation between neighbourhood-level material deprivation and immunologic and virologic response.

RESULTS

This study included 8274 people living with HIV, of which 1754 (21.2%) lived in the most materially deprived neighbourhoods. Most individuals (62.2%) showed a concordant positive response to combination ART. After adjustment, living in the most materially deprived neighbourhoods was associated with a CD4-/VL+ discordant response (adjusted odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.62) and a concordant negative response (adjusted OR 1.45, 95% CI 1.13-1.86), using a concordant positive response as the reference. No other deprivation quartile was independently associated with a particular response.

INTERPRETATION

People living with HIV from the most materially deprived neighbourhoods had increased odds of poor immunologic or virologic response to combination ART. These results motivate further study of the specific socioeconomic factors that potentially affect response to combination ART among people living with HIV in Canada.

Neighborhood Factors Associated with Racial/Ethnic Disparities in Achieving Sustained HIV Viral Suppression Among Miami-Dade County Ryan White Program Clients

Racial/ethnic minorities are disproportionately affected by poor HIV care outcomes. Studies have also examined the effects of neighborhood-level factor on an individual's health outcomes. Thus, the objective of this study was to assess the effects of neighborhood factors on the association between race/ethnicity and sustained viral suppression (all viral load tests <200 copies/mL per year). Data for 6491 people with HIV in the 2017 Miami-Dade County Ryan White Program and neighborhood-level data by ZIP code tabulated areas from the American Community Survey were utilized. Multi-level logistic regression models were used to assess the role of neighborhood factors on the association between race/ethnicity and sustained viral suppression. Results show that non-Hispanic Blacks had lower odds of sustained viral suppression in low socioeconomic disadvantage [adjusted odds ratio (aOR): 0.39; 95% confidence interval (CI): 0.20-0.74], moderate residential instability (aOR: 0.31; 95% CI: 0.15-0.65), and low and high racial/language homogeneity neighborhoods (aOR: 0.38; 95% CI: 0.16-0.88) and (aOR: 0.38; 95% CI: 0.19-0.75), respectively, when compared to non-Hispanic Whites (NHWs). Haitians also exhibited poor outcomes in neighborhoods characterized by moderate residential instability (aOR: 0.42; 95% CI: 0.18-0.97) and high racial/language homogeneity (aOR: 0.49; 95% CI: 0.26-0.93), when compared to NHWs. In conclusion, disparities in rates of sustained viral suppression were observed for racial/ethnic minorities within various neighborhood-level factors. These findings indicate the importance of addressing neighborhood characteristics to achieve optimal care for minorities.

Structural Interventions for HIV Prevention and Care Among US Men Who Have Sex with Men: A Systematic Review of Evidence, Gaps, and Future Priorities

The preponderance of HIV interventions have been behavioral, targeting individual, dyadic, or group dynamics. However, structural-level interventions are required to decrease HIV transmission and increase engagement in care, especially for men who have sex with men (MSM), particularly Black and Latinx MSM. A systematic literature review was conducted to assess the current state of structural interventions; only two studies detailing structural interventions related to HIV for Black and Latinx MSM in the US were identified. An additional 91 studies which discussed structural-level barriers to optimal HIV outcomes among MSM, yet which did not directly evaluate a structural intervention, were also identified. While this paucity of findings was discouraging, it was not unexpected. Results of the systematic review were used to inform guidelines for the implementation and evaluation of structural interventions to address HIV among MSM in the U.S. These include deploying specific interventions for multiply marginalized individuals, prioritizing the deconstruction of structural stigma, and expanding the capacity of researchers to evaluate “natural” policy-level structural interventions through a standardization of methods for rapid evaluative response, and through universal application of sex, sexual orientation, and gender identity demographic measures.

Community-Level Factors and HIV Health Among Older People Living With HIV (PLWH) in Alabama, United States: A Qualitative Analysis

ABSTRACT

As the number of older people living with HIV (PLWH) is increasing, there is an urgent need for research on community-level factors to better understand the health care needs of this population. In-depth interview transcripts of 20 older PLWH who participated in a community-based participatory research study conducted in Alabama, in the United States, were analyzed through a phenomenological research approach. Results suggest that crime, lack of resources, and social isolation experienced at the community levels were found to be associated with the wellbeing of older PLWH. Moreover, community characteristics may confound older PLWH's comorbid conditions and resultant polypharmacy. An increased understanding of the impact of contextual factors on HIV health can inform more holistic individual- and community-level interventions aimed at addressing barriers to retention or re-engagement in HIV medical care and viral suppression among older PLWH.

Neighborhood Deprivation and Racial/Ethnic Disparities in Human Immunodeficiency Virus Viral Suppression: A Single-center, Cross-sectional Study in the United States Midwest

Combating disparities is a crucial goal of ongoing efforts to end the human immunodeficiency virus (HIV) epidemic. In a multivariable analysis of a cohort in the Midwestern United States, racial/ethnic disparities in HIV viral suppression were no longer robust after accounting for other sociodemographic factors. Neighborhood deprivation and low income were independently inversely associated with viral suppression.

Longitudinal Associations Between Neighborhood Factors and HIV Care Outcomes in the WIHS

Identifying structural determinants affecting HIV outcomes is important for informing interventions across heterogeneous geographies. Longitudinal hierarchical generalized mixed-effects models were used to quantify the associations between changes in certain structural-level factors on HIV care engagement, medication adherence, and viral suppression. Among women living with HIV in the WIHS, ten-unit increases in census-tract level proportions of unemployment, poverty, and lack of car ownership were inversely associated with viral suppression and medication adherence, while educational attainment and owner-occupied housing were positively associated with both outcomes. Notably, increased residential stability (aOR 5.68, 95% CI 2.93, 9.04) was positively associated with HIV care engagement, as were unemployment (aOR: 1.59, 95% CI 1.57, 1.60), lack of car ownership (aOR 1.14, 95% CI 1.13, 1.15), and female-headed households (aOR 1.23, 95% CI 1.22, 1.23). This underscores the importance of understanding neighborhood context, including factors that may not always be considered influential, in achieving optimal HIV-related outcomes.

Neighborhood Matters: Impact on Time Living with Detectable Viral Load for New Adult HIV Diagnoses in South Carolina

We examined the association between neighborhood disadvantages and percent person-time spent with increased transmission risk (VL > 1500 copies/ml) for people living with HIV (PLWH) in South Carolina (SC). The study population included PLWH diagnosed between 1/1/2014 and 12/31/2017, with two or more VL tests 6 months apart (n = 2076). Proportion of time living with VL > 1500 copies/ml after linkage to care was determined. Neighborhood disadvantage was assessed using the area deprivation index (ADI). A generalized linear model was fit to generate parameter estimates for time spent with detectable VL. Almost half of PLWH (49.5%) lived with VL > 1500 copies/ml for some time (median days = 46). Young adults and PLWH who injected drugs experienced the highest proportion for time living with detectable VL. Targeted programs are needed to improve VL suppression, reduce new transmissions and decrease disparities in HIV outcomes in all neighborhoods.

Neighborhood Racial Diversity, Socioeconomic Status, and Perceptions of HIV-Related Discrimination and Internalized HIV Stigma Among Women Living with HIV in the United States

Relationships that traverse sociodemographic categories may improve community attitudes toward marginalized groups and potentially protect members of those groups from stigma and discrimination. The present study evaluated whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual- and neighborhood-level characteristics of women living with HIV (WLHIV). We also sought to extend previous conceptual and empirical work to explore whether perceived HIV-related discrimination mediated the association between neighborhood racial diversity and internalized HIV stigma. A total of 1256 WLHIV in the Women's Interagency HIV Study (WIHS) attending 10 sites in metropolitan areas across the United States completed measures of internalized HIV stigma and perceived HIV-related discrimination in health care settings. Participants also provided residential information that was geocoded into Federal Information Processing Standard (FIPS) codes and linked with census-tract level indicators. In cross-sectional analyses, greater neighborhood racial diversity was associated with less internalized HIV stigma and less perceived HIV-related discrimination regardless of individual race. Neighborhood median income was positively associated with internalized HIV stigma and perceived discrimination, while individual income was negatively associated with perceptions of stigma and discrimination. In an exploratory mediation analysis, neighborhood racial diversity had a significant indirect effect on internalized HIV stigma through perceived HIV-related discrimination. An indirect effect between neighborhood income and internalized stigma was not supported. These findings suggest that greater neighborhood racial diversity may lessen HIV stigma processes at the individual level and that HIV stigma-reduction interventions may be most needed in communities that lack racial diversity.