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

Abstract

Retention in care and viral suppression are critical to delaying HIV progression and reducing transmission. Neighborhood socioeconomic context (NSEC) may affect HIV care receipt. We therefore assessed NSEC's impact on retention and viral suppression in a diverse HIV clinical cohort. HIV-positive adults with ≥1 visit at the Vanderbilt Comprehensive Care Clinic and 5-digit ZIP code tabulation area (ZCTA) information between 2008 and 2012 contributed. NSEC z-score indices used neighborhood-level socioeconomic indicators for poverty, education, labor-force participation, proportion of males, median age, and proportion of residents of black race by ZCTA. Retention was defined as ≥2 HIV care visits per calendar year, >90 days apart. Viral suppression was defined as an HIV-1 RNA <200 copies/mL at last measurement per calendar year. Modified Poisson regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI). Among 2272 and 2541 adults included for retention and viral suppression analyses, respectively, median age and CD4 count at enrollment were approximately 38 (1st and 3rd quartile: 30, 44) years and 351 (176, 540) cells/μL, respectively, while 24% were female, and 39% were black. Across 243 ZCTAs, median NSEC z-score was 0.09 (-0.66, 0.48). Overall, 79% of person-time contributed was retained and 74% was virally suppressed. In adjusted models, NSEC was not associated with retention, though being in the 4th vs. 1st NSEC quartile was associated with lack of viral suppression (RR = 0.88; 95% CI: 0.80-0.97). Residing in the most adverse NSEC was associated with lack of viral suppression. Future studies are needed to confirm this finding.

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

“…From such research we learned that unsuppressed HIV viral load is more common among PLHIV in the most socioeconomically disadvantaged neighborhoods. 10 When controlling for individual demographic characteristics, including age, gender, race, and income, such evidence emerges: PLHIV residing in neighborhoods with a higher proportion of poverty had 1.50 greater odds of having a CD4 cell count characteristic of an AIDS diagnosis (<200 cells/lL), PLHIV in neighborhoods with higher prevalence of unemployment were almost 50% less likely to have a current antiretroviral prescription, and PLHIV were more likely to report depressive symptoms if they resided in racially segregated neighborhoods. 11 Moreover, a measure of neighborhood disorder, an indicator of economic disadvantage, was associated with poorer antiretroviral treatment (ART) adherence.…”

Individual, Community, and Structural Factors Associated With Linkage to HIV Care Among People Diagnosed with HIV in Tennessee

“…A rich body of data supports an association between community factors and important health outcomes (35)(36)(37). Much of this research has focused on poor socioeconomic status (SES) and other characteristics of neighborhood deprivation (18,35,37,38). One study set in TN found that individuals living in neighborhoods with the most adverse socioeconomic features were least likely to achieve virologic suppression (18).…”

“…Much of this research has focused on poor socioeconomic status (SES) and other characteristics of neighborhood deprivation (18,35,37,38). One study set in TN found that individuals living in neighborhoods with the most adverse socioeconomic features were least likely to achieve virologic suppression (18). Some authors hypothesize that the relationship between SES and health outcomes are mediated by distribution of stressors, which may be more prevalent in poorer neighborhoods and among racial and ethnic minorities (35,(39)(40)(41).…”

“…We assessed community and structural factors at the county-level representing measures of healthcare access, socioeconomic status and burden of disease grounded in the social ecological model as a framework to consider barriers to linkage to HIV care (18,19). The measures were drawn from several sources including a CDC-developed Vulnerability Index (VI) which provided a means of identifying counties at high risk for incident cases of HIV/HCV (20,21).…”

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

“…Moreover, this framing allows us to see how the distribution of socioeconomic capital makes barriers to care such as cost and health insurance coverage even more pertinent in communities [ 4 , 42 , 43 ]. Similarly, a number of studies have found links between neighborhood socioeconomic context, resource availability, care engagement, and viral suppression [ 44 , 45 ]. For example, historically Black and resource-deprived neighborhoods are less likely to have an HIV care clinic nearby, therefore increasing travel time to appointments and reducing retention in care [ 46 ].…”