Low Socioeconomic Status Is Associated With a Higher Rate of Death in the Era of Highly Active Antiretroviral Therapy, San Francisco

Abstract

Highly active antiretroviral therapy (HAART) has dramatically improved survival after AIDS. The benefits of HAART have not been equally realized for all communities, however. We characterize the association of socioeconomic status (SES) with survival after AIDS diagnosis in San Francisco in the period before (1980-1995) and after (1996 - 2001) the wider use of HAART. Using citywide surveillance data, we examined differences in survival after AIDS diagnosis by neighborhood household income using Kaplan-Meier survival analysis and Cox proportional hazards analysis to adjust for significant covariates. Residing in higher SES neighborhoods significantly predicted better survival after AIDS from 1996 to 2001 (hazard ratio = 0.92 per $10,000 increase in neighborhood household income, 95% CI: 0.85-0.99) after adjusting for CD4 count at diagnosis, age, and injection drug user status. Persons living in poorer neighborhoods were less likely to use HAART at any time in the past compared with persons in wealthier neighborhoods. Moreover, no association between survival and neighborhood SES was evident in the era prior to the wide use of HAART. Finally, the difference in survival by neighborhood income level disappeared after controlling for the use of HAART, suggesting that use of or access to treatment explained the association. From 1996 to 2001, survival with AIDS was worse for people living in poorer neighborhoods compared with those living in wealthier neighborhoods of San Francisco as a result of unequal access to or use of HAART.

An Epidemic in Evolution: The Need for New Models of HIV Care in the Chronic Disease Era

“…The geographic disparities mentioned above overlap with underlying socioeconomic and racial inequalities driving the US epidemic: for example, poorer communities have higher rates of HIV/AIDS and patients with low socioeconomic status have lower survival rates; [35][36][37][38] patients without adequate insurance are less likely to be on antiretroviral therapy; 39 substance users and minorities are more likely to delay 43 To complement clinician-based changes such as those suggested previously, primary care networks can help improve access to HIV treatment and reduce important health disparities by implementing systemsbased strategies (e.g., community-based HIV service programs) to provide appropriate care. These programs may be especially valuable for patients who cannot easily travel to specialty centers as well as vulnerable and medically underserved groups.…”

Neighborhood-level Determinants of Delayed HIV Diagnosis and Survival among HIV-positive Latinos, Florida 2000-2011

“…Consistent with previous studies of the general HIVpositive population , McFarland et al, 2003, Trepka et al, 2013b, Residing in an area with <25% Latinos compared with ≥50% Latinos was protective for Latinos with history of IDU. This effect was not observed among Latinos without history of IDU.…”

“…Additionally, neighborhood-level educational attainment has been associated with late HIV diagnosis in urban areas (Trepka et al, 2014). Areas with low SES have also been associated with low HIV and AIDS survival , Joy et al, 2008, McFarland et al, 2003.…”

“…Contributing to the association between neighborhood disadvantage and drug use behaviors are increased psychological stress, decreased positive social networks, and fewer health and social support services (Boardman et al, 2001, Galea et al, 2003, Kirby and Toshiko, 2005. Neighborhood disadvantage also is associated with increased mortality risk among the general HIV-positive population , Joy et al, 2008, McFarland et al, 2003. However, no studies to date have examined the association between neighborhood socioeconomic status (SES) and mortality among HIV-positive injection drug users.…”

“…Areas with low socioeconomic status (SES) are associated with high HIV rates (Lopez-De Fede et al, 2011, Ishida et al, 2012 and low AIDS survival , McFarland et al, 2003. Neighborhood poverty has also been shown to partially account for racial/ethnic disparities in HIV/AIDS survival (Trepka et al, 2013, Arnold et al, 2009) and antiretroviral initiation (Arnold et al, 2009).…”