Race, place and AIDS: The role of socioeconomic context on racial disparities in treatment and survival in San Francisco

Abstract

Prior evidence suggests that the health and longevity benefits of antiretroviral therapy (ART) for persons living with AIDS (PLWAs) have not been equally distributed across racial/ethnic groups in the United States. Notably, black PLWAs tend to fare worse than their counterparts. We examine the role of neighborhood socioeconomic context on racial/ethnic differences in AIDS treatment and survival in San Francisco. The study population encompassed 4211 San Francisco residents diagnosed with AIDS between 1996 and 2001. Vital status was reported through 2006. Census data were used to define neighborhood-level indicators of income, housing, demographics, employment and education. Cox proportional hazards models were employed in multivariate analyses of survival times. Compared to whites, blacks had a significant 1.4 greater mortality hazard ratio (HR), which decreased after accounting for ART initiation. PLWAs in the lowest socioeconomic neighborhoods had a significant HR of 1.4 relative to those in higher socioeconomic neighborhoods, independent of race/ethnicity. The neighborhood association decreased after accounting for ART initiation. Path analysis was used to explore causal pathways to ART initiation. Racial/ethnic differences in neighborhood residence accounted for 19-22% of the 1.6-1.8 black-white relative odds ratio (ROR) and 14-15% of the 1.3-1.4 Latino-white ROR for delayed or no treatment. Our findings illuminate the independent and synergistic contributions of race and place on treatment disparities and highlight the need for future studies and interventions to address treatment initiation as well as neighborhood effects on treatment differences.

Socioeconomic Status and Survival of People with Human Immunodeficiency Virus Infection before and after the Introduction of Highly Active Antiretroviral Therapy: A Systematic Literature Review

“…Four studies examined effects of SES on mortality with HIV/AIDS in the years of pre-HAART period [70][71][72][73]. Fifteen studies provided an assessment of SES in relation to survival in HIV-infected patients during the years of commercial availability of HAART [74][75][76][77][78][79][80][81][82][83][84][85][86][87][88]. Two studies [34,35] evaluated the impact of SES on survival with HIV/AIDS in both periods.…”

“…The most common rationale for the selection of a particular socioeconomic measure in the reports was that it had been adopted in the past and had high predictive validity. A calculated SES index was used in five studies [34,71,79,82,88] because of a perception that a complex index discriminates better than its components. Homelessness and access to health insurance or the type of health insurance as a factor affecting survival with HIV/AIDS was considered only in the US studies of post-HAART period indicating the importance of these variables in the pathways between effective therapy initiation and survival.…”

“…Seven reports provided data on survival of persons with AIDS (PWAs) only [34,71,72,79,80,85,88], one examined survival of HIV-infected parents of adolescents [73], one looked at survival in HIV-infected children [78], and the remaining studies assessed HIV-infected patients of both genders and various age groups (Table 1). While the majority of retrieved publications looked at all-cause mortality in individuals diagnosed with HIV/AIDS, two Canadian reports [75,83] and one US study [80] covering the post-HAART period described HIV/ AIDS-related mortality.…”

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

“…Furthermore, neighborhood poverty has 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). Possible mechanisms to the relationship between neighborhood-level SES and health include increased psychological stress, decreased positive social networks, and fewer health and social support services (Boardman et al, 2001, Galea et al, 2003, Kirby & Toshiko, 2005.…”

“…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). Although few studies have examined the role of neighborhood factors on late HIV diagnosis , Trepka et al, 2014, research suggests that residential neighborhood might predict availability and utilization of health care (Haas et al, 2004, Gaskin et al, 2012 and preventive services (Kaestle & Wiles, 2010, Quinn et al, 2009.…”