Association between community socioeconomic position and HIV diagnosis rate among adults and adolescents in the United States, 2005 to 2009

Disparities in mortality trends of adults with HIV in the USA: A comprehensive examination across 2 decades

Approximately 38 million people worldwide are affected by human immunodeficiency virus (HIV), with 4000 new infections daily. While literature explores HIV mortality among the elderly in the US, there is an underrepresentation of mortality data for adults. By scrutinizing mortality trends based on demographic factors such as gender, race or ethnicity, age groups, and geographic location, the study seeks to uncover patterns that may facilitate a longitudinal perspective for tailoring interventions and allocating resources effectively. Crude death rates and age-adjusted mortality rates (AAMR) per 100,000 individuals were calculated using HIV mortality data (ICD-10 Codes B20-24) from CDC WONDER database. Permutation test was used to calculate annual percentage changes in AAMR with 95% confidence interval. Average annual percentage changes were computed as weighted average of annual percentage changes. Between 1999 to 2020, US adult HIV deaths totaled 225,396 (AAMR: 5.03), with a significantly decreasing average annual percentage changes (-5.94). Males exhibited a 3-fold higher AAMR (7.50) than females (2.67). Non-Hispanic Blacks had the highest AAMR (21.82), while Non-Hispanic Asians had the lowest (0.67). The South and Northeast regions had the highest AAMRs (6.91 and 6.33, respectively). Notably, the District of Columbia had an alarmingly high mortality rate of 39.9, while North Dakota had the lowest (0.7). Urban regions (5.47) had double the mortality rates of rural regions (2.70). Mortality rate peaked in age groups 45 to 54 (8.65) and 35 to 44 (7.42). While overall HIV mortality is declining, disparities persist among demographics. Targeted interventions are crucial to improve preventive measures and healthcare access for disproportionately affected groups.

Connection Between HIV and Mitochondria in Cardiovascular Disease and Implications for Treatments

HIV infection and antiretroviral therapy alter mitochondrial function, which can progressively lead to mitochondrial damage and accelerated aging. The interaction between persistent HIV reservoirs and mitochondria may provide insight into the relatively high rates of cardiovascular disease and mortality in persons living with HIV. In this review, we explore the intricate relationship between HIV and mitochondrial function, highlighting the potential for novel therapeutic strategies in the context of cardiovascular diseases. We reflect on mitochondrial dynamics, mitochondrial DNA, and mitochondrial antiviral signaling protein in the context of HIV. Furthermore, we summarize how toxicities related to early antiretroviral therapy and current highly active antiretroviral therapy can contribute to mitochondrial dysregulation, chronic inflammation, and poor clinical outcomes. There is a need to understand the mechanisms and develop new targeted therapies. We further consider current and potential future therapies for HIV and their interplay with mitochondria. We reflect on the next-generation antiretroviral therapies and HIV cure due to the direct and indirect effects of HIV persistence, associated comorbidities, coinfections, and the advancement of interdisciplinary research fields. This includes exploring novel and creative approaches to target mitochondria for therapeutic intervention.

Post-migration HIV acquisition: A systematic review and meta-analysis

Migrants in Europe face a disproportionate burden of HIV infection; however, it remains unclear if this can be prevented through public health interventions in host countries. We undertake a systematic review and meta-analysis to estimate post-migration HIV acquisition (PMHA) as a proportion of all HIV cases in European migrants. MEDLINE, EMBASE, Global Health, HMIC, and Cochrane Library were searched with terms capturing 'HIV', 'migration', and 'Europe'. Data relating to the proportion of HIV acquired following migration were extracted and random-effects model (REM) meta-analysis was undertaken to calculate a pooled estimate for the proportion of PMHA in European countries. Subgroup meta-analysis was undertaken for PMHA by migrant demographic characteristics and host country. Fifteen articles were included for systematic review following retrieval and screening of 2,320 articles. A total of 47,182 migrants in 11 European countries were included in REM meta-analysis, showing an overall PMHA proportion of 0.30 (95% CI: 0.23-0.38). Subgroup analysis showed no significant difference in PMHA between host country and migrant demographic characteristics. This work illustrates that migrants continue to be at high risk of HIV acquisition in Europe. This indicates the need for targeted screening and HIV prevention interventions, ensuring resources are appropriately directed to combat the spread of HIV.

Incorporating social determinants of health into the mathematical modeling of HIV/AIDS

Currently, it is estimated that 37.6 million people are living with the HIV/AIDS virus worldwide, placing HIV/AIDS among the ten leading causes of death, mostly among low- and lower-middle-income countries. Despite the effective intervention in the prevention and treatment, this reduction did not occur equally among populations, subpopulations and geographic regions. This difference in the occurrence of the disease is associated with the social determinants of health (SDH), which could affect the transmission and maintenance of HIV. With the recognition of the importance of SDH in HIV transmission, the development of mathematical models that incorporate these determinants could increase the accuracy and robustness of the modeling. This article aims to propose a theoretical and conceptual way of including SDH in the mathematical modeling of HIV/AIDS. The theoretical mathematical model with the Social Determinants of Health has been developed in stages. For the selection of SDH that were incorporated into the model, a narrative literature review was conducted. Secondly, we proposed an extended model in which the population (N) is divided into Susceptible (S), HIV-positive (I), Individual with AIDS (A) and individual under treatment (T). Each SDH had a different approach to embedding in the model. We performed a calibration and validation of the model. A total of 31 SDH were obtained in the review, divided into four groups: Individual Factors, Socioeconomic Factors, Social Participation, and Health Services. In the end, four determinants were selected for incorporation into the model: Education, Poverty, Use of Drugs and Alcohol abuse, and Condoms Use. the section "Numerical simulation" to simulate the influence of the poverty rate on the AIDS incidence and mortality rates. We used a Brazilian dataset of new AIDS cases and deaths, which is publicly available. We calibrated the model using a multiobjective genetic algorithm for the years 2003 to 2019. To forecast from 2020 to 2035, we assumed two lines of poverty rate representing (i) a scenario of increasing and (ii) a scenario of decreasing. To avoid overfitting, we fixed some parameters and estimated the remaining. The equations presented with the chosen SDH exemplify some approaches that we can adopt when thinking about modeling social effects on the occurrence of HIV. The model was able to capture the influence of the employment/poverty on the HIV/AIDS incidence and mortality rates, evidencing the importance of SDOH in the occurrence of diseases. The recognition of the importance of including the SDH in the modeling and studies on HIV/AIDS is evident, due to its complexity and multicausality. Models that do not take into account in their structure, will probably miss a great part of the real trends, especially in periods, as the current on, of economic crisis and strong socioeconomic changes.

Social disorganization and new HIV diagnoses, 2013-2017, Florida: Rural-urban differences

PURPOSE

To compare the role of neighborhood social disorganization factors on human immunodeficiency virus (HIV) diagnosis rates in urban and rural areas in Florida, we conducted an ecologic study of HIV diagnosis rates during 2013-2017 and social disorganization components, including concentrated disadvantage, ethnic heterogeneity, and residential instability.

METHODS

Indices of social disorganization components were obtained from principal component analyses of American Community Survey variables for 910 postal codes. Rural/urban classification was based on the United States Department of Agriculture Rural Urban Commuting Area codes. Using multivariable linear regression, the relationship between social disorganization indices and HIV diagnosis rates was assessed.

FINDINGS

The only social disorganization index that was significantly higher in rural than urban areas was concentrated disadvantage. In rural areas, the concentrated disadvantage index was significantly associated with HIV diagnosis rates (P = .007) when controlling for the other social disorganization factors but was no longer significant after additionally controlling for prevalence of people with an HIV diagnosis who were not virally suppressed. In urban areas, even after controlling for prevalence of people with HIV who were not virally suppressed, lower male-to-female population ratios and higher scores of residential instability, concentrated disadvantage, and LatinX/immigrant density indices were associated with higher HIV diagnosis rates (all P < .01).

CONCLUSIONS

In addition to improving community levels of viral suppression, the community contextual environment, including the rurality of the environment, needs to be considered in strategies to end the HIV epidemic in the United States.

Is race-specific neighborhood social cohesion key to reducing racial disparities in late HIV diagnosis: A multiyear ecological study

We examined whether race/ethnic-specific social cohesion is associated with race/ethnic-specific HIV diagnosis rates using Bayesian space-time zero-inflated Poisson multivariable models, across 376 Census tracts. Social cohesion data were from the Southeastern Pennsylvania Household Health Survey, 2008-2015 and late HIV diagnosis data from eHARS system, 2009-2016. Areas where trust in neighbors reported by Black/African Americans was medium (compared to low) had lower rates of late HIV diagnosis among Black/African Americans (Relative Risk (RR)=0.52, 95% credible interval (CrI)= 0.34, 0.80). In contrast, areas where trust in neighbors reported by Black/African Americans were highest had lower late HIV diagnosis rates among Whites (RR=0.35, 95% CrI= 0.16, 0.76). Race/ethnic-specific differences in social cohesion may have implications for designing interventions aimed at modifying area-level social factors to reduce racial disparities in late HIV diagnosis.

Modeling the Impact of Race, Socioeconomic Status, Discrimination and Cognitive Appraisal on Mental Health Concerns Among Heavy Drinking HIV+ Cisgender MSM

Prior research has attributed mental health disparities between marginalized and non-marginalized populations to socioeconomic differences (i.e., education, income, employment), stigma (e.g., HIV-related discrimination), and cognitive appraisal (i.e., optimism, hostility, satisfaction with life), but the relations among these variables have not been examined concomitantly. The current study utilized structural equation modeling to examine how race and socioeconomic status impact mental health outcomes through increased exposure to stigma and more negative cognitive appraisals. Data came from a randomized controlled trial of motivational interviewing to address heavy drinking in cisgender men with HIV who have sex with men (n = 180). We found that self-reported discrimination experiences related to race/ethnicity, sexual orientation, and HIV status significantly mediated the relation between socioeconomic status and mental health concerns, whereas cognitive appraisal did not. These findings suggest that, among heavy drinking men with HIV who have sex with men, having low socioeconomic resources may increase exposure to discrimination which, in turn, may worsen mental health. Interventions that address social determinants, like socioeconomic disadvantage, and that enhance coping resources related to stigma, may have positive effects on mental health.ClinicalTrials.gov Identifier NCT01328743. Date of Registration 09/09/2019.

A Census Tract-Level Examination of Differences in Social Determinants of Health Among People With HIV, by Race/Ethnicity and Geography, United States and Puerto Rico, 2017

OBJECTIVE

Social and structural factors, referred to as social determinants of health (SDH), create pathways or barriers to equitable sexual health, and information on these factors can provide critical insight into rates of diseases such as HIV. Our objectives were to describe and identify differences, by race/ethnicity and geography, in SDH among adults with HIV.

METHODS

We conducted an ecological study to explore SDH among people with HIV diagnosed in 2017, by race/ethnicity and geography, at the census-tract level in the United States and Puerto Rico. We defined the least favorable SDH as the following: low income (<$40 000 in median annual household income), low levels of education (≥18% of residents have

RESULTS

HIV diagnosis rates increased 1.4 to 4.0 times among men and 1.5 to 5.5 times among women as census-tract poverty levels increased, education levels decreased, income decreased, unemployment increased, lack of health insurance increased, and vacant housing increased. Among racial/ethnic groups by region and SDH, we observed higher HIV diagnosis rates per 100 000 population among non-Hispanic Black (49.6) and non-Hispanic White (6.5) adults in the South and among Hispanic/Latino (27.4) adults in the Northeast than in other regions. We observed higher HIV diagnosis rates per 100 000 population among non-Hispanic Black (44.3) and Hispanic/Latino (21.1) adults than among non-Hispanic White (5.1) adults.

CONCLUSION

Our findings highlight the importance of SDH in HIV infection and support the need for effective, targeted local interventions to specific populations based on HIV diagnoses and prevalence to prevent infection and reduce racial/ethnic disparities.

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Key Words

• HIV
• SDH
• epidemiology
• racial/ethnic differences
• social determinants of health

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MESH Headings

• Adult
• Census Tract
• Ethnicity
• Female
• Geography
• HIV Infections/diagnosis
• HIV Infections/epidemiology
• Humans
• Male
• Puerto Rico/epidemiology
• Social Determinants of Health
• United States/epidemiology

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Affiliation(s)

Shacara Johnson Lyons Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Zanetta Gant Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Chan Jin Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA ICF, Atlanta, GA, USA
André Dailey Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Ndidi Nwangwu-Ike Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Anna Satcher Johnson Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

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Incident and Prevalent HIV Infections Attributed to Sexual Transmission in the United States, 2018

BACKGROUND

The Ending the HIV Epidemic: A Plan for America initiative aims to reduce new infections by 2030. Routine assessment of incident and prevalent HIV by transmission risk is essential for monitoring the impact of national, state, and local efforts to end the HIV epidemic.

METHODS

Data reported to the National HIV Surveillance System were used to estimate numbers of incident and prevalent HIV infection attributed to sexual transmission in the United States in 2018. The first CD4 result after diagnosis and a CD4 depletion model were used to generate estimates by transmission category, sex at birth, age group, and race/ethnicity.

RESULTS

In 2018, there were an estimated 32,600 (50% confidence interval [CI], 31,800-33,400) incident and 984,000 (50% CI, 977,000-990,900) prevalent HIV infections attributed to sexual transmission in the United States. Male-to-male sexual contact comprised 74.8% and 69.1% of incident and prevalent HIV infections, respectively. Persons aged 25 to 34 years comprised 39.6% (12,900; 50% CI, 12,400-13,400) of incident infections; however, the number of prevalent infections was highest among persons 55 years and older (29.3%; 288,300 [50% CI, 285,600-291,000]). There were racial/ethnic differences in numbers of incident and prevalent infections among both men who have sex with men and persons with HIV attributable to heterosexual contact.

CONCLUSIONS

In 2018, most incident sexually transmitted HIV infections occurred in men who have sex with men, and the burden was disproportionate for persons aged 24 to 35 years, and Black/African American and Hispanic/Latino adults and adolescents. Efforts to increase the use of effective biomedical and behavioral prevention methods must be intensified to reach the goal to end the HIV epidemic in the United States.

Spatial pattern and determinants of HIV infection among adults aged 15 to 54 years in India - Evidence from National Family Health Survey-4 (2015-16)

OBJECTIVE

To assess the spatial pattern and determinants of HIV infection in India.

METHODS

We conducted a secondary data analysis using the National Family Health Survey-4 data obtained from the Demographic Health Survey programme. We accounted for clustering and stratification in the sampling design using the svyset command. Spatial analysis was performed by generating the Moran's I statistic and local indicators for spatial association (LISA) maps. Logistic regression was performed to identify the determinants of HIV infection.

RESULTS

230 213 individuals were included. Prevalence of HIV infection in India was 0.24% (95% CI: 0.21%-0.28%). Being separated/widowed/divorced (aOR = 2.58, 95% CI: 1.22-5.40), living in an urban area (aOR = 2.46, 95% CI: 1.79-3.37), being resident in the North-Eastern (aOR = 4.25, 95% CI: 2.60-6.93), Southern (aOR = 3.13, 95% CI: 1.99-4.91) or Western region (aOR = 2.17, 95% CI: 1.08-4.33), having a history of multiple sexual partners (aOR = 1.99, 95% CI:1.42-2.79), a suspected STI (aOR = 2.32, 95% CI: 1.38-3.90) or self-reported TB (aOR = 7.80, 95% CI: 2.52-24.05) were significantly in association with HIV infection. Moran's I was 0.377, suggesting positive spatial autocorrelation. The LISA cluster map indicated 60 hotspot districts in India, mostly in southern states such as Karnataka, Andhra Pradesh and Telangana followed by north-eastern states such as Nagaland, Manipur, Mizoram, Tripura and Assam.

CONCLUSION

HIV infection among adults aged 15-54 years in India is spatially clustered with the majority occurring in southern and north-eastern states. Hence, region- or district-specific strategies with focused interventions should be adopted.

PrEP Knowledge and Attitudes Among Adults Attending Public Health Clinics in Southern Arizona

HIV pre-exposure prophylaxis (PrEP) is underutilized among Hispanics, women, and low-income individuals. To better understand PrEP barriers in this population, questionnaires were administered to 500 patients attending public health clinics in southern Arizona which provide family planning and sexually transmitted infections care. Sixty-three percent believed that they had no risk of HIV infection. When asked "Before today, did you know that there was a pill that can prevent HIV infection?" 80% of persons answered no. Among women, 88% answered no to this question. As expected, individuals with a higher perceived HIV risk (OR 1.76) or one HIV risk factor (OR 5.85) had a higher probability of knowledge. Among survey participants 87% would take a daily pill, 91% would visit a health-care provider every 3 months, and 92% would have laboratory testing every 3 months. Fifty-four percent would not be afraid or embarrassed if friends or family knew they were taking PrEP. Seventy-two percent would take PrEP despite temporary nausea. Sixty-two percent would pay ≥ $40 every 3 months for PrEP. Lack of knowledge, rather than patient attitudes, is the more important barrier to wider utilization of PrEP among individuals, especially women, attending public health clinics in Southern Arizona. Future efforts need to focus on education and access to PrEP in underserved populations including women and Hispanics.

Characterization of HIV risks in a Brazilian sickle cell disease population

BACKGROUND

A low prevalence of HIV in sickle cell disease (SCD) patients has been reported in the literature though mechanisms for this are not understood.

METHODS

HIV risk behaviors were compared between SCD cases and non-SCD controls using a self-administered audio computer-assisted self-interview. SCD cases were recruited from a multi-center SCD cohort established in Brazil; controls were recruited from SCD social contacts. Categorical variables were analyzed using Chi-Square or Fisher exact test. Continuous variables were compared using the Mann-Whitney U test.

RESULTS

There were 152 SCD cases and 154 age/location matched controls enrolled at three participating Brazilian centers during 2016-17. No significant differences in number of sexual partners (lifetime or previous 12 months), male-to-male sex partners or intravenous drug use were observed. Cases received more transfusions, surgeries, and acupuncture treatment.

CONCLUSIONS

Besides the risk of transfusion-transmitted HIV, which is now exceedingly rare, SCD and non-SCD participants demonstrated similar HIV risk behaviors. Causes other than risk behaviors such as factors inherent to SCD pathophysiology may explain the reported low prevalence of HIV in SCD.

County-level factors affecting Latino HIV disparities in the United States

OBJECTIVE

To determine which county-level social, economic, demographic, epidemiologic and access to care factors are associated with Latino/non-Latino White disparities in prevalence of diagnosed HIV infection.

METHODS AND FINDINGS

We used 2016 county-level prevalence rates of diagnosed HIV infection rates for Latinos and non-Latino Whites obtained from the National HIV Surveillance System and factors obtained from multiple publicly available datasets. We used mixed effects Poisson modeling of observed HIV prevalence at the county-level to identify county-level factors that explained homogeneous effects across race/ethnicity and differential effects for Latinos and NL-Whites. Overall, the median Latinos disparity in HIV prevalence is 2.4; 94% of the counties have higher rates for Latinos than non-Latinos, and one-quarter of the counties' disparities exceeded 10. Of the 41 county-level factors examined, 24 showed significant effect modification when examined individually. In multi-variable modeling, 11 county-level factors were found that significantly affected disparities. Factors that increased disparity with higher, compared to lower values included proportion of HIV diagnoses due to injection drug use, percent Latino living in poverty, percent not English proficient, and percent Puerto Rican. Latino disparities increased with decreasing percent severe housing, drug overdose mortality rate, percent rural, female prevalence rate, social association rate, percent change in Latino population, and Latino to NL-White proportion of the population. These factors while significant had minimal effects on diminishing disparity, but did substantially reduce the variance in disparity rates.

CONCLUSIONS

Large differences in HIV prevalence rates persist across almost all counties even after controlling for county-level factors. Counties that are more rural, have fewer Latinos, or have lower NL-White prevalence rates tend to have higher disparities. There is also higher disparity when community risk is low.

Behavioral Weight Loss: A Promising Treatment for Obesity in Adults with HIV

Obesity and chronic disease are growing problems among people living with HIV (PLWH) across the globe. While a variety of treatments have been developed to address cardiovascular and metabolic disease among PLWH, few treatments have focused on helping PLWH and obesity lose weight. In the general population, behavioral weight loss interventions (i.e., diet, physical activity, and behavior therapy) are the first-line treatment for adults for whom weight loss is recommended. However, little research has tested whether the benefits of these programs translate to PLWH. This paper highlights the key components of behavioral weight loss programs, their outcomes in the general population and in the few studies of PLWH, and suggestions for tailoring these programs for PLWH. Behavioral weight loss programs are a strong potential treatment for reducing the burden of obesity among PLWH and merit future research attention.

Relationship of Racial Residential Segregation to Newly Diagnosed Cases of HIV among Black Heterosexuals in US Metropolitan Areas, 2008-2015

Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton's isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV.

Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South

Purpose:

In the United States (U.S.), southern states have the highest HIV incidence. Uptake of pre-exposure prophylaxis (PrEP) has been slow among Black people, particularly in the South. We know little about how area-level HIV risk influences one's willingness to use PrEP.

Methods:

169 Black participants across 142 ZIP codes in the South completed the 2016 National Survey on HIV in the Black Community. We performed log-binomial regression to estimate the prevalence risk associated with residing in the upper 25th percentile of increases in new HIV diagnosis (2014–2015) within ZIP code and an individual's willingness to use PrEP, adjusting for individual and area-level covariates.

Results:

Participants were 68% female, mean age of 36 years, and 24% willing to use PrEP. Among the ZIP codes, 23% were within Atlanta, GA. The median increase in new HIV diagnoses was 25 per 100,000 population from 2014 to 2015 (IQR, 14–49). Participants living in ZIP codes within the upper 25th (compared-to-lower 75th) percentile of new HIV diagnoses were more willing to use PrEP (adjusted prevalence ratio (aPR) = 2.02, 95% CI = 1.06–3.86, P = .03). Area-level socioeconomic factors attenuated that association (aPR = 1.63, 95% CI = 0.78–3.39, P = .19).

Conclusions:

Area-level factors may influence PrEP uptake among Black people in the South.

Improving the HIV Prevention Landscape to Reduce Disparities for Black MSM in the South

Black men who have sex with men (MSM) in the South have the highest rates of HIV diagnosis in the country adding to the persistent racial disparities in HIV experienced by this population. The current HIV prevention and care landscape is heavily driven by individual-level clinical and biomedical approaches that have shown progress in reducing HIV diagnoses, but yield less than adequate results in reducing the HIV racial disparities for Black MSM in the South. In efforts to enhance focus on reducing the racial HIV disparities and more completely address the needs of Black MSM in the South, we offer insight on comprehensive approaches that can complement our current HIV prevention and care portfolio. There are five domains we discuss which include: (1) leveraging and integrating resources; (2) building upon existing program models designed to reduce disparities; (3) workforce development and cultural sensitivity; (4) social determinants of health data utilization; and 5) policy considerations. We urge public health practitioners and healthcare providers to consider and incorporate the outlined approaches to improve HIV outcomes along the continuum of care and ultimately reduce disparities in HIV affecting the quality of life of Black MSM living in the South.

Determinants of consistently high HIV prevalence in Indian Districts: A multi-level analysis

INTRODUCTION

Factors associated with persistently high Human Immunodeficiency Virus (HIV) prevalence levels in several districts of India are not well understood. This study was undertaken to determine the association of socio-demographic characteristics, economic factors, awareness about HIV and Sexually Transmitted Infections (STIs), and condom use with consistently high HIV prevalence in the Indian districts and to ascertain whether these associations differed across various regions of India.

METHODS

This study was carried out including all 640 districts of India. Secondary analysis of data obtained from the Census of India-2011, HIV Sentinel Surveillance in India and District Level Household Survey-III was done. Population profile, socio-economic characteristics, levels of HIV/STI/condom awareness and condom use, were compared between the districts with and without consistently high HIV prevalence. Due to the presence of collinearity among predictor variables, we used principal component analysis and the principal component scores were included as covariates for further analysis. Considering the districts at level 1 and the regions at level 2, multi-level analysis was done by generalised linear mixed models. Variance partition coefficient and median odds ratio were also calculated.

RESULTS

Sixty-three districts with consistently high HIV prevalence were found clustered in the South and the North-east regions of India. Population size, density and urbanisation were found to be positively associated with consistently high HIV prevalence in these districts. Higher levels of literacy, better socio-economic status, higher proportion of population in reproductive age group and late marriages were positively associated with consistently high HIV prevalence in all regions of India except in the Southern region. Higher levels of knowledge about the role of condoms in HIV prevention and condom use were associated with low HIV prevalence at the district level.

CONCLUSIONS

Considerable heterogeneity among factors associated with consistently high HIV prevalence at the district level in different regions of India necessitates special region-specific strategies for HIV control. Increasing awareness about HIV alone is not sufficient for controlling the HIV epidemic and there is a need to raise knowledge levels about preventive measures against HIV and promote the use of condoms amongst population.

Association of Household Income Level and In-Hospital Mortality in Patients With Sepsis: A Nationwide Retrospective Cohort Analysis

OBJECTIVE

Associations between low socioeconomic status (SES) and poor health outcomes have been demonstrated in a variety of conditions. However, the relationship in patients with sepsis is not well described. We investigated the association of lower household income with in-hospital mortality in patients with sepsis across the United States.

METHODS

Retrospective nationwide cohort analysis utilizing the Nationwide Inpatient Sample (NIS) from 2011. Patients aged 18 years or older with sepsis were included. Socioeconomic status was approximated by the median household income of the zip code in which the patient resided. Multivariate logistic modeling incorporating a validated illness severity score for sepsis in administrative data was performed.

RESULTS

A total of 8 023 590 admissions from the 2011 NIS were examined. A total of 671 858 patients with sepsis were included in the analysis. The lowest income residents compared to the highest were younger (66.9 years, standard deviation [SD] = 16.5 vs 71.4 years, SD = 16.1, P < .01), more likely to be female (53.5% vs 51.9%, P < .01), less likely to be white (54.6% vs 76.6%, P < .01), as well as less likely to have health insurance coverage (92.8% vs 95.9%, P < .01). After controlling for severity of sepsis, residing in the lowest income quartile compared to the highest quartile was associated with a higher risk of mortality (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.03-1.08, P < .01). There was no association seen between the second (OR: 1.02, 95% CI: 0.99-1.05, P = .14) and third (OR: 0.99, 95% CI: 0.97-1.01, P = .40) quartiles compared to the highest.

CONCLUSION

After adjustment for severity of illness, patients with sepsis who live in the lowest median income quartile had a higher risk of mortality compared to residents of the highest income quartile. The association between SES and mortality in sepsis warrants further investigation with more comprehensive measures of SES.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

Census Tract Poverty and Racial Disparities in HIV Rates in Milwaukee County, Wisconsin, 2009-2014

Previous work has documented associations between poverty and HIV. Understanding of these relationships at local levels could help target prevention efforts; however, HIV surveillance systems do not capture individual-level poverty measures. We utilized the Public Health Disparities Geocoding Project methods to examine HIV rates by census tract poverty. HIV rates and rate ratios were computed by census tract poverty (< 5.0, 5.0-9.9, 10.0-19.9, > 20.0% of individual below the federal poverty level) for all races and stratified by Black and White race using Poisson regression. We observed higher HIV rates in the highest poverty gradient compared to the lowest poverty gradient for all races combined and among White cases. After adjustment, HIV rates were similar across poverty gradients for all comparisons. Our findings suggest that the association between poverty and HIV may differ by subpopulation, while demonstrating the potential for HIV prevention targeting residents of high poverty areas.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Neighborhood Characteristics Associated with Achievement and Maintenance of HIV Viral Suppression Among Persons Newly Diagnosed with HIV in New York City

We investigated the effect of neighborhood characteristics on achievement and maintenance of HIV viral suppression among New York City (NYC) residents aged 13 years and older diagnosed between 2006 and 2012. Individual records from the NYC HIV surveillance registry (n = 12,547) were linked to U.S. Census and American Community Survey data by census tract of residence. Multivariable proportional hazards regression models indicated the likelihood of achievement and maintenance of suppression by neighborhood characteristics including poverty, accounting for neighborhood clustering and for individual characteristics. In adjusted analyses, no neighborhood factors were associated with achievement of suppression. However, residents of high- or very-high-poverty neighborhoods were less likely than residents of low-poverty neighborhoods to maintain suppression. In conclusion, higher neighborhood poverty was associated with lesser maintenance of suppression. Assistance with post-diagnosis retention in care, antiretroviral therapy prescribing, or adherence targeted to residents of higher-poverty neighborhoods may improve maintenance of viral suppression in NYC.

The relationship between higher social trust and lower late HIV diagnosis and mortality differs by race/ethnicity: results from a state-level analysis

INTRODUCTION

Black men who have sex with men (MSM) continue to suffer a disproportionate burden of new HIV diagnoses and mortality. To better understand some of the reasons for these profound disparities, we examined whether the association between social trust and late HIV diagnosis and mortality differed by race/ethnicity, and investigated potential indirect effects of any observed differences.

METHODS

We performed generalized structural equation modelling to assess main and interaction associations between trust among one's neighbours in 2009 (i.e. social trust) and race/ethnicity (Black, White, and Hispanic) predicting late HIV diagnosis (a CD4 count ≤200 cell/µL within three months of a new HIV diagnosis) rates and all-cause mortality rates of persons ever diagnosed late with HIV, across 47 American states for the years 2009-2013. We examined potential indirect effects of state-level HIV testing between social trust and late HIV diagnosis. Social trust data were from the Gallup Healthways Survey, HIV data from the Centers for Disease Control and Prevention, and HIV testing from the Behavioral Risk Factor Surveillance System. Covariates included state-level structural, healthcare, and socio-demographic factors including income inequality, healthcare access, and population density. We stratified analysis by transmission group (male-to-male, heterosexual, and injection drug use (IDU)).

RESULTS

States with higher levels of social trust had lower late HIV diagnosis rates: Adjusted Rate Ratio [aRR] were consistent across risk groups (0.57; 95%CI 0.53-0.62, male-to-male), (aRR 0.58; 95%CI 0.54-0.62, heterosexual) and (aRR 0.64; 95%CI 0.60-0.69, IDU). Those associations differed by race/ethnicity (all p < 0.001). The associations were most protective for Blacks followed by Hispanics, and least protective for Whites. HIV testing mediated between 18 and 32% of the association between social trust and late HIV diagnosis across transmission group but for Blacks relative to Whites only. Social trust was associated with lower all-cause mortality rates and that association varied by race/ethnicity within the male-to-male and IDU transmission groups only.

CONCLUSION

Social trust may promote timely HIV testing, which can facilitate earlier HIV diagnosis, thus it can be a useful determinant to monitor the relationship with HIV care continuum outcomes especially for racial/ethnic minority groups disproportionately infected by HIV.

Structural inequalities drive late HIV diagnosis: The role of black racial concentration, income inequality, socioeconomic deprivation, and HIV testing

In the United States, research is limited on the mechanisms that link socioeconomic and structural factors to HIV diagnosis outcomes. We tested whether neighborhood income inequality, socioeconomic deprivation, and black racial concentration were associated with gender-specific rates of HIV in the advanced stages of AIDS (i.e., late HIV diagnosis). We then examined whether HIV testing prevalence and accessibility mediated any of the associations above. Neighborhoods with highest (relative to lowest) black racial concentration had higher relative risk of late HIV diagnosis among men (RR=1.86; 95%CI=1.15, 3.00) and women (RR=5.37; 95%CI=3.16, 10.43) independent of income inequality and socioeconomic deprivation. HIV testing prevalence and accessibility did not significantly mediate the associations above. Research should focus on mechanisms that link black racial concentration to HIV diagnosis outcomes.

A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada

African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ² (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.

The Association Between Neighborhood Poverty and HIV Diagnoses Among Males and Females in New York City, 2010-2011

OBJECTIVE

We assessed the association of neighborhood poverty with HIV diagnosis rates for males and females in New York City.

METHODS

We calculated annual HIV diagnosis rates by ZIP Code, sex, and neighborhood poverty level using 2010-2011 New York City (NYC) HIV surveillance data and data from the U.S. Census 2010 and American Community Survey 2007-2011. Neighborhood poverty levels were percentage of residents in a ZIP Code with incomes below the federal poverty threshold, categorized as 0%-<10% (low poverty), 10%-<20% (medium poverty), 20%-<30% (high poverty), and 30%-100% (very high poverty). We used sex-stratified negative binomial regression models to measure the association between neighborhood-level poverty and HIV diagnosis rates, controlling for neighborhood-level education, race/ethnicity, age, and percentage of men who have sex with men.

RESULTS

In 2010-2011, 6,184 people were newly diagnosed with HIV. Median diagnosis rates per 100,000 population increased by neighborhood poverty level overall (13.7, 34.3, 50.6, and 75.6 for low-, medium-, high-, and very high-poverty ZIP Codes, respectively), for males, and for females. In regression models, higher neighborhood poverty remained associated with higher diagnosis rates among males (adjusted rate ratio [ARR] = 1.63, 95% confidence interval [CI] 1.34, 1.97) and females (ARR=2.14, 95% CI 1.46, 3.14) for very high- vs. low-poverty ZIP Codes.

CONCLUSION

Living in very high- vs. low-poverty urban neighborhoods was associated with increased HIV diagnosis rates. After controlling for other factors, the association between poverty and diagnosis rates was stronger among females than among males. Alleviating poverty may help decrease HIV-related disparities.

County-Level Correlates of CDC-Funded HIV Testing Events, United States, 2012

HIV prevalence and socio-demographic data were analyzed to assess the alignment of CDC-funded HIV testing activity in 2012 with its high-impact prevention approach. CDC-funded HIV-testing was conducted in counties with high HIV prevalence and in places potentially more affected by HIV as measured by urbanicity, percent black, percent poverty, and percent uninsured. The percent Hispanic/Latino was associated with a lower probability of HIV testing activity. Higher percentages of black and Hispanic/Latino in the population was positively associated with new HIV diagnoses. Analyzing county-level data confirmed the appropriateness of CDC-funded HIV testing activities under a high-impact prevention approach but also suggested areas for possible improvement.

Persistent racial/ethnic disparities in AIDS diagnosis rates among people who inject drugs in U.S. metropolitan areas, 1993-2007

OBJECTIVES

We estimated race/ethnicity-specific incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess the change in disparities after highly active antiretroviral therapy (HAART) dissemination.

METHODS

We compared IARs and 95% confidence intervals (CIs) for black/African American and Hispanic/Latino PWID with those of white PWID in 93 of the most populous MSAs. We selected two three-year periods from the years immediately preceding HAART (1993-1995) and the years with the most recent available data (2005-2007). To maximize stability, we aggregated data across three-year periods, and we aggregated data for black/African American and Hispanic/Latino PWID for most comparisons with data for white PWID. We assessed disparities by comparing IAR 95% CIs for overlap.

RESULTS

IARs were significantly higher for black/African American and Hispanic/Latino PWID than for white PWID in 81% of MSAs in 1993-1995 and 77% of MSAs in 2005-2007. MSAs where disparities became non-significant over time were concentrated in the West. Significant differences were more frequent in comparisons between black/African American and white PWID (85% of MSAs in 1993-1995, 79% of MSAs in 2005-2007) than in comparisons between Hispanic/Latino and white PWID (53% of MSAs in 1993-1995, 56% of MSAs in 2005-2007). IARs declined modestly across racial/ethnic groups in most MSAs.

CONCLUSIONS

AIDS diagnosis rates continue to be substantially higher for black/African American and Hispanic/Latino PWID than for white PWID in most large MSAs. This finding suggests a need for increased targeting of prevention and treatment programs, as well as research on MSA-level conditions that may serve to maintain the disparities.

Home testing past, present and future: lessons learned and implications for HIV home tests

The recent approval in the United States of the first rapid home test to diagnose HIV raises questions about its potential use and impact. We reviewed the existing literature on the unassisted use of home tests involving self-collection and testing of biological samples by untrained users-including existing HIV self-testing studies-to shed some light on what can be expected from the availability of the HIV home test. The studies reviewed showed that most participants could properly perform home tests, obtain accurate results, and interpret them-yielding high correlations with laboratory and health-professional performed tests. Users often had trouble performing blood-based tests. Participants generally understood the need to confirm positive test results. Materials accompanying HIV home tests should emphasize symptoms of acute infection and the need for additional testing when recent infection is suspected. Different home-test-based screening modalities, personalized HIV-counseling resources and HIV home test impact evaluation methods should be studied.

Beyond race and place: distal sociological determinants of HIV disparities

Informed behavior change as an HIV prevention tool has yielded unequal successes across populations. Despite decades of HIV education, some individuals remain at high risk. The mainstream media often portrays these risk factors as products of race and national borders; however, a rich body of recent literature proposes a host of complex social factors that influence behavior, including, but not limited to: poverty, income inequality, stigmatizing social institutions and health care access. We examined the relationship between numerous social indicators and HIV incidence across eighty large U.S. cities in 1990 and 2000. During this time, major correlating factors included income inequality, poverty, educational attainment, residential segregation and marriage rates. However, these ecological factors were weighted differentially across risk groups (e.g. heterosexual, intravenous drug use, men who have sex with men (MSM)). Heterosexual risk rose significantly with poor economic indicators, while MSM risk depended more heavily on anti-homosexual stigma (as measured by same-sex marriage laws). HIV incidence among black individuals correlated significantly with numerous economic factors but also with segregation and imbalances in the male:female ratio (often an effect of mass incarceration). Our results support an overall model of HIV ecology where poverty, income inequality and social inequality (in the form of institutionalized racism and anti-homosexual stigma) have over time developed into synergistic drivers of disease transmission in the U.S., inhibiting information-based prevention efforts. The relative weights of these distal factors vary over time and by HIV risk group. Our testable model may be more generally applicable within the U.S. and beyond.

Rapid HIV self-testing: long in coming but opportunities beckon

The recent approval by the United States Food and Drug Administration of a rapid HIV self-test marks a significant milestone in the evolution of HIV testing approaches. With nearly one in five people living with HIV in the United States still undiagnosed and an even higher proportion unaware of their infection globally, this decision reflects a new willingness to offer diverse options to get tested for HIV. Rapid self-testing offers several distinct opportunities to improve testing among those with undiagnosed HIV: to encourage testing among those who might not otherwise be tested, to increase the frequency of testing among persons at highest risk for new infection, and to facilitate mutual HIV testing with sex partners. To date, the path to regulatory approval has been long but instructive. The studies and clinical trials required for regulatory approval in the United States provide insight into the performance and potential implications of HIV self-tests as they become available for sale directly to consumers. Although some persistent reservations about self-testing for HIV remain, including the 'window period' of the current test kit, its cost, and its effectiveness for facilitating entry to medical care, others have been dispelled. Self-testing in resource-constrained settings is also promising, including self-testing of health professionals. At present, although the impact has yet to be determined, availability of this new option might offer potential opportunities to improve HIV diagnosis and facilitate both treatment and prevention.

HIV and risk behaviors of persons of low socio-economic status, Popayan-Colombia (2008-2009)

OBJECTIVE

To determine HIV presence and risk behaviors of persons of low socio-economic status in the city of Popayan-Colombia.

METHODS

Cross-sectional study; between 2008 and 2009, 363 participants of Popayan signed informed consent and received pre and post HIV test counseling. Socio-demographic characteristics and history of STDs, risk behaviors and previous HIV testing were assessed. Descriptive statistics, correlations and multivariate logistic regression were calculated.

RESULTS

Mean age 33.5±10,2; 66 %women. Frequency of HIV-positive patients was 3.86 % (95% CI:1.87-5.85), greater in men (7.38%; p= 0.013). Greater frequency of HIV-positive patients was observed in people age 29-37, those without a stable partner, and those with history of risky alcohol consumption (more than five drinks in 2 h).

CONCLUSIONS

HIV-positive patients frequency in this population was greater than national estimate for general population, aged 15-49 in Colombia, with even greater frequency in men. This study suggests that characteristics associated with low socioeconomic status, in economically active population, without a stable partner and with risky alcohol use, can potentially increase risk of HIV infection.