Community poverty and trends in racial/ethnic survival disparities among people diagnosed with AIDS in Florida, 1993-2004

Are spatial models advantageous for predicting county-level HIV epidemiology across the United States?

Predicting human immunodeficiency virus (HIV) epidemiology is vital for achieving public health milestones. Incorporating spatial dependence when data varies by region can often provide better prediction results, at the cost of computational efficiency. However, with the growing number of covariates available that capture the data variability, the benefit of a spatial model could be less crucial. We investigate this conjecture by considering both non-spatial and spatial models for county-level HIV prediction over the US. Due to many counties with zero HIV incidences, we utilize a two-part model, with one part estimating the probability of positive HIV rates and the other estimating HIV rates of counties not classified as zero. Based on our data, the compound of logistic regression and a generalized estimating equation outperforms the candidate models in making predictions. The results suggest that considering spatial correlation for our data is not necessarily advantageous when the purpose is making predictions.

An Occupational Heat Stress and Hydration Assessment of Agricultural Workers in North Mexico

Expanding agribusiness in Northern Mexico has increased demand for workers from Southern Mexico, with hundreds of thousands migrating for work annually. Extreme temperatures, physical labor, and low fluid consumption place workers at risk for heat strain and dehydration, commonly underreported hazards in the agricultural industry. The objectives of this pilot study were to assess heat exposure and hydration status of a population of migratory agricultural workers in Northern Mexico throughout the grape harvest season. In addition to demographic information, environmental conditions, hydration status, and core body temperatures were collected. The majority listed Chiapas as their home state, nearly half spoke an Indigenous language, and none had completed high school. The wet-bulb globe temperature was significantly higher during the harvest and post-harvest seasons compared to the pre-harvest season. Across the different seasons, the majority were dehydrated post-shift, and mean core body temperature of workers was not significantly different. This project highlights the need for targeted interventions to improve hydration and prevent heat stress in this region. As the number of warm days is expected to rise each year worldwide, it will be increasingly important to engage in practices to protect vulnerable populations, such as migratory agriculture workers.

Individual and Neighborhood Determinants of Late HIV Diagnosis Among Latinos, Florida, 2007-2011

The objective of this study was to examine individual and neighborhood determinants of late HIV diagnosis by gender and birthplace among Latinos. Florida HIV surveillance data for 2007-2011 were merged with American Community Survey data to estimate the odds of late HIV diagnosis (AIDS within 3 months of HIV diagnosis). Of 5522 HIV-positive Latinos, 26.5 % were diagnosed late. The odds ratio (OR) for late diagnosis was 1.39 times higher for males than females [95 % confidence interval (CI) 1.14-1.69]. Neighborhood-level factors associated with late diagnosis included residing in the 3 highest quartiles of neighborhood unemployment for males. The OR was 1.22 times higher for foreign- than US-born Latinos (95 % CI 1.07-1.40). Among foreign-born, residing in areas in the 2nd and 3rd quartiles of unemployment, in rural areas, and areas with <25 % Hispanic/Latino population were associated with late diagnosis. Population-based HIV testing campaigns may require tailoring to ensure that they effectively reach male Latinos in areas with high unemployment and foreign-born Latinos in rural and predominantly non-Latino areas.

Racial/Ethnic Disparities in Failure to Initiate HIV Care: Role of HIV Testing Site, Individual Factors, and Neighborhood Factors, Florida, 2014-2015

Delayed initiation of human immunodeficiency virus (HIV) care affects disease progression. To determine the role of HIV testing site and neighborhood- and individual-level factors in racial/ethnic disparities in initiation of care, we examined Florida population-based HIV/AIDS surveillance system records. We performed multilevel Poisson regression to calculate adjusted prevalence ratios (APR) for non-initiation of care by race/ethnicity adjusting for HIV testing site type and individual- and neighborhood-level characteristics. Of 8,913 people diagnosed with HIV during 2014-2015 in the final dataset, 18.3% were not in care within three months of diagnosis. The APR for non-initiation of care for non-Hispanic Blacks relative to non-Hispanic Whites was 1.57 (95% confidence interval [CI] 1.38-1.78) and for those tested in plasma/donation centers relative to outpatient clinics was 2.45 (95% CI 2.19-2.74). Testing site and individual variables contribute to racial/ethnic disparities in non-initiation of HIV care. Linkage procedures, particularly at plasma/blood donation centers, warrant improvement.

Black-White and Country of Birth Disparities in Retention in HIV Care and Viral Suppression among Latinos with HIV in Florida, 2015

The study's purpose was to identify HIV, Black-White race, and birth country disparities in retention in HIV care and HIV viral load (VL) suppression among Latinos, in 2015. Florida's surveillance data for Latinos diagnosed with HIV (2000-2014) were merged with American Community Survey data. Multi-level (random effects) models were used to estimate adjusted odds ratios (aOR) for non-retention in care and non-viral load suppression. Blacks and Whites experienced similar odds of non-retention in care. Racial differences in VL suppression disappeared after controlling for neighborhood factors. Compared to U.S.-born Latinos, those born in Mexico (retention aOR 2.00, 95% CI 1.70-2.36; VL 1.85, 95% CI 1.57-2.17) and Central America (retention aOR 1.33, 95% CI 1.16-1.53; VL 1.28, 95% CI 1.12-2.47) were at an increased risk after controlling for individual and neighborhood factors. Among Central Americans, those born in Guatemala (retention aOR 2.39, 95% CI 1.80-3.18; VL 2.20, 95% CI 1.66-2.92) and Honduras (retention aOR 1.39, 95% CI 1.13-1.72; VL 1.42, 95% CI 1.16-1.74) experienced the largest disparities, when compared to U.S.-born Latinos. Disparities in care and treatment exist within the Latino population. Cultural and other factors, unique to Latino Black-White racial and birth country subgroups, should be further studied and considered for intervention.

Structural Determinants of Antiretroviral Therapy Use, HIV Care Attendance, and Viral Suppression among Adolescents and Young Adults Living with HIV

BACKGROUND

The authors examined associations between structural characteristics and HIV disease management among a geographically diverse sample of behaviorally and perinatally HIV-infected adolescents and young adults in the United States.

METHODS

The sample included 1891 adolescents and young adults living with HIV (27.8% perinatally infected; 72.2% behaviorally infected) who were linked to care through 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions Units. All completed audio computer-assisted self-interview surveys. Chart abstraction or blood draw provided viral load data. Geographic-level variables were extracted from the United States Census Bureau (e.g., socioeconomic disadvantage, percent of Black and Latino households, percent rural) and Esri Crime (e.g., global crime index) databases as Zip Code Tabulation Areas. AIDSVu data (e.g., prevalence of HIV among youth) were extracted at the county-level. Using HLM v.7, the authors conducted means-as-outcomes random effects multi-level models to examine the association between structural-level and individual-level factors and (1) being on antiretroviral therapy (ART) currently; (2) being on ART for at least 6 months; (3) missed HIV care appointments (not having missed any vs. having missed one or more appointments) over the past 12 months; and (4) viral suppression (defined by the corresponding assay cutoff for the lower limit of viral load at each participating site which denoted nondetectability vs. detectability).

RESULTS

Frequencies for the 4 primary outcomes were as follows: current ART use (n = 1120, 59.23%); ART use for ≥6 months (n = 861, 45.53%); at least one missed HIV care appointment (n = 936, 49.50); and viral suppression (n = 577, 30.51%). After adjusting for individual-level factors, youth living in more disadvantaged areas (defined by a composite score derived from 2010 Census indicators including percent poverty, percent receiving public assistance, percent of female, single-headed households, percent unemployment, and percent of people with less than a high school degree) were less likely to report current ART use (OR: 0.85, 95% CI: 0.72-1.00, p = .05). Among current ART users, living in more disadvantaged areas was associated with greater likelihood of having used ART for ≥6 months. Participants living in counties with greater HIV prevalence among 13-24 year olds were more likely to report current ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), ≥6 months ART use (OR: 1.32, 95% CI: 1.05-1.65, p = .02), and to be virally suppressed (OR: 1.50, 95% CI: 1.20-1.87, p = .001); however, youth in these areas were also more likely to report missed medical appointments (OR: 1.32, 95% CI: 1.07-1.63, p = .008).

CONCLUSIONS

The findings underscore the multi-level and structural factors associated with ART use, missed HIV care appointments, and viral suppression for adolescents and young adults in the United States. Consideration of these factors is strongly recommended in future intervention, clinical practice, and policy research that seek to understand the contextual influences on individuals' health behaviors.

Racial-ethnic differences in all-cause and HIV mortality, Florida, 2000-2011

PURPOSE

We compared all-cause and human immunodeficiency virus (HIV) mortality in a population-based, HIV-infected cohort.

METHODS

Using records of people diagnosed with HIV during 2000-2009 from the Florida Enhanced HIV-acquired immunodeficiency syndrome (AIDS) Reporting System, we conducted a proportional hazards analysis for all-cause mortality and a competing risk analysis for HIV mortality through 2011 controlling for individual-level factors, neighborhood poverty, and rural-urban status and stratifying by concurrent AIDS status (AIDS within 3 months of HIV diagnosis).

RESULTS

Of 59,880 HIV-infected people, 32.2% had concurrent AIDS and 19.3% died. Adjusting for period of diagnosis, age group, sex, country of birth, HIV transmission mode, area-level poverty, and rural-urban status, non-Hispanic black (NHB) and Hispanic people had an elevated adjusted hazards ratio (aHR) for HIV mortality relative to non-Hispanic whites (NHB concurrent AIDS: aHR 1.34, 95% confidence interval [CI], 1.23-1.47; NHB without concurrent AIDS: aHR 1.41, 95% CI 1.26-1.57; Hispanic concurrent AIDS: aHR 1.18, 95% CI 1.05-1.32; Hispanic without concurrent AIDS: aHR 1.18, 95% CI 1.03-1.36).

CONCLUSIONS

Considering competing causes of death, NHB and Hispanic people had a higher risk of HIV mortality even among those without concurrent AIDS, indicating a need to identify and address barriers to HIV care in these populations.

Black-White Latino Racial Disparities in HIV Survival, Florida, 2000-2011

This research aimed to estimate Black/White racial disparities in all-cause mortality risk among HIV-positive Latinos. Florida surveillance data for Latinos diagnosed with HIV (2000–2008) were merged with 2007–2011 American Community Survey data. Crude and adjusted hazard ratios (aHR) were calculated using multi-level Cox regression. Of 10,903 HIV-positive Latinos, 8.2% were Black and 91.9% White. Black Latinos were at increased mortality risk compared with White Latinos after controlling for individual and neighborhood factors (aHR 1.40, 95% confidence interval (CI) 1.21–1.62). In stratified analyses, risk factors for Black Latinos included: age ≥60 years compared with ages 13–19 (aHR 4.63, 95% CI 1.32–16.13); US birth compared with foreign birth (aHR 1.56, 95% CI 1.16–2.11); diagnosis of AIDS within three months of HIV diagnosis (aHR 3.53, 95% CI 2.64–4.74); residence in the 3rd (aHR 1.82, 95% CI 1.13–2.94) and 4th highest quartiles (aHR 1.79, 95% CI 1.12–2.86) of neighborhood poverty compared with the lowest quartile; and residence in neighborhood with 25%–49% (aHR 1.59, 95% CI 1.07–2.42) and ≥50% Latinos compared with <25% Latinos (aHR 1.58, 95% CI 1.03–2.42). Significant racial disparities in HIV survival exist among Latinos. Differential access to—and quality of—care and perceived/experienced racial discrimination may be possible explanations.

A county-level analysis of persons living with HIV in the southern United States

This study uses county-level surveillance data to systematically analyze geographic variation and clustering of persons living with diagnosed HIV (PLWH) in the southern United States in 2011. Clusters corresponding to large metropolitan areas - including Miami, Atlanta, and Baltimore - had HIV prevalence rates higher (p < .001) than the regional rate. Regression analysis within the counties included in these clusters determined that race was a significant indicator for PLWH. These results provide a general picture of the distribution of PLWH in the southern United States at the county level and provide insights for identifying local geographic areas with a high number of PLWH, as well as subpopulations that may have an increased risk of infection.

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000-2009

OBJECTIVE

This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.

METHODS

Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables.

RESULTS

Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001).

CONCLUSION

Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.

Individual and neighborhood predictors of mortality among HIV-positive Latinos with history of injection drug use, Florida, 2000-2011

BACKGROUND

The objectives are to examine disparities in all-cause mortality risk among HIV-positive Latinos with injection drug use (IDU) history, and to identify individual- and neighborhood-level predictors.

METHODS

Florida surveillance data for persons diagnosed with HIV 2000-2008 were merged with 2007-2011 administrative data from the American Community Survey. Hazard ratios (HR) were calculated using multi-level weighted Cox regression adjusting for individual and neighborhood (ZCTA-level) factors.

RESULTS

Of 10,989 HIV-positive Latinos, 10.3% had IDU history. Latinos with IDU history were at increased mortality risk compared with Latinos without IDU history after controlling for individual and neighborhood factors (adjusted HR [aHR] 1.61, 95% confidence interval [CI] 1.43-1.80). Factors associated with mortality for those with IDU history included: being 40-59 (aHR 6.48, 95% CI 1.41-121.05) and ≥60 years (aHR 18.75, 95% CI 3.83-356.45) compared with 13-19 years of age; being diagnosed with AIDS within 3 months of HIV (aHR 2.31, 95% CI 1.87-2.86); residing in an area with ≥50% Latinos compared with <25% Latinos (aHR 1.56, 95% CI 1.19-2.04); and residing in a rural compared with an urban area at the time of diagnosis (aHR 1.73, 95% CI 1.06-2.70). Race and neighborhood poverty were not predictors among those with IDU, but were among those without.

CONCLUSION

HIV-positive Latinos with IDU history are at increased mortality risk and have unique contributing factors. Tertiary prevention strategies should target those who are older, diagnosed at later stages, and those who live in predominantly Latino and rural areas.