A County-Level Examination of the Relationship Between HIV and Social Determinants of Health: 40 States, 2006-2008

Ryan White HIV/AIDS Part B and AIDS Drug Assistance Programs during COVID-19: safety net public health programs' challenges and innovations

Introduction

We characterized the challenges and innovations of states' Ryan White HIV/AIDS Program (RWHAP) Part B programs, including AIDS Drug Assistance Programs (ADAPs), during the COVID-19 pandemic. In the United States, these are important safety net programs for HIV healthcare, providing essential medical and support services, and medications, to people with HIV with low incomes who are uninsured/underinsured.

Methods

Data were collected via the 2021-2022 NASTAD National RWHAP Part B and ADAP Monitoring Project Report, a cross-sectional survey of state, district, and territorial programs through a mixed method study design. For quantitative data, we used descriptive statistics. Qualitative responses were coded and analyzed using content analysis.

Results

Forty-seven RWHAP Part B and ADAPs responded (92% response rate). The majority of respondents reported that maintaining client eligibility (78%) and working remotely (70%) were the most challenging aspects of the pandemic, particularly in regards to implementing new telehealth and e-certification platforms. In response to COVID-19, programs introduced enrollment "grace periods" (19%), bolstered client outreach (11%), allowed more than a 30 day supply of medications (79%), and supported medication home delivery for clients (80%).

Discussion

Despite the challenges of the COVID-19 pandemic, RWHAP Part B and ADAPs implemented several operational innovations in order to continue providing essential medicines and services. Other public health programs may adopt similar innovations, including digital innovations, for greater public health benefit. Future studies should assess the retention of policy innovations over time, their impact on the individual client level satisfaction or health outcomes, and what factors may improve the acceptability of telehealth and e-certification platforms.

Pathways linking relative deprivation to blood pressure control: the mediating role of depression and medication adherence among Chinese middle-aged and older hypertensive patients

BACKGROUND

Studies have demonstrated that individuals of low socioeconomic status have higher blood pressure. Yet, whether socioeconomic inequality would influence blood pressure control and the underlying mechanisms associated with socioeconomic inequality in blood pressure control are unknown. Central to socioeconomic inequality is relative deprivation. We aim to examine the association between relative deprivation and blood pressure control and to investigate the pathways of the association among middle-aged and older adults with hypertension.

METHODS

Data were collected from the 2020 Household Health Interview Survey in Taian City, Shandong province. This study included 2382 eligible respondents aged 45 years and older with a diagnosis of hypertension. Our primary outcome was dichotomous blood pressure control. Relative deprivation was calculated with the Deaton Index. Depressive symptoms and medication adherence were considered as mediators. Multivariable binary logistic regression models were used to estimate the effect of relative deprivation on blood pressure control. The "KHB-method" was used to perform mediation analysis.

RESULTS

Among 2382 middle-aged and older adults with hypertension, the mean age was 64.9 years (SD 9.1), with 61.3% females. The overall proportion of participants with uncontrolled blood pressure was 65.1%. Increased relative deprivation was likely to have higher odds of uncontrolled blood pressure (OR: 2.35, 95%CI: 1.78-7.14). Furthermore, depressive symptoms and medication adherence partially mediated the overall association between relative deprivation and blood pressure control, with depressive symptoms and medication adherence explaining 5.91% and 37.76%, respectively, of the total effect of relative deprivation on blood pressure control.

CONCLUSIONS

Individual relative deprivation could threaten blood pressure control among middle-aged and older hypertension patients through the mechanisms of depression and medication adherence. Hence, improving blood pressure control may require more than just health management and education but fundamental reform of the income distribution and social security system to narrow the income gap, reducing relative economic deprivation. Additionally, interventions tailoring psychological services and medication adherence could be designed to reduce the harmful effect of relative deprivation on blood pressure control among disadvantaged individuals.

The neurocognitive implications of depression and socioeconomic status in people with HIV

OBJECTIVE

This cross-sectional study investigates the independent and interactive effects of depression and socioeconomic status (SES) on neurocognition in a diverse sample of people with HIV (PWH).

METHOD

The sample of 119 PWH (71% Latinx, 27% female) completed comprehensive neurocognitive and psychosocial evaluations and were separated into two groups: those with a history of depression diagnosis (n = 47) and those without (n = 72).

RESULTS

The results of regression analyses indicated that lifetime depression was not associated with lower SES nor with worse neurocognitive performance on any neurocognitive outcome. However, a significant main effect of SES was observed on the Hopkins Verbal Learning Test (total), indicating that higher SES was associated with better verbal learning performance (B= .11, SE = .05, p< .02). Lastly, the results revealed an interactive effect of lifetime depression and SES, such that individuals with depression and higher SES performed better on tests of attention/working memory (i.e., WAIS-III Letter-Number Sequencing, B= .08, SE = .04, p< .02; Paced Auditory Serial Addition Test, B= .39, SE = .16, p< .02).

CONCLUSIONS

Depression and SES appear to play an important role in the neurocognitive performance of PWH. Specifically, higher SES appears to have a protective effect on attention/working memory among PWH only if they have co-morbid history of lifetime depression.

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.

The Association of Distinct Social Determinants of Health with Added Sweetener Knowledge and Consumption in a U.S. Sample of People Living with HIV

Prior studies in people living with HIV (PLWH) suggest added sweetener intake exceeds recommendations and associates with cardiometabolic abnormalities. Little is known of factors that associate with increased sweetener consumption in PLWH. This cross-sectional study explored knowledge and consumption of added sweeteners and associations of social determinants of health (SDoH) among 900 PLWH residing in the United States. Demographics, SDoH, and added sweetener knowledge and consumption were assessed via an online survey, multivariable analyses were completed. Results demonstrate that sex, race, and low educational level associated with lower sweetener knowledge. Race, age, body mass index, income, limited access to fresh fruits/vegetables, and low sweetener knowledge associated with higher sweetener consumption. Findings highlight the need for consideration of specific demographics and inequitable social circumstances when developing nutrition lifestyle strategies, inclusive of added sweetener education, that are feasible and sustainable across diverse community settings of PLWH.

Pathways linking climate change and HIV/AIDS: An updated conceptual framework and implications for the Philippines

As we commemorate the 40th anniversary of the discovery of Human Immunodeficiency Virus (HIV) while fighting the ongoing COVID-19 pandemic, another global crisis - climate change - is threatening the progress achieved so far in the global fight against HIV/AIDS. The climate emergency is anticipated to generate dire health consequences worldwide in the coming decades. While the pathways that link climate change and different disease areas are better understood, the connection between climate change and HIV/AIDS is still yet to be recognized both in research and practice. In this review, we update one of the frameworks on the HIV-climate nexus described in earlier literature. Four major pathways have been identified: extreme weather events; sea level rise; changes in precipitation and temperature; and increased air pollution. These pathways impact the spectrum of HIV/AIDS-related outcomes through changes in social systems, healthcare disruption, and other climate-sensitive diseases, influenced by the social determinants of health. We also reflect on the significance of this updated framework for the Philippines, a country that is both highly vulnerable to the climate crisis and facing a rising HIV/AIDS epidemic. The framework can aid countries like the Philippines in filling gaps in research, policy, and program design to mount climate-adaptive HIV/AIDS responses. The HIV/AIDS and climate justice movements must also join forces in calling for accelerated worldwide decline in greenhouse gas emissions from all sectors to stabilize the global climate - this will benefit not just people affected by HIV/AIDS but everyone.

Social Determinants of Disease: HIV and COVID-19 Experiences

PURPOSE OF REVIEW

The differential impact of the COVID-19 and HIV pandemics on marginalized communities has renewed calls for more robust and deeper investigation into structural and social causes of health inequities contributing to these infections, including underlying factors related to systematic racism. Using the Social Determinants of Health (SDOH) framework, we analyzed parallel and divergent factors associated with COVID-19 and HIV/AIDS and the prevalence of disparate disease in diverse communities. We utilized PRISMA guidelines to identify relevant literature (N = 210 articles) that resulted in a review of 125 articles included in our synthesis.

RECENT FINDINGS

With racial health inequities as a core contributor to disease vulnerability, we also identified other factors such as economic stability, social and community support, the neighborhood and built environment, healthcare access and quality, and education access and quality as important socioecological considerations toward achieving health equity. Our review identifies structural and systematic factors that drive HIV and COVID-19 transmission. Our review highlights the importance of not solely focusing on biomedical interventions as solutions to ending HIV and COVID-19, but rather call for building a more just public health and social service safety net that meets the needs of people at the intersection of multiple vulnerabilities.

Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study

Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll >33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 28) met our recruitment goal. Most participants had positive feelings about Medicaid before enrollment (general: 68%; good for general health: 75%, and good for HIV care: 67%) and after enrollment (general: 93% and good for HIV care: 93%). All participants expressed incomplete understanding about Medicaid before enrollment. Seventy-nine percent needed outside help to complete enrollment. Approximately 40% described overlaps of Medicaid with other insurance/payers or gaps in insurance coverage when transitioning from one insurance/payer (such as AIDS Drug Assistance Program [ADAP] medication provision and ADAP-subsidized insurance) to Medicaid. Participants suggested more access or easier access to information about Medicaid and more explanation of Medicaid benefits would be helpful. Our findings indicate participants had mostly positive perceptions of Medicaid before and after enrollment. Even with enrollment help, participants voiced that dealing with insurance is hard. Medicaid and other programs should prioritize more access to information, smoother processes, and less burdensome enrollment/re-enrollment.

A Tale of 2 Pneumos: The Impact of Human Immunodeficiency Virus Exposure or Infection Status on Pediatric Nasopharyngeal Carriage of Streptococcus pneumoniae and Pneumocystis jiroveci: A Nested Case Control Analysis From the Pneumonia Etiology Research In Child Health Study

BACKGROUND

The majority of pediatric human immunodeficiency virus (HIV) cases in Africa reflect maternal-to-child transmission. HIV exposed but uninfected (HEU) children have increased rates of morbidity and mortality when compared to HIV unexposed and uninfected (HUU) children. The mechanisms behind these unexpected trends are only partially understood but could be explained by the differences in the immune response to infections triggered by an altered immune system state.

METHODS

Using quantitative reverse transcription polymerase chain reaction, we compared the nasopharyngeal carriage prevalence and density of Streptococcus pneumoniae (SP) and Pneumocystis jirovecii (PJ) between children living with HIV and HEU or HUU cases (pneumonia) and controls (without pneumonia).

RESULTS

The cohort included 1154 children (555 cases and 599 matched controls). The SP carriage prevalence rates were similar between cases and controls. Among SP carriers with pneumonia, carriage density was increased among children living with HIV, versus HEU or HUU children (15.8, 4.7, and 3.6 × 105 copies/mL, respectively). The rate of PJ carriage was significantly higher among children living with HIV than among HEU and HUU children (31%, 15%, and 10%, respectively; P < .05), as was carriage density (63.9, 20.9, and 4.8 × 103 copies/mL, respectively; P < .05).

CONCLUSIONS

Carriage prevalences and densities for SP and PJ show different kinetics in terms of their relationship with HIV exposure and clinical status, particularly for Pneumocystis jirovecii. This supports the theory that the increased morbidity and mortality observed among HEU children may reflect deficits not just in humoral immunity but in cell-mediated immunity as well.

Financial, Food, and Housing Insecurity Due to Coronavirus Disease 2019 Among At-Risk People With Human Immunodeficiency Virus in a Nonurban Ryan White HIV/AIDS Program Clinic

Coronavirus disease 2019 negatively impacts social determinants of health that contribute to disparities for people with human immunodeficiency virus (HIV). Insecurity of food, housing, and employment increased significantly in April 2020 among patients with lower incomes at a Ryan White HIV/AIDS program clinic in the Southern United States.

Income Inequality Is Associated With Low Cumulative Antiretroviral Adherence in Persons With Human Immunodeficiency Virus

Background

The adherence biomarker tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is associated with viral suppression and predicts future viremia. However, its association with social determinants of health (SDoH) in people with human immunodeficiency virus (PWH) remains unknown.

Methods

Dried blood spots for TFV-DP were longitudinally collected from a clinical cohort of PWH receiving tenofovir disoproxil fumarate-based therapy (up to 3 visits over 48 weeks) residing in 5 Colorado counties. To assign SDoH, zip codes at enrollment were matched with SDoH data from AIDSVu (https://aidsvu.org/). The SDoH included household income, percentage living in poverty, education level, and income inequality (quantified using Gini coefficient, where 0 and 1 represent perfect income equality and inequality, respectively). Log-transformed TFV-DP concentrations were analyzed using a mixed-effects model to estimate percentage change (95% confidence interval) in TFV-DP for every significant change in the SDoH and adjusted for relevant covariates including age, gender, race, estimated glomerular filtration rate, body mass index, hematocrit, CD4⁺ T-cell count, antiretroviral drug class, and 3-month self-reported adherence.

Results

Data from 430 PWH totaling 950 person-visits were analyzed. In an adjusted analysis, income inequality was inversely associated with TFV-DP in DBS. For every 0.1 increase in the Gini coefficient, TFV-DP concentrations decreased by 9.2% (−0.5 to −17.1; P = .039). This remained significant after adjusting for human immunodeficiency virus viral suppression, where a 0.1 increase in Gini was associated with a decrease of 8.7% (−0.3 to −17.9; P = .042) in TFV-DP.

Conclusions

Higher income inequality was associated with lower cumulative antiretroviral adherence. These findings support the need for further research on how SDoH impact adherence and clinical care.

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.

Does internalized racism matter in HIV risk? Correlates of biomedical HIV prevention interventions among Black men who have sex with men in the United States

Black men who have sex with men (MSM) account for 26% of all new HIV infections in the United States. Biomedical HIV interventions have proven to reduce HIV infections however the use of these interventions by Black MSM is inconsistent. Research suggests that internalized racism may contribute to inconsistent biomedical HIV interventions (condom use and PrEP use) among Black MSM. Using a national sample of 432 Black MSM, we examined the relationship between condom and PrEP use and internalized racism. The results suggest there is some evidence for an association between internalized racism and PrEP use. In addition, internalized racism was not associated with condom use for both insertive and receptive anal sex among Black MSM. These finding suggest the relationship between internalized racism and HIV prevention strategies is not facile and more attention is needed to understand the true impact of racism, both internal and societal, on HIV prevention strategies among Black MSM. These findings underscore the nature of racism in the daily lives of Black MSM and how it impacts HIV prevention strategies adopted by these men.

Neighborhood Alcohol Environment: Differential Effects on Hazardous Drinking and Mental Health by Sex in Persons Living with HIV (PLWH)

Despite greater mental health co-morbidities and heavier alcohol use among PLWH, few studies have examined the role of the neighborhood alcohol environment on either alcohol consumption or mental health. Utilizing cross-sectional data from a cohort study in a southern U.S. metropolitan area, we examine the association between neighborhood alcohol environments on hazardous drinking and mental health among 358 in-care PLWH (84% African American, 31% female). Multilevel models were utilized to quantify associations between neighborhood alcohol exposure on hazardous drinking and effect modification by sex. Neighborhood alcohol density was associated with hazardous drinking among men but not women. Women living in alcohol dense neighborhoods were nearly two-fold likely to report depression compared to those in less dense neighborhoods, with no association between neighborhood alcohol density and depression among men. Neighborhood alcohol environments may be an important contextual factor to consider in reducing heavy alcohol consumption and improving mental health among PLWH.

HIV Stigma, Mental Health, and Alcohol Use Disorders among People Living with HIV/AIDS in New Orleans

Evidence suggests that HIV-related stigma is a contributing factor to mental health and substance use problems among people living with HIV (PLWH). Limited research, however, has examined the differential effects that multiple stigma constructs, specifically, anticipated, enacted, and internalized stigma may have on mental health and alcohol use disorders among PLWH. Furthermore, no studies have examined this relationship within the larger context of urban life stressors. The purpose of this study was to examine associations of an overall HIV-related stigma measure and four HIV stigma subscales on depression, anxiety, and hazardous drinking among a sample of 380 PLWH in New Orleans. Log-Poisson models with generalized estimating equations were used to estimate relative risks (RR) and 95% confidence intervals (CI). A test of interaction was used to determine presence of effect modification by urban life stressors. Overall, higher levels of HIV-stigma were associated with depressive symptoms (RR 1.67, 95% CI 1.25, 2.23), anxiety symptoms (RR 1.91, 95% CI 1.17, 3.12), and hazardous drinking (RR 1.45, 95% CI 1.02, 2.05). Internalized HIV-stigma (measured using the negative self-image subscale) was associated with all three outcomes and had the highest magnitude point estimates across the four stigma subscales. Urban life stressors, measured by the Urban Life Stressors Scale (ULSS), modified the association between HIV-related stigma and mental health and alcohol use disorders (P < 0.2), highlighting the importance for examining the larger urban environmental context. Findings from this study may inform interventions to reduce HIV-related stigma operating at the individual and structural level.

Health Characteristics Associated With Hot Flashes in Women With HIV During Menopause: An Integrative Review

Hot flashes (HFs) are a prominent symptom of menopause known to unfavorably influence mood, sleep, and quality of life. More women living with HIV are entering menopause and may experience a greater prevalence of HFs and more severe HFs compared with uninfected women. This integrative review evaluated existing evidence on potential health characteristics associated with HFs in women living with HIV during menopause. A search strategy was conducted within 6 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. Five articles met the review eligibility criteria. Three content categories emerged from the key findings of the 5 articles: HIV-specific characteristics, mental health and cognitive characteristics, and quality of life and social characteristics. Implications for research and clinical care were identified.

Exploring Social Determinants of Health as Predictors of Mortality During 2012-2016, Among Black Women with Diagnosed HIV Infection Attributed to Heterosexual Contact, United States

BACKGROUND

In 2016, black women with HIV infection attributed to heterosexual contact accounted for 47% of all women living with diagnosed HIV, and 41% of deaths that occurred among women with diagnosed HIV in the USA that year. Social determinants of health have been found to be associated with mortality risk among people with HIV. We analyzed the role social determinants of health may have on risk of mortality among black women with HIV attributed to heterosexual contact.

METHODS

Data from the Center for Disease Control and Prevention's National HIV Surveillance System were merged at the county level with three social determinants of health (SDH) variables from the U.S. Census Bureau's American Community Survey for black women aged ≥ 18 years with HIV infection attributed to heterosexual contact that had been diagnosed by 2011. SDH variables were categorized into four empirically derived quartiles, with the highest quartile in each category serving as the reference variable. For black women whose deaths occurred during 2012-2016, mortality rate ratios (MRR) were calculated using age-stratified multivariate logistic regressions to evaluate associations between SDH variables and all-cause mortality risk.

RESULTS

Risk of mortality was lower for black women aged 18-34 years and 35-54 years who lived in counties with the lowest quartile of poverty (adjusted mortality rate ratio aMRR = 0.56, 95% confidence interval CI [0.39-0.83], and aMRR = 0.67, 95% CI [0.58-0.78], respectively) compared to those who lived in counties with the highest quartile of poverty (reference group). Compared to black women who lived in counties with the highest quartile of health insurance coverage (reference group), the mortality risk was lower for black women aged 18-34 years and black women aged 35-54 who lived in counties with the lowest 2 quartiles of health insurance coverage. Unemployment status was not associated with mortality risk.

CONCLUSIONS

This ecological analysis found poverty and lack of health insurance to be predictors of mortality, suggesting a need for increased prevention, care, and policy efforts targeting black women with HIV who live in environments characterized by increased poverty and lack of health insurance.

Healthcare facility characteristics associated with achievement and maintenance of HIV viral suppression among persons newly diagnosed with HIV in New York City

Health care facility characteristics have been shown to influence intermediary health outcomes among persons with HIV, but few longitudinal studies of suppression have included these characteristics. We studied the association of these characteristics with the achievement and maintenance of HIV viral suppression among New York City (NYC) residents aged 13 years and older newly diagnosed with HIV between 2006 and 2012. The NYC HIV surveillance registry provided individual and facility data (N = 12,547 persons). Multivariable proportional hazards models estimated the likelihood of individual achievement and maintenance of suppression by type of facility, patient volume, and distance from residence, accounting for facility clustering and for individual-level confounders. Viral suppression was achieved within 12 months by 44% and at a later point by another 29%. Viral suppression occurred at a lower rate in facilities with low HIV patient volume (e.g., 10-24 diagnoses per year vs. ≥75, adjusted hazard ratio [AHR] = 0.87, 95% confidence interval [CI] 0.79-0.95) and in screening/diagnosis sites (vs. hospitals, AHR = 0.86, 95% CI 0.80-0.92). Among persons achieving viral suppression, 18% experienced virologic failure within 12 months and 24% later. Those receiving care at large outpatient facilities or large private practices had a lower rate of virologic failure (e.g., large outpatient facilities vs. large hospitals, AHR = 0.63, 95% CI 0.53-0.75). Achievement and maintenance of viral suppression were associated with facilities with higher HIV-positive caseloads. Some facilities with small caseloads and screening/diagnosis sites may need stronger care or referral systems to help persons with HIV achieve and maintain viral suppression.

Neighborhood social cohesion and viral suppression after HIV diagnosis

Social cohesion has varying effects on health. We investigated the association of perceived neighborhood social cohesion with HIV viral suppression using individual-level data from the New York City HIV registry and surveillance-based interviews (n = 92). Suppression was achieved within 12 months of HIV diagnosis by 60 percent of persons perceiving low cohesion and 71 percent of those perceiving high (p = 0.31). Controlling for demographic and clinical characteristics and neighborhood poverty, per proportional hazards regression, cohesion was not associated with suppression (adjusted hazards ratio (95% confidence interval) for high versus low cohesion: 0.79 (0.49-1.28)). Cohesion may have heterogeneous effects on HIV medication adherence.

Structural Effects on HIV Risk Among Youth: A Multi-level Analysis

We proposed a multilevel model of structural influences on HIV-risky sexual partnerships in a diverse sample of 1793 youth residing in 23 states and the District of Columbia. We examined the influence of concentrated disadvantage, HIV stigma, and sexual and gender minority stigma on engagement in HIV risky sexual partnerships and whether youth's participation in opportunity structures, anticipation of HIV stigma, and perceptions of their community as youth-supportive settings mediated structural effects. After controlling for age, HIV status, and race, we found structural HIV stigma had deleterious indirect effects on youth's participation in HIV-risky sexual partnerships. Concentrated disadvantage and structural sexual and gender minority stigma had direct negative effects on youth's perceptions of their communities as supportive and on their participation in prosocial activity. Support perceptions had direct, protective effects on avoidance of HIV-risky sexual partnerships. Structural stigma undermines youth's belief that their communities invest in their safety and well-being.

Outcomes Among Persons with HIV Following a Mental Health Admission: A Population-Based Study

To compare outcomes following psychiatric hospitalization between people with and without HIV. Population-based study of people with (n = 1,089) and without (n = 280,888) HIV who were hospitalized for psychiatric illness between January 1, 2006 and December 31, 2014. Overall, 9 (0.8%) people with HIV died within 30 days of discharge, compared with 3,710 (1.3%) HIV-negative individuals. Following multivariable adjustment, there was no difference in the risk of readmission or emergency department (ED) visits for psychiatric illness in the 90 days following discharge. Conversely, people with HIV were at higher risk of ED visits for substance use disorders and less likely to receive psychiatry follow-up during this period. HIV is associated with ED use for substance use disorders and less psychiatry follow-up within 90 days of hospital discharge for psychiatric illness. Interventions facilitating continuity of care following discharge are warranted.

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.

Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV

Our understanding of how community-level context impacts care of persons living with HIV (PLWH), including antiretroviral therapy (ART) adherence and retention in care, is limited. The objective of this study was to characterize the activity spaces of PLWH from an urban area in Southeastern U.S., where the epidemic is among the nation's highest, and to examine how such activity spaces are associated with daily mood and health behaviors. In this small, pilot study, 11 participants were tracked with a global positioning system (GPS)-enabled application on their smartphones for 2 weeks. Activity spaces were created by connecting GPS points sequentially and adding buffers. Contextual exposure data (e.g., alcohol outlets) were connected to activity spaces. Participants also completed daily diary entry through texts 3 times per day regarding outcomes of substance use behaviors, mood, and medication adherence. This yielded a total of 18,007 GPS polyline records that we aggregated into 258 person-days that captured discrete occasions of exposure to contextual factors and subjects' behaviors and moods. On average, the participants spent 19% of their time awake during the 2-week periods in their residential census tract. Exposure to social and built environment factors such as alcohol outlets was greater when participants were outside versus inside their residential census tract. Exposures on daily routes were also significantly associated with ART adherence, alcohol consumption, and mood. Findings suggest substantial differences between activity spaces and residential contexts. Activity spaces are relevant for PLWH and may impact HIV care and behavioral outcomes such as ART adherence and substance use.

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.

Mortality and Health Service Use Following Acute Myocardial Infarction Among Persons with HIV: A Population-Based Study

People with HIV have higher rates of acute myocardial infarction (AMI) than HIV-negative individuals. We compared mortality risk and health service use following AMI among people with and without HIV between January 1, 2002, and March 31, 2015. We conducted a population-based study using Ontario's administrative databases. Our primary outcomes were risk of inpatient death and death at 30 days following hospital discharge. In secondary analyses, we compared use of revascularization procedures within 90 days of AMI, as well as readmission or emergency department visits for heart disease and cardiology follow-up within 90 days of discharge. We studied 259,475 AMI patients, of whom 345 (0.13%) were people with HIV. AMI patients with HIV were younger than HIV-negative patients (mean age ± standard deviation: 54.4 ± 10.5 years vs. 69.3 ± 14.3 years). Following multivariable adjustment, the odds ratios for inpatient death and death at 30 days following discharge were 1.04 [95% confidence intervals (CI) 0.64-1.56] and 2.42 (95% CI 1.00-4.92), respectively. In secondary analyses, no differences were observed in receipt of revascularization procedures (hazard ratio (HR) 0.98; 95% CI 0.85-1.12), readmission or emergency department visit for heart disease (HR 1.18; 95% CI 0.85-1.62), or cardiology follow-up (HR 0.88; 95% CI 0.76-1.01). People with HIV experience AMI at younger ages and may be at higher risk of death in the 30 days following hospital discharge, underscoring the importance of targeting modifiable cardiovascular disease risk factors in these patients.

Neighborhood Social Capital in Relation to Late HIV Diagnosis, Linkage to HIV Care, and HIV Care Engagement

High neighborhood social capital could facilitate earlier diagnosis of HIV and higher rates of linkage and HIV care engagement. Multivariate analysis was used to examine whether social capital (social cohesion, social participation, and collective engagement) in 2004/2006 was associated with lower 5-year average (2007-2011) prevalence of (a) late HIV diagnosis, (b) linked to HIV care, and (c) engaged in HIV care within Philadelphia, PA, United States. Census tracts (N = 332). Higher average neighborhood social participation was associated with higher prevalence of late HIV diagnosis (b = 1.37, se = 0.32, p < 0.001), linked to HIV care (b = 1.13, se = 0.20, p < 0.001) and lower prevalence of engaged in HIV care (b = -1.16, se = 0.30, p < 0.001). Higher collective engagement was associated with lower prevalence of linked to HIV care (b = -0.62, se = 0.32, p < 0.05).The findings of different directions of associations among social capital indicators and HIV-related outcomes underscore the need for more nuanced research on the topic that include longitudinal assessment across key populations.

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.

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.

Risk Factors Associated With HIV Among Men Who Have Sex With Men (MSM) in Ecuador

The Joint United Nations Program on HIV/AIDS estimates that between 0.3% and 0.7% of adults aged 15 to 49 years were living with HIV in Ecuador in 2013. However, very little is known about the HIV prevalence rate among men who have sex with men (MSM) in that country. A cross-sectional survey was conducted to investigate the knowledge, attitudes, and practices regarding HIV/AIDS as well as to estimate the prevalence of HIV among MSM in one of the cities with high HIV prevalence rates in Ecuador. In this study, questionnaires were administered to 307 adult MSM. An HIV prevalence of 10% was observed. Knowledge about HIV was high; 91% of participants could identify how HIV is transmitted. Although consistent condom use for anal sex was relatively high (89%) among participants who reported having pay-for-service clients, only 64% reported using a condom during oral sex with a client. Participants who had multiple male sexual partners (i.e., their stable male partners plus other partner[s]) had 3.7 times higher odds of testing positive for HIV compared with those who did not. They also had reduced odds of condom use. Participants who were forced to have anal receptive sex had 3 times higher odds of testing positive for HIV. Despite the finding that participants exhibited high knowledge about HIV/AIDS, a high prevalence rate of HIV was observed, which warrants targeted behavioral interventions. These data are consistent with MSM being one of the highest at-risk population groups for HIV in this region of Ecuador.

Young People and HIV: A Call to Action

HIV is having a significant impact on young people, among whom the rate of new diagnoses is high and health disparities are more pronounced. Incidence is increasing among young gay and bisexual men, and, among Black males, the largest percentage of new infections occur among those aged between 13 and 24 years. Youths are least likely to experience the health and prevention benefits of treatment. Nearly half of young people with HIV are not diagnosed; among those diagnosed, nearly a quarter are not linked to care, and three quarters are not virally suppressed. Addressing this burden will require renewed efforts to implement effective prevention strategies across multiple sectors, including educational, social, policy, and health care systems that influence prevention knowledge, service use, and treatment options for youths.

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.

The Epidemiology of Human Immunodeficiency Virus Infection and Care among Adult and Adolescent Females in the United States, 2008-2012

OBJECTIVE

We sought to determine epidemiological patterns in diagnoses of human immunodeficiency virus (HIV) infection and prevalence among females by age, race/ethnicity and transmission category, and essential steps in the continuum of HIV care.

METHODS

Using data from the National HIV Surveillance System, we estimated the number of females aged 13 years or older diagnosed with HIV infection in 2008 through 2012 and living with HIV at the end of 2011 in the United States. We determined percentages of females linked to care, retained in care, and virally suppressed in 18 jurisdictions with complete reporting of CD4 and viral load test results.

RESULTS

From 2008 to 2012, the estimated rate of HIV diagnoses among females decreased from 9.3 to 6.9 per 100,000 (-7.1% per year; 95% confidence interval [CI], -7.9, -6.3). In 2012, the diagnosis rate was highest among Blacks/African Americans (35.7), followed by Hispanics or Latinos (6.4), and Native Hawaiian Other Pacific Islander (5.1), and lowest among Whites (1.8). Most females diagnosed in 2012 were linked to care within 3 months of diagnosis (82.5%). About one-half (52.4%) of females living with HIV in 2011 received ongoing care in 2011 and 44.3% had a suppressed viral load. Viral suppression was lower among American Indian/Alaska Native (29.7%) and Black/African American (41.6%) compared with White females (46.5%). The percentage in care and with viral suppression was lower among younger compared with older females.

CONCLUSION

HIV diagnoses continue to decrease among females; however, disparities exist in HIV burden and viral suppression. Improvements in care and treatment outcomes are needed for all women with particular emphasis on younger women.

Changes in Exposure to Neighborhood Characteristics are Associated with Sexual Network Characteristics in a Cohort of Adults Relocating from Public Housing

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every 9 months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Neighborhood Condition and Geographic Locale in Assessing HIV/STI Risk Among African American Adolescents

Although region and neighborhood condition's effect on HIV/sexually transmitted infection (STI) risk has been studied separately, there is little research examining their interplay. African American adolescents (n = 1,602) from four matched cities in the Northeastern and Southeastern US completed Audio Computer Assisted Self-Interviews and submitted biospecimen samples to detect Sexually Transmitted Infections (chlamydia, gonorrhea, and trichomonas). Logistic and negative binomial regressions determined HIV/STI risk differences by region, neighborhood stress, and stress-region dyads. Northeastern participants demonstrated lower HIV/STI risk while participants from higher stress neighborhoods exhibited greater risk. Relationships between neighborhood condition and ever having anal sex (p < 0.01), anal condom use (p < 0.05), and number of anal partners (p < 0.05) were significant in the Northeast only. Participants in unstressed Northeastern neighborhoods were less likely to have vaginal sex than those in comparable Southeastern neighborhoods (p < 0.05). Participants in unfavorable Northeastern neighborhoods had fewer anal partners than participants in comparable Southeastern neighborhoods (p < 0.01). In concert, neighborhood and region differentially affect HIV/STI risk.

A census tract-level examination of social determinants of health among black/African American men with diagnosed HIV infection, 2005-2009--17 US areas

BACKGROUND

HIV disproportionately affects black men in the United States: most diagnoses are for black gay, bisexual, and other men who have sex with men (collectively referred to as MSM). A better understanding of the social conditions in which black men live and work may better explain why HIV incidence and diagnosis rates are higher than expected in this population.

METHODS

Using data from the National HIV Surveillance System and the US Census Bureau's American Community Survey, we examined the relationships of HIV diagnosis rates and 5 census tract-level social determinants of health variables for 21,948 black MSM and non-MSM aged ≥ 15 years residing in 17 areas in the United States. We examined federal poverty status, marital status, education level, employment status, and vacancy status and computed rate ratios (RRs) and prevalence odds ratios (PORs), using logistic regression with zero-inflated negative binomial modeling.

RESULTS

Among black MSM, HIV diagnosis rates decreased as poverty increased (RR: 0.54). At the time of HIV diagnosis, black MSM were less likely than black non-MSM to live in census tracts with a higher proportion below the poverty level (POR: 0.81) and with a higher proportion of vacant houses (POR: 0.86). In comparison, housing vacancy was positively associated with HIV diagnosis rates among black non-MSM (RR: 1.65). HIV diagnosis rates were higher for black MSM (RR: 2.75) and non-MSM (RR: 4.90) whose educational level was low. Rates were significantly lower for black MSM (RR: 0.06) and non-MSM (RR: 0.26) as the proportion unemployed and the proportion married increased.

CONCLUSIONS

This exploratory study found differences in the patterns of HIV diagnosis rates for black MSM and non-MSM and provides insight into the transmission of HIV infection in areas that reflect substantial disadvantage in education, housing, employment, and income.

Social-structural indices and between-nation differences in HIV prevalence

Research emphasises the role that social structures play in shaping national HIV prevalence. This study examined how social, economic, and political contexts that may represent the confluence of individual capabilities and environmental affordances or constraints are associated with national HIV prevalence. Based on social-ecological perspectives, we examined social-structural dimensions in relation to national HIV prevalence. The study identified six publicly available nation-level social, political, and economic indices and examined their associations with national 2009 HIV prevalence across 225 nations. National indices, (a) education expenditures, (b) unemployment rate, (c) homicide rate, (d) freedom of religion, and (e) women's social rights, altogether explained 43% of the variability in national HIV prevalence. Education expenditures, homicide rate, and freedom of religion were significant predictors of national HIV prevalence in the multivariate analysis. The present study identified nation-level factors that capture social, economic, and political contexts to explain between-nation differences in HIV prevalence. Findings extend current literature on the social-structural foundation of HIV-risk and the relationship between human rights and health. National safeguards that afford individuals the power to promote general quality of life and protection from structural violence may be most important to lowering overall rates of HIV transmission.

Spatial epidemiology of recently acquired HIV infections across rural and urban areas of North Carolina

Transmission of HIV continues in the United States (US), despite prevention efforts aimed at education and treatment. Concurrently, drug resistance in HIV, particularly in patients being infected with HIV for the first time, poses a threat to the continued success of treatment for HIV positive individuals. In North Carolina, nearly one in five individuals with acute HIV infection (AHI) is infected with a drug-resistant strain, a phenomenon known as transmitted drug resistance (TDR). Few studies of AHI or TDR take into account both the spatial aspects of residence at time of infection and the genetic characteristics of the viruses, and questions remain about how viruses are transmitted across space and the rural-urban divide. Using AHI strains from North Carolina, we examined whether differences exist in the spatial patterns of AHI versus AHI with TDR, as well as whether the genetic characteristics of these HIV infections vary by rural-urban status and across Health Service Areas. The highest amounts of TDR were detected in persons under age 30, African Americans, and men who have sex with men (MSM) - similar to the populations where the highest numbers of AHI without TDR are observed. Nearly a quarter of patients reside in rural areas, and there are no significant differences between rural and urban residence among individuals infected with drug resistant or drug susceptible viruses. We observe similar levels of genetic distance between HIV found in rural and urban areas, indicating that viruses are shared across the rural-urban divide. Genetic differences are observed, however, across Health Service Areas, suggesting that local areas are sites of genetic differentiation in viruses being transmitted to newly infected individuals. These results indicate that future efforts to prevent HIV transmission need to be spatially targeted, focusing on local-level transmission in risky populations, in addition to statewide anti- HIV efforts.

A pandemic of the poor: social disadvantage and the U.S. HIV epidemic

The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.