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Sullivan PS, Taussig J, Valentine-Graves M, Luisi N, Del Rio C, Guest JL, Jones J, Millett G, Rosenberg ES, Stephenson R, Kelley C. Disparities in Care Outcomes in Atlanta Between Black and White Men Who Have Sex With Men Living With HIV: Protocol for a Prospective Cohort Study (Engage[men]t). JMIR Res Protoc 2021; 10:e21985. [PMID: 33320821 PMCID: PMC7943338 DOI: 10.2196/21985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The US HIV epidemic is driven by infections in men who have sex with men and characterized by profound disparities in HIV prevalence and outcomes for Black Americans. Black men who have sex with men living with HIV are reported to have worse care outcomes than other men who have sex with men, but the reasons for these health inequities are not clear. We planned a prospective observational cohort study to help understand the reasons for worse HIV care outcomes for Black versus White men who have sex with men in Atlanta. OBJECTIVE The aim of this study is to identify individual, dyadic, network, neighborhood, and structural factors that explain disparities in HIV viral suppression between Black and White men who have sex with men living with HIV in Atlanta. METHODS Black and White men who have sex with men living with HIV were enrolled in a prospective cohort study with in-person visits and viral suppression assessments at baseline, 12 months, and 24 months; additional surveys of care and risk behaviors at 3, 6, and 18 months; analysis of care received outside the study through public health reporting; and qualitative interviews for participants who experienced sentinel health events (eg, loss of viral suppression) during the study. The study is based on the Bronfenbrenner socioecological theoretical model. RESULTS Men who have sex with men (n=400) were enrolled between June 2016 and June 2017 in Atlanta. Follow-up was completed in June 2019; final study retention was 80% at 24 months. CONCLUSIONS Health disparities for Black men who have sex with men are hypothesized to be driven by structural racism and barriers to care. Observational studies are important to document and quantify the specific factors within the socioecological framework that account for disparities in viral suppression. In the meantime, it is also critical to push for steps to improve access to care, including Medicaid expansion in Southern states, such as Georgia, which have not yet moved to expand Medicaid. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21985.
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Affiliation(s)
- Patrick Sean Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jennifer Taussig
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Mariah Valentine-Graves
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Nicole Luisi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, United States
| | - Jodie L Guest
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jeb Jones
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Greg Millett
- amFAR, the Foundation for AIDS Research, Washington, DC, United States
| | - Eli S Rosenberg
- Department of Epidemiology, School of Public Health, University at Albany, State University of New York, Albany, NY, United States
| | - Rob Stephenson
- Department of Systems, Population, and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI, United States.,The Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, United States
| | - Colleen Kelley
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, United States
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Chang LW, Mbabali I, Kong X, Hutton H, Amico KR, Kennedy CE, Nalugoda F, Serwadda D, Bollinger RC, Quinn TC, Reynolds SJ, Gray R, Wawer M, Nakigozi G. Impact of a community health worker HIV treatment and prevention intervention in an HIV hotspot fishing community in Rakai, Uganda (mLAKE): study protocol for a randomized controlled trial. Trials 2017; 18:494. [PMID: 29061194 PMCID: PMC5654192 DOI: 10.1186/s13063-017-2243-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 10/07/2017] [Indexed: 11/30/2022] Open
Abstract
Background Effective yet practical strategies are needed to increase engagement in HIV treatment and prevention services, particularly in high-HIV-prevalence hotspots. We designed a community-based intervention called “Health Scouts” to promote uptake and adherence to HIV services in a highly HIV-prevalent fishing community in Rakai, Uganda. Using a situated Information, Motivation, and Behavioral skills theory framework, the intervention consists of community health workers, called Health Scouts, who use motivational interviewing strategies and mobile health tools to promote engagement in HIV treatment and prevention services. Methods/design The Health Scout intervention is being evaluated through a pragmatic, parallel, cluster-randomized controlled trial with an allocation ratio of 1:1. The study setting is a single high-HIV-prevalence fishing community in Rakai, Uganda divided into 40 contiguous neighborhood clusters each containing about 65 households. Twenty clusters received the Health Scout Intervention; 20 clusters received standard of care. The Health Scout intervention is delivered within the community at the household level, targeting all residents aged 15 years or older. The primary programmatic outcomes are self-reported HIV care, antiretroviral therapy, and male circumcision coverage; the primary biologic outcome is population-level HIV viremia prevalence. Follow-up is planned for about 3 years. Discussion HIV treatment and prevention service engagement remains suboptimal in HIV hotspots. New, community-based implementation approaches are needed. If found to be effective in this trial, the Health Scout intervention may be an important component of a comprehensive HIV response. Trial registration ClinicalTrials.gov, ID: NCT02556957. Registered on 20 September 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2243-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Larry W Chang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Rakai Health Sciences Program, Rakai, Uganda.
| | | | - Xiangrong Kong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Rakai, Uganda
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - K Rivet Amico
- Department of Health Behavior Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Rakai, Uganda
| | | | | | - Robert C Bollinger
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Thomas C Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Steven J Reynolds
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Rakai Health Sciences Program, Rakai, Uganda.,Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ronald Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Rakai, Uganda
| | - Maria Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Rakai Health Sciences Program, Rakai, Uganda
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Kenyon C. Strong associations between national prevalence of various STIs suggests sexual network connectivity is a common underpinning risk factor. BMC Infect Dis 2017; 17:682. [PMID: 29025419 PMCID: PMC5639489 DOI: 10.1186/s12879-017-2794-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/04/2017] [Indexed: 12/13/2022] Open
Abstract
Background If national peak Human Immunodeficiency Virus (HIV) prevalence is positively associated with the prevalence of other sexually transmitted infections (STIs) from before or early on in the HIV epidemics this would suggest common underlying drivers. Methods Pearson’s correlations were calculated between the prevalence of seven STIs at a country-level: chlamydia, gonorrhoea, trichomoniasis, syphilis, bacterial vaginosis, herpes simplex virus-2 (HSV-2) and HIV. Results The prevalence of all the STIs was highest in the sub-Saharan African region excluding chlamydia. The prevalence of all seven STIs were positively correlated excluding chlamydia. The correlations were strongest for HIV-HSV-2 (r = 0.85, P < 0.0001) and HSV-2-trichomoniasis (r = 0.82, P < 0.0001). Conclusion Our results of a generally positive association between the prevalences of a range of STIs suggests that higher prevalences were driven by common underlying determinants. We review different types of evidence which suggest that differential sexual connectivity is a plausible common determinant.
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Affiliation(s)
- Chris Kenyon
- Sexually Transmitted Infections HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium. .,Division of Infectious Diseases and HIV Medicine, University of Cape Town, Anzio Road, Observatory, 7700, South Africa.
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HIV self-testing values and preferences among sex workers, fishermen, and mainland community members in Rakai, Uganda: A qualitative study. PLoS One 2017; 12:e0183280. [PMID: 28813527 PMCID: PMC5558930 DOI: 10.1371/journal.pone.0183280] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/01/2017] [Indexed: 11/19/2022] Open
Abstract
HIV self-testing may encourage greater uptake of testing, particularly among key populations and other high-risk groups, but local community perceptions will influence test uptake and use. We conducted 33 in-depth interviews and 6 focus group discussions with healthcare providers and community members in high-risk fishing communities (including sex workers and fishermen) and lower-risk mainland communities in rural Uganda to evaluate values and preferences around HIV self-testing. While most participants were unfamiliar with HIV self-testing, they cited a range of potential benefits, including privacy, convenience, and ability to test before sex. Concerns focused on the absence of a health professional, risks of careless kit disposal and limited linkage to care. Participants also discussed issues of kit distribution strategies and cost, among others. Ultimately, most participants concluded that benefits outweighed risks. Our findings suggest a potential role for HIV self-testing across populations in these settings, particularly among these key populations. Program implementers will need to consider how to balance HIV self-testing accessibility with necessary professional support.
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Kenyon CR, Osbak K, Buyze J. The Prevalence of HIV by Ethnic Group Is Correlated with HSV-2 and Syphilis Prevalence in Kenya, South Africa, the United Kingdom, and the United States. Interdiscip Perspect Infect Dis 2014; 2014:284317. [PMID: 25328516 PMCID: PMC4190824 DOI: 10.1155/2014/284317] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/10/2014] [Indexed: 12/03/2022] Open
Abstract
Background. This paper investigates two issues: do ethnic/racial groups with high HIV prevalences also have higher prevalences of other STIs? and is HIV prevalence by ethnic group correlated with the prevalence of circumcision, concurrency, or having more than one partner in the preceding year? Methods. We used Spearman's correlation to estimate the association between the prevalence of HIV per ethnic/racial group and HSV-2, syphilis, symptoms of an STI, having more than one partner in the past year, concurrency, and circumcision in Kenya, South Africa, the United Kingdom, and the United States. Results. We found that in each country HSV-2, syphilis, and symptomatic STIs were positively correlated with HIV prevalence (HSV-2: Kenya rho = 0.50, P = 0.207; South Africa rho-1, P = 0.000; USA rho-1, P = 0.000, Syphilis: Kenya rho = 0.33, P = 0.420; South Africa rho-1, P = 0.000; USA rho-1, P = 0.000, and STI symptoms: Kenya rho = 0.92, P = 0.001; South Africa rho-1, P = 0.000; UK rho = 0.87, P = 0.058; USA rho-1, P = 0.000). The prevalence of circumcision was only negatively associated with HIV prevalence in Kenya. Both having more than one partner in the previous year and concurrency were positively associated with HIV prevalence in all countries (concurrency: Kenya rho = 0.79, P = 0.036; South Africa rho-1, P = 0.000; UK 0.87, P = 0.058; USA rho-1, P = 0.000 and multiple partners: Kenya rho = 0.82, P = 0.023; South Africa rho-1, P = 0.000; UK rho = 0.87, P = 0.058; USA rho-1, P = 0.000). Not all associations were statistically significant. Conclusion. Further attention needs to be directed to what determines higher rates of partner change and concurrency in communities with high STI prevalence.
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Affiliation(s)
- Chris Richard Kenyon
- Sexually Transmitted Infections, HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Anzio Road, Observatory 7700, South Africa
| | - Kara Osbak
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jozefien Buyze
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
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Kenyon CR, Vu L, Menten J, Maughan-Brown B. Male circumcision and sexual risk behaviors may contribute to considerable ethnic disparities in HIV prevalence in Kenya: an ecological analysis. PLoS One 2014; 9:e106230. [PMID: 25171060 PMCID: PMC4149563 DOI: 10.1371/journal.pone.0106230] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/30/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND HIV prevalence varies between 0.8 and 20.2% in Kenya's various ethnic groups. The reasons underlying these variations have not been evaluated before. METHODS We used data from seven national surveys spanning the period 1989 to 2008 to compare the prevalence of a range of risk factors in Kenya's ethnic groups. Spearman's and linear regression were used to assess the relationship between HIV prevalence and each variable by ethnic group. RESULTS The ethnic groups exhibited significant differences in a number of HIV related risk factors. Although the highest HIV prevalence group (the Luo) had the highest rates of HIV testing (Men 2008 survey: 56.8%, 95% CI 51.0-62.5%) and condom usage at last sex (Men 2008∶28.6%, 95% CI 19.6-37.6%), they had the lowest prevalence of circumcision (20.9%, 95% CI 15.9-26.0) the highest prevalence of sex with a non-married, non-cohabiting partner (Men: 40.2%, 95% CI 33.2-47.1%) and pre-marital sex (Men 2008∶73.9%, 95% CI 67.5-80.3%) and the youngest mean age of debut for women (1989 SURVEY: 15.7 years old, 95% CI 15.2-16.2). At a provincial level there was an association between the prevalence of HIV and male concurrency (Spearman's rho = 0.79, P = 0.04). Ethnic groups with higher HIV prevalence were more likely to report condom use (Men 2008 survey: R2 = 0.62, P = 0.01) and having been for HIV testing (Men 2008 survey: R2 = 0.47, P = 0.04). CONCLUSION In addition to differences in male circumcision prevalence, variation in sexual behavior may contribute to the large variations in HIV prevalence in Kenya's ethnic groups. To complement the prevention benefits of the medical male circumcision roll-out in several parts of Kenya, interventions to reduce risky sexual behavior should continue to be promoted.
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Affiliation(s)
- Chris Richard Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Lung Vu
- Population Council, Washington, D.C., United States of America
| | - Joris Menten
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa
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Vaughan AS, Rosenberg E, Shouse RL, Sullivan PS. Connecting race and place: a county-level analysis of White, Black, and Hispanic HIV prevalence, poverty, and level of urbanization. Am J Public Health 2014; 104:e77-84. [PMID: 24832420 DOI: 10.2105/ajph.2014.301997] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization. METHODS Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black-White and Hispanic-White prevalence rate ratios (PRRs) across levels of urbanization and poverty. RESULTS We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black-White and Hispanic-White PRRs were not statistically different from 1.0 at high poverty rates (Black-White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic-White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty. CONCLUSIONS The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.
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Affiliation(s)
- Adam S Vaughan
- Adam S. Vaughan, Eli Rosenberg, and Patrick S. Sullivan are with the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA. R. Luke Shouse is with the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Income inequality and sexually transmitted in the United States: who bears the burden? Soc Sci Med 2013; 102:174-82. [PMID: 24565155 DOI: 10.1016/j.socscimed.2013.11.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 11/12/2013] [Indexed: 11/22/2022]
Abstract
Three causal processes have been proposed to explain associations between group income inequality and individual health outcomes, each of which implies health effects for different segments of the population. We present a novel conceptual and analytic framework for the quantitative evaluation of these pathways, assessing the contribution of: (i) absolute deprivation - affecting the poor in all settings - using family income; (ii) structural inequality - affecting all those in unequal settings - using the Gini coefficient; and (iii) relative deprivation - affecting only the poor in unequal settings - using the Yitzhaki index. We conceptualize relative deprivation as the interaction of absolute deprivation and structural inequality. We test our approach using hierarchical models of 11,183 individuals in the National Longitudinal Study of Adolescent Health (Add Health). We examine the relationship between school-level inequality and sexually transmitted infections (STI) - self-reported or laboratory-confirmed Chlamydia, Gonorrhoea or Trichomoniasis. Results suggest that increased poverty and inequality were both independently associated with STI diagnosis, and that being poor in an unequal community imposed an additional risk. However, the effects of inequality and relative deprivation were confounded by individuals' race/ethnicity.
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THE HIV–POVERTY THESIS RE-EXAMINED: POVERTY, WEALTH OR INEQUALITY AS A SOCIAL DETERMINANT OF HIV INFECTION IN SUB-SAHARAN AFRICA? J Biosoc Sci 2012; 44:459-80. [DOI: 10.1017/s0021932011000745] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SummaryAlthough health is generally believed to improve with higher wealth, research on HIV in sub-Saharan Africa has shown otherwise. Whereas researchers and advocates have frequently advanced poverty as a social determinant that can help to explain sub-Saharan Africa's disproportionate burden of HIV infection, recent evidence from population surveys suggests that HIV infection is higher among wealthier individuals. Furthermore, wealthier countries in Africa have experienced the fastest growing epidemics. Some researchers have theorized that inequality in wealth may be more important than absolute wealth in explaining why some countries have higher rates of infection and rapidly increasing epidemics. Studies taking a longitudinal approach have further suggested a dynamic process whereby wealth initially increases risk for HIV acquisition and later becomes protective. Prior studies, conducted exclusively at either the individual or the country level, have neither attempted to disentangle the effects of absolute and relative wealth on HIV infection nor to look simultaneously at different levels of analysis within countries at different stages in their epidemics. The current study used micro-, meso- and macro-level data from Demographic and Health Surveys (DHS) across 170 regions within sixteen countries in sub-Saharan Africa to test the hypothesis that socioeconomic inequality, adjusted for absolute wealth, is associated with greater risk of HIV infection. These analyses reveal that inequality trumps wealth: living in a region with greater inequality in wealth was significantly associated with increased individual risk of HIV infection, net of absolute wealth. The findings also reveal a paradox that supports a dynamic interpretation of epidemic trends: in wealthier regions/countries, individuals with less wealth were more likely to be infected with HIV, whereas in poorer regions/countries, individuals with more wealth were more likely to be infected with HIV. These findings add additional nuance to existing literature on the relationship between HIV and socioeconomic status.
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