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Abstract

Objectives

To reduce the number of new HIV infections and improve HIV health care outcomes, the social conditions in which people live and work should be assessed. The objective of this study was to describe linkage to HIV medical care by selected demographic characteristics and social determinants of health (SDH) among US adults with HIV at the county level.

Methods

We used National HIV Surveillance System data from 42 US jurisdictions and data from the American Community Survey to describe differences in linkage to HIV medical care among adults aged ≥18 with HIV infection diagnosed in 2017. We categorized SDH variables into higher or lower levels of poverty (where <13% or ≥13% of the population lived below the federal poverty level), education (where <13% or ≥13% of the population had <high school diploma), and health insurance coverage (where <12% or ≥12% of the population lacked health insurance). We calculated prevalence ratios (PRs) and 95% CIs.

Results

Of 33 204 adults with HIV infection diagnosed in 2017, 78.4% were linked to HIV medical care ≤1 month after diagnosis. Overall, rates of linkage to care were significantly lower among men and women living in counties with higher versus lower poverty (PR = 0.96; 95% CI, 0.94-0.97), with lower versus higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94), and with lower versus higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

Conclusions

Increasing health insurance coverage and addressing economic and educational disparities would likely lead to better HIV care outcomes in these areas.

Keywords

human immunodeficiency virus linkage to HIV medical care social determinants of health health disparity HIV health care outcomes

More than 1.1 million people in the United States were living with HIV in 2016.¹ In 2017, almost 40 000 adults and adolescents received an HIV diagnosis.² Despite previous declines, the annual number of new HIV infections was stable from 2013 to 2016.^2
-4 To reduce HIV transmission in the United States, several federal initiatives were implemented, including Ending the HIV Epidemic: A Plan for America.⁵ Components of these initiatives focus on efforts to increase linkage to HIV medical care and understand the social determinants of health (SDH) that affect HIV-related care outcomes.^2,6,7

After diagnosis, linkage to care is a crucial stage in the HIV care continuum. Although immediate referral to HIV care is recommended, linkage is often delayed for many people. A Centers for Disease Control and Prevention (CDC) report found lower linkage rates among Black/African American people (hereinafter referred to as Black people), adolescents and young adults aged 13-24, and males with infection attributed to male-to-male sexual conduct and injection drug use (MMSC/IDU).⁸ Most research has focused on demographic characteristics such as race/ethnicity and age to describe differences in linkage to care and other HIV health outcomes; however, SDH can provide insight on other pertinent characteristics, which may help increase understanding about the effects of the shortage or absence of health and treatment resources on the HIV care continuum.

SDH are overlapping social structures and economic systems (eg, social and physical environments, health services, structural and societal factors) that contribute to health inequities.⁹ Although several studies identified socioeconomic barriers among people with HIV including, but not limited to, poverty,^10

-14 lack of health insurance coverage,^15
-17 and low education level,^18
-20 few have explored associations between linkage to care and SDH in various geographic areas (urban, metropolitan, rural) of the United States. The objective of our study was to describe linkage to care among adults with diagnosed HIV by demographic and SDH characteristics at the county level.

Methods

HIV Surveillance Data

We analyzed data from CDC’s National HIV Surveillance System (NHSS)²¹ for adults aged ≥18 with HIV diagnosed in 2017 to determine linkage to care within 1 month of diagnosis.²¹ We measured linkage to care by documentation of ≥1 CD4+ T-lymphocyte test (CD4 test) (measured as a count in cells/μL or as a CD4 percentage of total lymphocytes) or ≥1 viral load test (measured as copies/mL) performed ≤1 month after diagnosis, the standard used by CDC.³ Our analysis included data from 42 jurisdictions (41 states and the District of Columbia) with complete reporting of CD4 and viral load test results to CDC as of December 2018. Data from these jurisdictions represent 87.9% of all adults who received a diagnosis of HIV in the United States in 2017. We analyzed linkage to care for selected characteristics (sex at birth, age, race/ethnicity, and transmission category) and by population of residence (metropolitan [≥500 000 population], urban [50 000-499 999 population], or rural [<50 000 population]). We adjusted data in transmission category to account for people with missing data on risk factors.²² We did not seek institutional review board approval for this study because our research was a public health activity and did not involve human subjects.

Census Data

We obtained county-level data for 3 SDH variables (federal poverty level [FPL], education level, and health insurance coverage) from the US Census Bureau’s American Community Survey (ACS) 5-year estimates.²³ We calculated the proportion of residents who were living below the FPL at any time during the 12 months before the survey response, the proportion of residents with less than a high school diploma, and the proportion of residents without health insurance or a health coverage plan.

Analysis

We linked NHSS data for adults aged ≥18 with HIV diagnosed in 2017 with ACS data by county of residence at diagnosis. We categorized SDH variables into 2 levels of poverty, education, and health insurance coverage using the median values of poverty, education, and health insurance coverage from all counties in the 42 areas as cut points. We based the cut points on the medians of the empirically derived quartiles for poverty level, education level, and health insurance coverage (13%, 12%, and 12%, respectively). We excluded cases or counties when no county information was available for the case, no SDH information was available for the county, or we could not match the county indicated in the surveillance data with a county indicated in the ACS.

We calculated prevalence ratios (PRs) and 95% CIs by using the SAS GENMOD procedure (SAS Institute, Inc) to assess significant differences in linkage to care between adults with HIV diagnosed in 2017 residing in counties at or above the SDH variable cut point and adults with HIV diagnosed in 2017 in counties below the SDH variable cut point. We assessed significance using 95% CIs, where we considered values significant if the 95% CIs did not include 1. Linkage to care within 1 month of diagnosis was the outcome category, and the low-level SDH groups (<13% living below FPL, <12% without health insurance, and <13% with <high school diploma) were the referent groups.

Results

Linkage to Care

Among adults in the 42 areas, 33 381 received an HIV diagnosis during 2017 and 33 204 (99%) met study inclusion criteria. Of the 33 204 adults included in analysis, 26 033 (78.4%) were linked to care ≤1 month after diagnosis (Table 1). Among men, by age group, the prevalence of linkage to care was lowest among men aged 18-24 (74.6%). By race/ethnicity, the prevalence of linkage was lowest among Black people (74.6%), and by transmission category, linkage was lowest among men with infection attributed to MMSC/IDU (75.5%). By county of residence, linkage was lowest among men in urban areas (77.1%).

Table 1

HIV diagnoses and linkage to HIV medical care^a within 1 month of diagnosis among adults aged ≥18, by sex at birth and selected characteristics, 41 states^b and the District of Columbia, 2017^c

Characteristic	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)
Males
Age at diagnosis, y
18-24	6037	4501 (74.6)	1536 (25.4)
25-34	10 015	7744 (77.3)	2271 (22.7)
35-44	4922	3965 (80.6)	957 (19.4)
45-54	3652	2982 (81.7)	670 (18.3)
≥55	2302	1881 (81.7)	421 (18.3)
Race/ethnicity
American Indian/Alaska Native	121	101 (83.5)	20 (16.5)
Asian	748	608 (81.3)	140 (18.7)
Black/African American	10 615	7919 (74.6)	2696 (25.4)
Hispanic/Latino^d	7438	5896 (79.3)	1542 (20.7)
Native Hawaiian/Other Pacific Islander	33	28 (84.8)	5 (15.2)
White	7246	5937 (81.9)	1309 (18.1)
Multiple races	727	584 (80.3)	143 (19.7)
Transmission category^e
Male-to-male sexual contact	22 262	17 496 (78.6)	4766 (21.4)
Injection drug use	1066	815 (76.4)	252 (23.6)
Male-to-male sexual contact and injection drug use	1094	826 (75.5)	268 (24.5)
Heterosexual contact^f	2480	1915 (77.2)	565 (22.8)
Other^g	25	20 (79.8)	5 (20.2)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	21 941	17 218 (78.5)	4723 (21.5)
Urban (50 000-499 999)	3404	2624 (77.1)	780 (22.9)
Rural (<50 000)	1583	1231 (77.8)	352 (22.2)
Subtotal	26 928	21 073 (78.3)	5855 (21.7)
Females
Age at diagnosis, y
18-24	818	627 (76.7)	191 (23.3)
25-34	1726	1362 (78.9)	364 (21.1)
35-44	1476	1140 (77.2)	336 (22.8)
45-54	1232	998 (81.0)	234 (19.0)
≥55	1024	833 (81.3)	191 (18.7)
Race/ethnicity
American Indian/Alaska Native	36	32 (88.9)	4 (11.1)
Asian	97	73 (75.3)	24 (24.7)
Black/African American	3795	2995 (78.9)	800 (21.1)
Hispanic/Latino^d	958	766 (80.0)	192 (20.0)
Native Hawaiian/Other Pacific Islander	10	8 (80.0)	2 (20.0)
White	1230	965 (78.5)	265 (21.5)
Multiple races	150	121 (80.7)	29 (19.3)
Transmission category^e
Injection drug use	841	647 (76.8)	195 (23.2)
Heterosexual contact^f	5408	4292 (79.4)	1117 (20.6)
Other^g	26	22 (83.0)	5 (17.0)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	4983	3938 (79.0)	1045 (21.0)
Urban (50 000-499 999)	894	716 (80.1)	178 (19.9)
Rural (<50 000)	399	306 (76.7)	93 (23.3)
Unknown
Subtotal	6276	4960 (79.0)	1316 (21.0)
Total	33 204	26 033 (78.4)	7171 (21.6)

^aLinkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte test or ≥1 viral load test ≤1 month after HIV diagnosis. Of 38 381 people with HIV diagnosed in 2017, 33 204 met inclusion criteria for this analysis.

^bAlabama, Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

^cData sources: Cohen et al²¹ and US Census Bureau.²³

^dHispanic/Latino can be of any race.

^eData were adjusted to account for missing data on transmission category; therefore, values may not sum to row and column total.

^fHeterosexual contact with a person known to have or to be at high risk for HIV infection.

^gIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among women, by age group, the prevalence of linkage to care was lowest among women aged 18-24 (76.7%). By race/ethnicity, linkage was lowest among Asian people (75.3%), and by transmission category, linkage was lowest among women who injected drugs (76.8%). By county of residence, linkage was lowest among men in rural areas (76.7%).

Linkage to Care and FPL

Overall, among adults with HIV diagnosed in 2017, 21 000 (63.2%) resided in counties where ≥13% of the residents lived below the FPL (Table 2). The prevalence of linkage to care was lower among adults in counties with higher poverty than among adults in counties with lower poverty (77.1% vs 80.7%; PR = 0.96; 95% CI, 0.94-0.97).

Table 2

Linkage to HIV medical care^a within 1 month of HIV diagnosis, by federal poverty level (FPL) in county of residence, among adults aged ≥18, by sex at birth and selected characteristics, 41 states^b and the District of Columbia, 2017^c

Characteristic	Residence in counties where ≥13% of population lives below FPL			Residence in counties where <13% of population lives below FPL			Prevalence ratio^d (95% CI)
Characteristic	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Prevalence ratio^d (95% CI)
Males
Age at diagnosis, y
18-24	4022	2973 (73.9)	1049 (26.1)	2015	1528 (75.8)	487 (24.2)	0.97 (0.95-1.01)
25-34	6402	4862 (75.9)	1540 (24.1)	3613	2882 (79.8)	731 (20.2)	0.95 (0.93-0.97)
35-44	3117	2449 (78.6)	668 (21.4)	1805	1516 (84.0)	289 (16.0)	0.94 (0.91-0.96)
45-54	2177	1740 (79.9)	437 (20.1)	1475	1242 (84.2)	233 (15.8)	0.95 (0.92-0.98)
≥55	1370	1123 (82.0)	247 (18.0)	932	758 (81.3)	174 (18.7)	1.01 (0.97-1.05)
Race/ethnicity
American Indian/Alaska Native	81	67 (82.7)	14 (17.3)	40	34 (85.0)	6 (15.0)	0.97 (0.83-1.15)
Asian	326	247 (75.8)	79 (24.2)	422	361 (85.5)	61 (14.5)	0.89 (0.82-0.95)
Black/African American	7373	5461 (74.1)	1912 (25.9)	3242	2458 (75.8)	784 (24.2)	0.98 (0.95-1.00)
Hispanic/Latino^e	4976	3879 (78.0)	1097 (22.0)	2462	2017 (81.9)	445 (18.1)	0.95 (0.93-0.97)
Native Hawaiian/Other Pacific Islander	15	13 (86.7)	2 (13.3)	18	15 (83.3)	3 (16.7)	1.04 (0.78-1.39)
White	3905	3158 (80.9)	747 (19.1)	3341	2779 (83.2)	562 (16.8)	0.97 (0.95-0.99)
Multiple races	412	322 (78.2)	90 (21.8)	315	262 (83.2)	53 (16.8)	0.94 (0.88-1.01)
Transmission category^f
Male-to-male sexual contact	14 330	11 077 (77.3)	3254 (22.7)	7931	6420 (80.9)	1512 (19.1)	0.95 (0.94-0.97)
Injection drug use	633	474 (75.0)	158 (25.0)	434	340 (78.5)	94 (21.5)	0.96 (0.89-1.02)
Male-to-male sexual contact and injection drug use	586	429 (73.1)	158 (26.9)	508	398 (78.3)	110 (21.7)	0.93 (0.87-0.99)
Heterosexual contact^g	1521	1153 (75.8)	368 (24.2)	959	763 (79.5)	196 (20.5)	0.95 (0.91-0.99)
Other^h	18	15 (82.4)	3 (17.6)	8	6 (74.0)	2 (26.0)	1.11 (0.69-1.78)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	13 442	10 367 (77.1)	3075 (22.9)	8499	6851 (80.6)	1648 (19.4)	0.96 (0.94-0.97)
Urban (50 000-499 999)	2398	1826 (76.1)	572 (23.9)	1006	798 (79.3)	208 (20.7)	0.96 (0.92-0.99)
Rural (<50 000)	1248	954 (76.4)	294 (23.6)	335	277 (82.7)	58 (17.3)	0.92 (0.87-0.98)
Subtotal	17 088	13 147 (76.9)	3941 (23.1)	9840	7926 (80.5)	1914 (19.5)	0.96 (0.94-0.97)
Females
Age at diagnosis, y
18-24	534	405 (75.8)	129 (24.2)	284	222 (78.2)	62 (21.8)	0.97 (0.90-1.05)
25-34	1076	842 (78.3)	234 (21.7)	650	520 (80.0)	130 (20.0)	0.98 (0.93-1.03)
35-44	908	692 (76.2)	216 (23.8)	568	448 (78.9)	120 (21.1)	0.97 (0.91-1.02)
45-54	761	600 (78.8)	161 (21.2)	471	398 (84.5)	73 (15.5)	0.93 (0.88-0.98)
≥55	633	502 (79.3)	131 (20.7)	391	331 (84.7)	60 (15.3)	0.94 (0.88-0.99)
Race/ethnicity
American Indian/Alaska Native	21	17 (81.0)	4 (19.0)	15	15 (100.0)	0	—
Asian	44	31 (70.5)	13 (29.5)	53	42 (79.2)	11 (20.8)	0.89 (0.70-1.13)
Black/African American	2510	1954 (77.8)	556 (22.2)	1285	1041 (81.0)	244 (19.0)	0.96 (0.93-0.99)
Hispanic/Latino^e	602	478 (79.4)	124 (20.6)	356	288 (80.9)	68 (19.1)	0.98 (0.92-1.05)
Native Hawaiian/Other Pacific Islander	2	2 (100.0)	0	8	6 (75.0)	2 (25.0)	—
White	659	500 (75.9)	159 (24.1)	571	465 (81.4)	106 (18.6)	0.93 (0.88-0.99)
Multiple races	74	59 (79.7)	15 (20.3)	76	62 (81.6)	14 (18.4)	0.98 (0.84-1.14)
Transmission category^f
Injection drug use	512	398 (77.8)	114 (22.2)	329	248 (75.4)	81 (24.6)	1.03 (0.95-1.11)
Heterosexual contact^g	3386	2632 (77.7)	754 (22.3)	2022	1659 (82.1)	363 (17.9)	0.95 (0.92-0.97)
Other^h	14	10 (76.5)	3 (23.5)	13	12 (89.8)	1 (10.2)	0.85 (0.60-1.20)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	2907	2254 (77.5)	653 (22.5)	2076	1684 (81.1)	392 (18.9)	0.96 (0.93-0.98)
Urban (50 000-499 999)	667	528 (79.2)	139 (20.8)	227	188 (82.8)	39 (17.2)	0.96 (0.89-1.03)
Rural (<50 000)	338	259 (76.6)	79 (23.4)	61	47 (77.0)	14 (23.0)	0.99 (0.86-1.15)
Subtotal	3912	3041 (77.7)	871 (22.3)	2364	1919 (81.2)	445 (18.8)	0.96 (0.93-0.98)
Total	21 000	16 188 (77.1)	4812 (22.9)	12 204	9845 (80.7)	2359 (19.3)	0.96 (0.94-0.97)

^cData sources: Cohen et al.²¹

^dCompares percentage linked to care within 1 month of HIV diagnosis.

^eHispanic/Latino can be of any race.

^fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

^gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

^hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with higher poverty than in counties with lower poverty (PR = 0.96; 95% CI, 0.94-0.97) by age, for males aged 35-44 (PR = 0.94; 95% CI, 0.91-0.96), 25-34 (PR = 0.95; 95% CI, 0.93-0.97), and 45-54 (PR = 0.95; 95% CI, 0.92-0.98); by race/ethnicity, for Asian (PR = 0.89; 95% CI, 0.82-0.95), Hispanic/Latino (PR = 0.95; 95% CI, 0.93-0.97), and White (PR = 0.97; 95% CI, 0.95-0.99) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.93; 95% CI, 0.87-0.99), males with MMSC (PR = 0.95; 95% CI, 0.94-0.97), and males with heterosexual contact (PR = 0.95; 95% CI, 0.91-0.99); and by population of residence, in rural (PR = 0.92; 95% CI, 0.87-0.98), metropolitan (PR = 0.96; 95% CI, 0.94-0.97), and urban (PR = 0.96; 95% CI, 0.92-0.99) areas.

Among females, linkage to care was lower in counties with higher poverty than in counties with lower poverty (PR = 0.96; 95% CI, 0.93-0.98) by age, for females aged 45-54 (PR = 0.93; 95% CI, 0.88-0.98) and ≥55 (PR = 0.94; 95% CI, 0.88-0.99); by race/ethnicity, for White (PR = 0.93; 95% CI, 0.88-0.99) and Black (PR = 0.96; 95% CI, 0.93-0.99) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.95; 95% CI, 0.92-0.97); and by population of residence, in metropolitan areas (PR = 0.96; 95% CI, 0.93-0.98).

Linkage to Care and Health Insurance Coverage

Overall, among adults with HIV diagnosed in 2017, 22 169 (66.8%) adults resided in counties with lower insurance coverage, where ≥12% of residents did not have health insurance (Table 3). Linkage to care was lower among adults in counties with lower health insurance coverage than among adults in counties with higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94).

Table 3

Linkage to HIV medical care^a within 1 month of HIV diagnosis, by health insurance coverage in county of residence among adults aged ≥18, by sex at birth and selected characteristics, 41 states^b and the District of Columbia, 2017^c

Characteristic	Residence in counties where ≥12% of population lacks health insurance			Residence in counties where <12% of population lacks health insurance			Prevalence ratio^d (95% CI)
Characteristic	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Prevalence ratio^d (95% CI)
Males
Age at diagnosis, y
18-24	4121	2993 (72.6)	1128 (27.4)	1916	1508 (78.7)	408 (21.3)	0.92 (0.90-0.95)
25-34	6713	5082 (75.7)	1631 (24.3)	3302	2662 (80.6)	640 (19.4)	0.94 (0.92-0.96)
35-44	3324	2609 (78.5)	715 (21.5)	1598	1356 (84.9)	242 (15.1)	0.92 (0.90-0.95)
45-54	2373	1871 (78.8)	502 (21.2)	1279	1111 (86.9)	168 (13.1)	0.91 (0.88-0.94)
≥55	1498	1215 (81.1)	283 (18.9)	804	666 (82.8)	138 (17.2)	0.98 (0.94-1.02)
Race/ethnicity
American Indian/Alaska Native	93	74 (79.6)	19 (20.4)	28	27 (96.4)	1 (3.6)	0.83 (0.73-0.94)
Asian	400	310 (77.5)	90 (22.5)	348	298 (85.6)	50 (14.4)	0.91 (0.85-0.97)
Black/African American	7392	5428 (73.4)	1964 (26.6)	3223	2491 (77.3)	732 (22.7)	0.95 (0.93-0.97)
Hispanic/Latino^e	5590	4323 (77.3)	1267 (22.7)	1848	1573 (85.1)	275 (14.9)	0.91 (0.89-0.93)
Native Hawaiian/Other Pacific Islander	15	12 (80.0)	3 (20.0)	18	16 (88.9)	2 (11.1)	0.90 (0.67-1.22)
White	4126	3293 (79.8)	833 (20.2)	3120	2644 (84.7)	476 (15.3)	0.94 (0.92-0.96)
Multiple races	413	330 (79.9)	83 (20.1)	314	254 (80.9)	60 (19.1)	0.99 (0.92-1.06)
Transmission category^f
Male-to-male sexual contact	15 064	11 553 (76.7)	3510 (23.3)	7198	5943 (82.6)	1255 (17.4)	0.93 (0.92-0.94)
Injection drug use	571	425 (74.4)	146 (25.6)	496	390 (78.7)	106 (21.3)	0.95 (0.89-1.01)
Male-to-male sexual contact and injection drug use	618	445 (72.1)	173 (27.9	477	381 (80.0)	95 (20.0)	0.90 (0.84-0.96)
Heterosexual contact^g	1761	1334 (75.8)	427 (24.2)	719	581 (80.8)	138 (19.2)	0.94 (0.90-0.98)
Other^h	16	13 (80.1)	3 (19.9)	10	8 (79.4)	2 (20.6)	1.01 (0.67-1.51)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	14 627	11 168 (76.4)	3459 (23.6)	7314	6050 (82.7)	1264 (17.3)	0.92 (0.91-0.94)
Urban (50 000-499 999)	2245	1709 (76.1)	536 (23.9)	1159	915 (78.9)	244 (21.1)	0.96 (0.93-1.00)
Rural (<50 000)	1157	893 (77.2)	264 (22.8)	426	338 (79.3)	88 (20.7)	0.97 (0.92-1.03)
Subtotal	18 029	13 770 (76.4)	4259 (23.6)	8899	7303 (82.1)	1596 (17.9	0.93 (0.92-0.94)
Females
Age at diagnosis, y
18-24	565	419 (74.2)	146 (25.8)	253	208 (82.2)	45 (17.8)	0.90 (0.84-0.97)
25-34	1154	883 (76.5)	271 (23.5)	572	479 (83.7)	93 (16.3)	0.91 (0.87-0.96)
35-44	965	730 (75.6)	235 (24.4)	511	410 (80.2)	101 (19.8)	0.94 (0.89-0.99)
45-54	807	640 (79.3)	167 (20.7)	425	358 (84.2)	67 (15.8)	0.94 (0.89-0.99)
≥55	649	499 (76.9)	150 (23.1)	375	334 (89.1)	41 (10.9)	0.86 (0.82-0.91)
Race/ethnicity
American Indian/Alaska Native	27	24 (88.9)	3 (11.1)	9	8 (88.9)	1 (11.1)	1.00 (0.77-1.31)
Asian	52	35 (67.3)	17 (32.7)	45	38 (84.4)	7 (15.6)	0.80 (0.64-1.00)
Black/African American	2605	1995 (76.6)	610 (23.4)	1190	1000 (84.0)	190 (16.0)	0.91 (0.88-0.94)
Hispanic/Latino^e	682	535 (78.4)	147 (21.6)	276	231 (83.7)	45 (16.3)	0.94 (0.88-1.00)
Native Hawaiian/Other Pacific Islander	5	3 (60.0)	2 (40.0)	5	5 (100.0)	0	—
White	690	518 (75.1)	172 (24.9)	540	447 (82.8)	93 (17.2)	0.91 (0.86-0.96)
Multiple races	79	61 (77.2)	18 (22.8)	71	60 (84.5)	11 (15.5)	0.91 (0.78-1.07)
Transmission category^f
Injection drug use	457	344 (75.1)	114 (24.9)	384	303 (78.9)	81 (21.1)	0.95 (0.88-1.03)
Heterosexual contact^g	3669	2817 (76.8)	852 (23.2)	1739	1475 (84.8)	265 (15.2)	0.91 (0.88-0.93)
Other^h	14	10 (75.7)	3 (24.3)	13	12 (90.6)	1 (9.4)	0.84 (0.59-1.18)
County of residence at diagnosis
Metropolitan (≥500 000)	3198	2435 (76.1)	763 (23.9)	1785	1503 (84.2)	282 (15.8)	0.90 (0.88-0.93)
Urban (50 000-499 999)	627	493 (78.6)	134 (21.4)	267	223 (83.5)	44 (16.5)	0.94 (0.88-1.01)
Rural (<50 000)	315	243 (77.1)	72 (22.9)	84	63 (75.0)	21 (25.0)	1.03 (0.90-1.18)
Subtotal	4140	3171 (76.6)	969 (23.4)	2136	1789 (83.8)	347 (16.2)	0.91 (0.89-0.94)
Total	22 169	16 941 (76.4)	5228 (23.6)	11 035	9092 (82.4)	1943 (17.6)	0.93 (0.92-0.94)

^cData source: Cohen et al.²¹

^dCompares percentage linked to care within 1 month of HIV diagnosis.

^eHispanic/Latino can be of any race.

^fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

^gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

^hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with lower health insurance coverage than in counties with higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94) by age, for males aged 18-24 (PR = 0.92; 95% CI, 0.90-0.95), 25-34 (PR = 0.94; 95% CI, 0.92-0.96), 35-44 (PR = 0.92; 95% CI, 0.90-0.95), and 45-54 (PR = 0.91; 95% CI, 0.88-0.94); by race/ethnicity, for American Indian/Alaska Native (PR = 0.83; 95% CI, 0.73-0.94), Asian (PR = 0.91; 95% CI, 0.85-0.97), Hispanic/Latino (PR = 0.91; 95% CI, 0.89-0.93), White (PR = 0.94; 95% CI, 0.92-0.96), and Black (PR = 0.95; 95% CI, 0.93-0.97) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.90; 95% CI, 0.84-0.96), males with MMSC (PR = 0.93; 95% CI, 0.92-0.94), and males with heterosexual contact (PR = 0.94; 95% CI, 0.90-0.98); and by population of residence, in metropolitan areas (PR = 0.92; 95% CI, 0.91-0.94).

Among females, linkage to care was lower in counties with lower health insurance coverage than in counties with higher health insurance coverage (PR = 0.91; 95% CI, 0.89-0.94) by age, for females aged 18-24 (PR = 0.90; 95% CI, 0.84-0.97), 25-34 (PR = 0.91; 95% CI, 0.87-0.96), 35-44 (PR = 0.94; 95% CI, 0.89-0.99), 45-54 (PR = 0.94; 95% CI, 0.89-0.99), and ≥55 (PR = 0.86; 95% CI, 0.82-0.91); by race/ethnicity, for Black (PR = 0.91; 95% CI, 0.88-0.94) and White (PR = 0.91; 95% CI, 0.86-0.96) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.91; 95% CI, 0.88-0.93); and by population of residence, in metropolitan areas (PR = 0.90; 95% CI, 0.88-0.93).

Linkage to Care and Education Level

Overall, among adults with HIV diagnosed in 2017, 16 372 (49.3%) adults resided in counties with lower education levels, where ≥13% of residents had less than a high school diploma (Table 4). Linkage to care was lower among adults in counties with lower education levels than among adults in counties with higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

Table 4

Linkage to HIV medical care^a within 1 month of HIV diagnosis, by education level of county of residence, among adults aged ≥18, by sex at birth and selected characteristics, 41 states^b and the District of Columbia, 2017^c

Characteristic	Residence in counties where ≥13% of population has <high school diploma			Residence in counties where <13% of population has <high school diploma			Prevalence ratio^d (95% CI)
Characteristic	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Total diagnoses, no.	Linked to care within 1 month, no. (%)	Not linked to care within 1 month, no. (%)	Prevalence ratio^d (95% CI)
Males
Age at diagnosis, y
18-24	2974	2192 (73.7)	782 (26.3)	3063	2309 (75.4)	754 (24.6)	0.98 (0.95-1.01)
25-34	4990	3810 (76.4)	1180 (23.6)	5025	3934 (78.3)	1091 (21.7)	0.98 (0.95-1.00)
35-44	2550	2020 (79.2)	530 (20.8)	2372	1945 (82.0)	427 (18.0)	0.97 (0.94-0.99)
45-54	1768	1391 (78.7)	377 (21.3)	1884	1591 (84.4)	293 (15.6)	0.93 (0.90-0.96)
≥55	1087	888 (81.7)	199 (18.3)	1215	993 (81.7)	222 (18.3)	1.00 (0.96-1.04)
Race/ethnicity
American Indian/Alaska Native	62	52 (83.9)	10 (16.1)	59	49 (83.1)	10 (16.9)	1.01 (0.86-1.18)
Asian	336	255 (75.9)	81 (24.1)	412	353 (85.7)	59 (14.3)	0.89 (0.82-0.95)
Black/African American	4961	3711 (74.8)	1250 (25.2)	5654	4208 (74.4)	1446 (25.6)	1.01 (0.98-1.03)
Hispanic/Latino^e	4820	3750 (77.8)	1070 (22.2)	2618	2146 (82.0)	472 (18.0)	0.95 (0.93-0.97)
Native Hawaiian/Other Pacific Islander	9	7 (77.8)	2 (22.2)	24	21 (87.5)	3 (12.5)	0.89 (0.61-1.30)
White	2870	2279 (79.4)	591 (20.6)	4376	3658 (83.6)	718 (16.4)	0.95 (0.93-0.97)
Multiple races	311	247 (79.4)	64 (20.6)	416	337 (81.0)	79 (19.0)	0.98 (0.91-1.05)
Transmission category^f
Male-to-male sexual contact	11 233	8682 (77.3)	2551 (22.7)	11 029	8814 (79.9)	2215 (20.1)	0.97 (0.95-0.98)
Injection drug use	504	377 (74.9)	127 (25.1)	563	438 (77.8)	125 (22.2)	0.96 (0.90-1.03)
Male-to-male sexual contact and injection drug use	465	337 (72.4)	128 (27.6)	629	490 (77.8)	140 (22.2)	0.93 (0.87-0.99)
Heterosexual contact^g	1155	895 (77.5)	260 (22.5)	1325	1021 (77.0)	305 (23.0)	1.01 (0.96-1.05)
Other^h	12	10 (80.6)	2 (19.4)	13	10 (79.1)	3 (20.9)	1.02 (0.69-1.51)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	10 645	8231 (77.3)	2414 (22.7)	11 296	8987 (79.6)	2309 (20.4)	0.97 (0.96-0.99)
Urban (50 000-499 999)	1538	1167 (75.9)	371 (24.1)	1866	1457 (78.1)	409 (21.9)	0.97 (0.94-1.01)
Rural (<50 000)	1186	903 (76.1)	283 (23.9)	397	328 (82.6)	69 (17.4)	0.92 (0.87-0.97)
Subtotal	13 369	10 301 (77.1)	3068 (22.9)	13 559	10 772 (79.4)	2787 (20.6)	0.97 (0.96-0.98)
Females
Age at diagnosis, y
18-24	402	304 (75.6)	98 (24.4)	416	323 (77.6)	93 (22.4)	0.97 (0.90-1.05)
25-34	846	651 (77.0)	195 (23.0)	880	711 (80.8)	169 (19.2)	0.95 (0.91-1.00)
35-44	709	550 (77.6)	159 (22.4)	767	590 (76.9)	177 (23.1)	1.01 (0.95-1.07)
45-54	584	466 (79.8)	118 (20.2)	648	532 (82.1)	116 (17.9)	0.97 (0.92-1.03)
≥55	462	361 (78.1)	101 (21.9)	562	472 (84.0)	90 (16.0)	0.93 (0.88-0.99)
Race/ethnicity
American Indian/Alaska Native	17	14 (82.4)	3 (17.6)	19	18 (94.7)	1 (5.3)	0.87 (0.68-1.11)
Asian	36	22 (61.1)	14 (38.9)	61	51 (83.6)	10 (16.4)	0.73 (0.55-0.97)
Black/African American	1830	1419 (77.5)	411 (22.5)	1965	1576 (80.2)	389 (19.8)	0.97 (0.94-0.99)
Hispanic/Latino^e	590	474 (80.3)	116 (19.7)	368	292 (79.3)	76 (20.7)	1.01 (0.95-1.08)
Native Hawaiian/Other Pacific Islander	2	2 (100.0)	0	8	6 (75.0)	2 (25.0)	—
White	464	353 (76.1)	111 (23.9)	766	612 (79.9)	154 (20.1)	0.95 (0.89-1.01)
Multiple races	64	48 (75.0)	16 (25.0)	86	73 (84.9)	13 (15.1)	0.88 (0.75-1.04)
Transmission category^f
Injection drug use	382	296 (77.6)	86 (22.4)	460	350 (76.2)	109 (23.8)	1.02 (0.94-1.10)
Heterosexual contact^g	2610	2028 (77.7)	582 (22.3)	2798	2264 (80.9)	534 (19.1)	0.96 (0.93-0.99)
Other^h	11	8 (72.3)	3 (27.7)	15	14 (90.8)	1 (9.2)	0.80 (0.54-1.18)
County of residence at diagnosis (population)
Metropolitan (≥500 000)	2240	1741 (77.7)	499 (22.3)	2743	2197 (80.1)	546 (19.9)	0.97 (0.94-0.99)
Urban (50 000-499 999)	441	341 (77.3)	100 (22.7)	453	375 (82.8)	78 (17.2)	0.93 (0.87-0.99)
Rural (<50 000)	322	250 (77.6)	72 (22.4)	77	56 (72.7)	21 (27.3)	1.07 (0.92-1.24)
Subtotal	3003	2332 (77.7)	671 (22.3)	3273	2628 (80.3)	645 (19.7)	0.97 (0.94-0.99)
Total	16 372	12 633 (77.2	3739 (22.8)	16 832	13 400 (79.6)	3432 (20.4)	0.97 (0.96-0.98)

^cData source: Cohen et al.²¹

^dCompares percentage linked to care within 1 month of HIV diagnosis.

^eHispanic/Latino can be of any race.

^fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

^gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

^hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with lower education levels than in counties with higher education levels (PR = 0.97; 95% CI, 0.96-0.98) by age, for males aged 35-44 (PR = 0.97; 95% CI, 0.94-0.99) and 45-54 (PR = 0.93; 95% CI, 0.90-0.96); by race/ethnicity, for Asian (PR = 0.89; 95% CI, 0.82-0.95), Hispanic/Latino (PR = 0.95; 95% CI, 0.93-0.97), and White (PR = 0.95; 95% CI, 0.93-0.97) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.93; 95% CI, 0.87-0.99) and MMSC (PR = 0.97; 95% CI, 0.95-0.98); and by population of residence, in rural (PR = 0.92; 95% CI, 0.87-0.97) and metropolitan (PR = 0.97; 95% CI, 0.96-0.99) areas.

Among females, linkage to care was lower in counties with lower education levels than in counties with higher education levels (PR = 0.97; 95% CI, 0.94-0.99) by age, for females aged ≥55 (PR = 0.93; 95% CI, 0.88-0.99); by race/ethnicity, for Asian (PR = 0.73; 95% CI, 0.55-0.97) and Black (PR = 0.97; 95% CI, 0.94-0.99) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.96; 95% CI, 0.93-0.99); and by population of residence, in urban (PR = 0.93; 95% CI, 0.87-0.99) and metropolitan (PR = 0.97; 95% CI, 0.94-0.99) areas.

Discussion

For adults with diagnosed HIV in 2017 in the United States, our analysis found lower rates of linkage to care in the overall population and among males with infection attributed to MMSC/IDU, for adults residing in areas characterized by the 3 SDH extremes of higher poverty, lower health insurance coverage, and lower education levels. Linkage was lowest among males aged 45-54 in counties with lower health insurance coverage and lower education levels, among Asian and Hispanic/Latino males in counties with higher poverty and lower education levels, among males residing in rural areas with higher poverty and lower education levels, and among White and Black females in counties with higher poverty and lower health insurance coverage.

Few studies have examined SDH and linkage to care in the United States, and direct comparisons of findings are limited because of differences in the outcomes measured and populations observed. However, in general, we found that most studies support our overall findings of lower linkage to care among people residing in high-poverty areas and areas with low health insurance coverage.^24

-27 These findings may be attributed to factors such as lack of social support services, socioeconomic instability, and limited public transportation and highlight that structural and societal factors such as social and physical environments, and availability, cost of, and access to health services, may create barriers to HIV care.^24

-27 Identifying the limitations to accessing care and the SDH factors that may contribute to these limitations is critical and will provide insight on additional factors associated with lower rates of linkage to care in the United States.

For results across race/ethnicity, we found that Asian and Hispanic/Latino males residing in counties with higher poverty and lower education levels had lower rates of linkage to care. Several studies on HIV health outcomes among Asian people in the United States have suggested that cultural, behavioral, and belief factors must be addressed to increase linkage-to-care rates among Asian people in general.^28,29 A study of Latino men in large US cities found factors such as limited education, inadequate health insurance, language barriers, and migration contribute to poor health outcomes in the Hispanic/Latino population, which can directly and indirectly affect opportunities to be linked to HIV care.^30,31 Considering the heterogeneous nature of Asian and Latino populations, it may be beneficial to disaggregate these populations for better insight in future analyses.

In our study, linkage-to-care rates were low among White and Black females in counties with higher poverty and lower health insurance coverage. Although national surveillance data on health outcomes and SDH found lower linkage-to-care rates among White women in counties with lower poverty, additional studies are needed to provide better insight into the effect of SDH on care outcomes in this population.¹⁴ Although recent studies have not analyzed SDH and linkage to care among Black women, some studies do support our findings of lower linkage-to-care rates among Black women in high-poverty areas.^13,32,33 A study of Florida residents found that non-initiation of care increased as poverty level increased and as the density of non-Hispanic Black people increased.³⁴ Limited access to quality health care, housing, transportation, and HIV education, in addition to stigma, discrimination, and fear, may directly affect linkage-to-care rates among Black women.^32,33

By population of residence, linkage to care was lowest among males residing in rural areas with higher poverty and lower education levels than among males in counties with lower poverty and higher education levels. People living in rural areas of the United States may be at a disadvantage for accessing and receiving HIV care, and HIV-related stigma is greater in rural areas than in large urban communities.^35,36 Although a study of care outcomes by geographic population found greater linkage-to-care rates among people in rural areas than in urban and metropolitan areas in the United States,³⁷ additional barriers such as living in an area of high poverty or low education generally affect other HIV-related outcomes, such as retention in care and adherence to treatment to attain viral suppression.¹⁸

Linkage-to-care rates were lower among young adults aged 18-24 than among adults in other age groups. Surveillance studies have found that 44% of undiagnosed HIV infections and 21% of new HIV diagnoses in the United States are among adolescents and young adults,^1,2 and this group is less likely than other age groups to be retained in care and to be virally suppressed.^3,38 Adolescents and young adults often face challenges to testing, entry, and maintenance of HIV care, which include limited transportation, underemployment, stigma and fear, and low levels of family support, which affect their decision making on care options.^27,39 Understanding these barriers and other SDH factors is critical and will provide insight for work to improve linkage to care among young adults.⁴⁰ In addition, increasing the availability of adolescent-friendly, culturally competent, confidential, and convenient health services may facilitate access to HIV care for this population.⁴¹

Limitations

Our analysis had several potential limitations. First, data were available from 42 jurisdictions with complete reporting of HIV-related laboratory data to CDC. These 42 areas represent 87.9% of all HIV diagnoses that occurred in the United States in 2017 and, as such, may not be representative of all people with diagnosed HIV infection in the United States. Third, because all people with HIV have not been tested and/or reported, the number and percentage of people linked to care may not be representative of all adults with diagnosed HIV infection in the 42 areas in 2017. Fourth, use of county-level aggregated data for this ecological analysis may not accurately reflect or represent the SDH environment at the individual level. Finally, although some SDH indicators may be correlated (eg, lack of education has been associated with both poverty and low income in the United States),^42,43 we did not analyze correlations between SDH indicators in our study.

Conclusions

Although health outcomes of people with HIV infection have improved in the past decade, some populations are disproportionately affected.⁸ Prevention interventions need to be supplemented to address underlying factors such as poverty, lack of health insurance, and lack of education. A key strategy of the Ending the HIV Epidemic initiative is to reduce HIV transmission through interventions that improve rates of viral suppression.^4,5,7 Linkage to care is the gateway to receiving prompt and proper HIV treatment for the attainment and maintenance of viral suppression. Increasing low- to no-cost health insurance options among low-income populations would likely lead to better HIV care outcomes for these populations. In addition, increased use of peer navigators and allied health workers and the development of targeted campaigns may improve linkage-to-care rates among groups that are at high risk of having poor HIV health outcomes. Future studies are needed to analyze the relative effects of both county-level and individual poverty, education, and health insurance measures to inform whether variance in linkage is attributed to individual or aggregate county SDH, or both.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Myrline Gillot, MPH

Zanetta Gant, PhD, MS

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Linkage to HIV Medical Care and Social Determinants of Health Among Adults With Diagnosed HIV Infection in 41 States and the District of Columbia,2017

Abstract

Objectives

Methods

Results

Conclusions

Keywords

Methods

HIV Surveillance Data

Census Data

Analysis

Results

Linkage to Care

Linkage to Care and FPL

Linkage to Care and Health Insurance Coverage

Linkage to Care and Education Level

Discussion

Limitations

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References