Are Neighborhood Conditions Associated With HIV Management?
Objectives HIV infection has become a manageable chronic disease as a result of treatment advances. Secondary prevention efforts have proved inadequate to reduce the estimated incidence of new HIV infections. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of low socioeconomic status. This study aimed to assess the relationship between neighbourhood conditions and HIV management and engagement in high-risk behaviours.
Methods During routine out-patient HIV clinic visits, 762 individuals from the St Louis metropolitan area completed behavioural assessments in 2008. Biomedical markers were abstracted from their medical records. Multi-level analyses were conducted based on individuals' census tracts.
Results The majority of the sample were male and African American. In the adjusted models, individuals residing in neighbourhoods with higher poverty rates were more likely to have lower CD4 cell counts and be current smokers. In neighbourhoods with higher rates of unemployment, individuals were less likely to have a current antiretroviral prescription. In more racially segregated neighbourhoods, individuals reported more depressive symptoms.
Conclusions Despite the advances in HIV disease management, neighbourhood characteristics contribute to disparities in HIV care. Interventions that address neighbourhood conditions as barriers to HIV management may provide improved health outcomes.
With treatment advances over the past decade, HIV infection has become a manageable chronic disease. With this encouraging success in terms of reduced mortality, new challenges have emerged. Specifically, secondary prevention efforts have been inadequate to prevent new HIV infections. Test and treat strategies are now being promoted as an effective method of HIV prevention. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas with populations of low socioeconomic status. Unfortunately, the development of evidence-based interventions to reduce HIV transmission has been limited in impact. Notably, few interventions have incorporated the neighbourhood environment in which individuals live as a determinant of behaviours.
Previous research has examined how social disorganization theoretical factors are associated with HIV infection and health outcomes. Some measures of the social disorganization theory are routinely operationalized by census tract-level data, including per cent in poverty, the racial make-up of a census tract, and unemployment rates. Early in the HIV epidemic, patterns of neighbourhood-level poverty were identified and this poverty was demonstrated to adversely affect infection and survival rates. Neighbourhood-level poverty is associated with poorer HIV-related outcomes even within universal health care settings. More recent research has demonstrated that neighbourhood poverty factors are associated with higher AIDS-related mortality. Additionally, higher AIDS prevalence occurred in the lowest income neighbourhoods and African Americans were more likely to live in those neighbourhoods. Other studies identified that higher rates of HIV testing occurred among neighbourhoods with more African American residents. This increased HIV testing rate may be a positive public health outcome; yet as it relates to residential segregation, it was also noted to be associated with stronger feelings of perceived racism. Thoughtful consideration of these factors and how they impact health behaviours and outcomes is imperative for furthering intervention development.
Previous research has suggested that there are neighbourhood factors that impact health behaviours, and thus health outcomes. Some of that work has been carried out in relation to risk behaviour engagement. Specifically, lower income neighbourhoods have been noted to have higher rates of alcohol use, attributable to a higher density of alcohol-selling establishments and the marketing of alcohol using mass media such as billboards. In other studies, HIV infection rates were predicted by the density of alcohol-serving establishments among men who have sex with men (MSM). These factors matter to HIV management, as alcohol use is associated with increased engagement in unplanned and unprotected sex, as well as medication nonadherence.
Reducing high-risk sexual behaviour also remains germane to HIV prevention efforts. Sexually transmitted infection (STI) incidence rates remain high in populations with HIV despite the decline in self-reported high-risk behaviours after HIV diagnosis. Individual-level risk reduction efforts have not been broadly successful. Evidence-based community-level interventions have rarely addressed neighbourhood factors that may be associated with HIV transmission.
This study aimed to assess the constructs associated with the social disorganization theory (poverty, unemployment and residential segregation) related to HIV management, specifically behaviours that facilitate the transmission of HIV and affect HIV-related health outcomes. HIV-related spatial analyses most often have been conducted to examine HIV infection rates by location and region to for service provision needs, and have been used to assist in the massive roll-out of combination antiretroviral therapy (cART). We aimed to study specific characteristics of adverse socioeconomic conditions to assess their relationship to poor HIV management and engagement in high-risk behaviours in this care context.
Abstract and Introduction
Abstract
Objectives HIV infection has become a manageable chronic disease as a result of treatment advances. Secondary prevention efforts have proved inadequate to reduce the estimated incidence of new HIV infections. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of low socioeconomic status. This study aimed to assess the relationship between neighbourhood conditions and HIV management and engagement in high-risk behaviours.
Methods During routine out-patient HIV clinic visits, 762 individuals from the St Louis metropolitan area completed behavioural assessments in 2008. Biomedical markers were abstracted from their medical records. Multi-level analyses were conducted based on individuals' census tracts.
Results The majority of the sample were male and African American. In the adjusted models, individuals residing in neighbourhoods with higher poverty rates were more likely to have lower CD4 cell counts and be current smokers. In neighbourhoods with higher rates of unemployment, individuals were less likely to have a current antiretroviral prescription. In more racially segregated neighbourhoods, individuals reported more depressive symptoms.
Conclusions Despite the advances in HIV disease management, neighbourhood characteristics contribute to disparities in HIV care. Interventions that address neighbourhood conditions as barriers to HIV management may provide improved health outcomes.
Introduction
With treatment advances over the past decade, HIV infection has become a manageable chronic disease. With this encouraging success in terms of reduced mortality, new challenges have emerged. Specifically, secondary prevention efforts have been inadequate to prevent new HIV infections. Test and treat strategies are now being promoted as an effective method of HIV prevention. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas with populations of low socioeconomic status. Unfortunately, the development of evidence-based interventions to reduce HIV transmission has been limited in impact. Notably, few interventions have incorporated the neighbourhood environment in which individuals live as a determinant of behaviours.
Previous research has examined how social disorganization theoretical factors are associated with HIV infection and health outcomes. Some measures of the social disorganization theory are routinely operationalized by census tract-level data, including per cent in poverty, the racial make-up of a census tract, and unemployment rates. Early in the HIV epidemic, patterns of neighbourhood-level poverty were identified and this poverty was demonstrated to adversely affect infection and survival rates. Neighbourhood-level poverty is associated with poorer HIV-related outcomes even within universal health care settings. More recent research has demonstrated that neighbourhood poverty factors are associated with higher AIDS-related mortality. Additionally, higher AIDS prevalence occurred in the lowest income neighbourhoods and African Americans were more likely to live in those neighbourhoods. Other studies identified that higher rates of HIV testing occurred among neighbourhoods with more African American residents. This increased HIV testing rate may be a positive public health outcome; yet as it relates to residential segregation, it was also noted to be associated with stronger feelings of perceived racism. Thoughtful consideration of these factors and how they impact health behaviours and outcomes is imperative for furthering intervention development.
Previous research has suggested that there are neighbourhood factors that impact health behaviours, and thus health outcomes. Some of that work has been carried out in relation to risk behaviour engagement. Specifically, lower income neighbourhoods have been noted to have higher rates of alcohol use, attributable to a higher density of alcohol-selling establishments and the marketing of alcohol using mass media such as billboards. In other studies, HIV infection rates were predicted by the density of alcohol-serving establishments among men who have sex with men (MSM). These factors matter to HIV management, as alcohol use is associated with increased engagement in unplanned and unprotected sex, as well as medication nonadherence.
Reducing high-risk sexual behaviour also remains germane to HIV prevention efforts. Sexually transmitted infection (STI) incidence rates remain high in populations with HIV despite the decline in self-reported high-risk behaviours after HIV diagnosis. Individual-level risk reduction efforts have not been broadly successful. Evidence-based community-level interventions have rarely addressed neighbourhood factors that may be associated with HIV transmission.
This study aimed to assess the constructs associated with the social disorganization theory (poverty, unemployment and residential segregation) related to HIV management, specifically behaviours that facilitate the transmission of HIV and affect HIV-related health outcomes. HIV-related spatial analyses most often have been conducted to examine HIV infection rates by location and region to for service provision needs, and have been used to assist in the massive roll-out of combination antiretroviral therapy (cART). We aimed to study specific characteristics of adverse socioeconomic conditions to assess their relationship to poor HIV management and engagement in high-risk behaviours in this care context.
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