PosterPDF Available

Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the United States?

Authors:
Paul Denning
Paul Denning
Paul Denning
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Elizabeth Dinenno at Centers for Disease Control and Prevention
Elizabeth Dinenno
Download file PDF
Read file
Download citation

Abstract

Results from National HIV Behavioral Surveillance among high risk heterosexuals in the United States, CDC.
Content uploaded by Elizabeth Dinenno
Author content
All content in this area was uploaded by Elizabeth Dinenno on Jun 06, 2017
Content may be subject to copyright.
Communities in Crisis: Is There a Generalized HIV Epidemic
in Impoverished Urban Areas of the United States?
Paul Denning, MD, MPH and Elizabeth DiNenno, PhD
METHODS
Background
According to UNAIDS, the United States (U.S.) has a concentrated
HIV epidemic, primarily among men who have sex with men (MSM)
and injection drug users (IDUs).1,2 While the HIV epidemic has not
had a broad impact on the general U.S. population, it has greatly
affected the economically disadvantaged in many urban areas. We
sought to characterize the HIV epidemic in impoverished urban
areas of the U.S. and determine whether the epidemic in these
areas meets the UNAIDS definition of a generalized epidemic.
UNAIDS Definitions
Concentrated HIV Epidemic: The HIV prevalence rate is <1% in the general
population, but >5% in at least one high-risk subpopulation, such as MSM, IDUs,
commercial sex workers (CSWs), or the clients of CSWs.
Generalized HIV Epidemic: The HIV prevalence rate is >1% in the general
population.
National HIV Behavioral Surveillance System for
Heterosexuals ±Round 1 (NHBS-HET-1)
ƔAnonymous, cross-sectional interview of men and women 18 í50
years old who had an opposite-gender sex partner in the past year.
ƔConducted in 25 cities throughout the U.S. from September 2006
to October 2007.
ƔSurvey topics included demographic characteristics, sexual
behavior, drug and alcohol use, HIV testing, sexually transmitted
diseases, health conditions, and the use of prevention services.
ƔAnonymous HIV testing was offered to all participants.
ƔParticipants were recruited using two methodologies: respondent-
driven sampling (RDS) and venue-based sampling (VBS).
ƔRecruitment efforts targeted census tracts with high rates of
SRYHUW\DQG+,9GLDJQRVLVFDOOHG³+LJK5LVN$UHDV´+5$V
±For RDS, only HRA residents were allowed to recruit other
participants.
±For VBS, recruitment venues were located in HRAs.
Analysis Sample
Ɣ/LYHGLQDSRYHUW\DUHDFHQVXVWUDFWZKHUH 20% of residents
had household incomes below the U.S. poverty level).
ƔConsented to HIV testing (98%) and had a valid HIV test result
(99%).
ƔResided in one of 23 cities with complete NHBS-HET-1 and
census tract data.
±Northeastern Region: Boston, Nassau/Suffolk Counties, New
Haven, New York City, Newark, and Philadelphia.
±Southern Region: Atlanta, Baltimore, Dallas, Fort Lauderdale,
Houston, Miami, New Orleans, and Washington, DC.
±Midwestern Region: Chicago, Detroit, and St. Louis.
±Western Region: Denver, Las Vegas, Los Angeles, San Diego,
San Francisco, and Seattle.
Data available
Data not availabl e
ƔNot a member of a high-risk sub-population (MSM, IDUs, CSWs,
or CSW clients).
Statistical Analysis
ƔAssociations with HIV prevalence were examined using chi-
VTXDUH)LVKHU¶VH[DFWWHVWDQGPXOWLSOHORJLVWLFUHJUHVVLRQ
ƔBecause outcomes did not differ by recruitment method (RDS
or VBS), data were combined in this analysis.
RESULTS
PLEASE NOTE: The data presented in this poster have been updated from the data presented in the published abstract.
Of 18,430 NHBS-HET-1 participants, 9,078 (49%) met our analysis criteria
and lived in urban poverty areas; 188 (2.1%) of whom had a positive HIV
test result. This HIV prevalence rate is more than 20 times greater than
the rate among all heterosexuals in the U.S. (0.1%).2,3
HIV Prevalence,
by Demographic Characteristics
Demographic characteristics significantly associated with HIV prevalence
were age, education, annual household income, poverty level, employment,
homeless status, and region. Multivariate modeling identified the same
predictors of HIV prevalence (data not shown).
HIV Prevalence Rate, by Country
Burundi Haiti
Percent HIV-positive
Ethiopia AngolaU.S.
Poverty
Areas
0.0
0.5
1.0
1.5
2.0
2.5
Data Sources: NHBS-HET-1 2006 í2007 and UNAIDS HIV Estimates 2007.1
The 2.1% HIV prevalence rate found in urban poverty areas in the U.S.
exceeded the 1% cut-off that defines a generalized HIV epidemic and is
similar to the rates found in several low-income countries that have
generalized HIV epidemics.1
HIV Prevalence Rate, by Income
10 í19,999 20 í49,999 50,000
Annual Household Income (in U.S. Dollars)
0í9,999
Percent HIV-positive
0
1
2
3
Data Source: NHBS-HET-1 2006 í2007.
HIV prevalence rates in urban poverty areas were inversely related to
annual household income-- the lower the income, the greater the HIV
prevalence rate.
This inverse relationship between HIV prevalence and socioeconomic
status (SES) was observed for all SES metrics examined (education,
annual household income, poverty level, employment, and homeless
status).
HIV Prevalence Rate, by Race/Ethnicity
0.0
0.5
1.0
1.5
2.0
2.5
U.S. Overall
U.S. Poverty Areas
Black Hispanic White
Percent HIV-positive
HIV prevalence rates in urban poverty areas did not differ significantly by
race or ethnicity. This contrasts with the substantial racial and ethnic
differences found in rates for the overall U.S. population (which includes
high-risk sub-populations). For the overall U.S. population, the HIV
prevalence rate for blacks (1.7%) is more than 8 times the rate for whites
(0.2%), and the rate for Hispanics (0.6%) is 3 times the rate for whites.2
Poverty may account for some of the racial and ethnic disparities found in
HIV prevalence rates for the overall U.S. population-- 46% of blacks and
40% of Hispanics live in poverty areas compared to just 10% of whites.4
Data Sources: NHBS-HET-1 2006 í2007 and U.S. HIV Prevalence Estimates 2006.2
References
1UNAIDS. 2008 report on the global AIDS epidemic 2008.
2CDC. HIV prevalence estimates±United States, 2006. MMWR
2008;57:1073-76.
3U.S. Census Bureau. Annual estimates of the resident population
by sex and selected age groups for the United States: April 1, 2000
to July 1, 2008. NC-EST2008-02 2009.
4U.S. Census Bureau. Areas with concentrated poverty: 1999.
Census 2000 Special Reports 2005.
DISCUSSION
Limitations
ƔSince NHBS-HET-1 is a convenience sample drawn from selected
cities, the urban poverty area residents who participated in the
survey may not be representative of all urban poverty area
residents in the U.S.
±Nevertheless, our analysis sample included demographically
diverse participants from a large number (23) of cities throughout
the U.S.
ƔOur findings are not generalizable to non-urban poverty area
residents.
ƔBecause NHBS-HET-1 targeted census tracts with high rates of
poverty and HIV diagnosis (HRAs), our results may overestimate
the HIV prevalence rate in urban poverty areas.
±However, despite this potential bias, we found that HIV preva-
lence rates did not differ significantly between participants who
were residents of HRAs (2.1%) and those who were not (2.0%).
Conclusions
ƔThe HIV prevalence rate among NHBS-HET-1 participants living
in urban poverty areas was very high (2.1%) and exceeded the
1% cut-off that defines a generalized HIV epidemic.
ƔHIV prevalence rates in urban poverty areas were inversely
related to socioeconomic status (SES)-- the lower the SES, the
greater the HIV prevalence rate.
ƔUnlike overall HIV prevalence rates in the U.S., HIV prevalence
rates in urban poverty areas did not differ significantly by race or
ethnicity.
Recommendations
ƔHIV prevention efforts should be expanded in urban poverty
areas in the U.S.
±Community-level interventions, in particular, would be ideal for
these foci of high HIV prevalence.
±Structural interventions to improve socioeconomic conditions in
these areas may reduce HIV infection rates.
ƔSpatial analysis should be used to identify areas of low
socioeconomic status for targeting HIV prevention activities for
heterosexuals at increased risk of HIV infection.
ƔThe impact of the HIV epidemic in non-urban poverty areas
should be assessed, especially in the Southern Region of the
U.S. where there are high levels of rural poverty.
Contact Information
Address: 1600 Clifton Road, MS E-46
Atlanta, GA 30333, USA
E-mail: pdenning@cdc.gov
The findings and conclusions in this poster are those of the authors
and do not necessarily represent the official position of the CDC.
... These refer broadly and dynamically to contextual factors and the position people occupy in a social hierarchy based on their intersecting systems of oppression and social determinants of health like gender, race/ethnic, and class inequities; geographic location; and HIV-related stigma [6,[8][9][10]. Structural and social factors such as poverty, geographic location and HIV-related stigma are driving factors in the differences by race and ethnicity [11][12][13][14]. Black/African American and Latina/Hispanic women, hereafter referred to as Black and Latina, are disproportionately poorer than other subpopulations in the US [15], a significant precipitating factor for acquiring HIV [12][13][14] and subsequent suboptimal treatment and care outcomes [14]. ...
... Structural and social factors such as poverty, geographic location and HIV-related stigma are driving factors in the differences by race and ethnicity [11][12][13][14]. Black/African American and Latina/Hispanic women, hereafter referred to as Black and Latina, are disproportionately poorer than other subpopulations in the US [15], a significant precipitating factor for acquiring HIV [12][13][14] and subsequent suboptimal treatment and care outcomes [14]. Moreover, since 2008, HIV diagnoses and mortality rates have consistently been the highest in the South, an area affected by high poverty rates, racial inequities, regional resource inequities, and a cultural climate that likely fosters HIV-related stigma [16]. ...
Social Location and Decision-Making Among Women Living with HIV in the Southern United States: An Intersectional Approach
Article
Full-text available
HIV care engagement and antiretroviral therapy (ART) adherence interventions aimed at decreasing viral suppression disparities for women living with HIV (WLWH) in the Southern United States (i.e., the South) are few and seldom consider diverse social locations. These refer broadly and dynamically to contextual factors and the position people occupy in a social hierarchy based on intersecting systems of oppression and social determinants of health like gender, race/ethnic, and class inequities; geographic location; and HIV-related stigma. Using an intersectional approach, we conducted in-depth interviews and used a phased approach to directed content analysis to describe women’s perceptions of their social location and how it impacts their decision-making about HIV care engagement and ART adherence. Participants were recruited to participate from a broad geographic area and represented the diverse social locations occupied by WLWH in the South. Findings from 40 in-depth interviews include descriptions of how geographic context impacts HIV care engagement and medication adherence through access to care, quality of care, and the place-based context of day-to-day experiences of living with HIV. Participants spoke of multilevel power relationships based on their gender and racial identities, and how social determinants and intersecting identities occur simultaneously and vary as a function of one another to impact health and HIV care decision-making. The findings offer a nuanced understanding of how WLWH perceive their contextually specific social locations and make critical decisions about their HIV care engagement and medication adherence.
View
... Given our interest in vulnerable populations and the expressed concerns about research payments to educationally and economically disadvantaged individuals being potentially coercive [2,13,20] and payments being used to purchase drugs or alcohol [11,12], we sampled studies on HIV/AIDs and studies funded by the National Institute of Mental Health (NIMH) [21,22]. We chose to sample HIV/AIDS studies because, in the United States, people at risk for or living with HIV/AIDS are disproportionately members of historically marginalized groups and economically disadvantaged [23,24]. Substance use is an important risk factor HIV/AIDS [21,22]. ...
A taxing problem: The impacts of research payment practices on participants and inclusive research
Article
Full-text available
Empirical data regarding payments to participants in research is limited. This lack of information constrains our understanding of the effectiveness of payments to achieve scientific goals with respect to recruitment, retention, and inclusion. We conducted a content analysis of consent forms and protocols available on clinicaltrials.gov to determine what information researchers provide regarding payment. We extracted data from HIV (n = 101) and NIMH-funded studies (n = 65) listed on clinicaltrials.gov that had publicly posted a consent form. Using a manifest content analysis approach, we then coded the language regarding payment from the consent document and, where available, protocol for purpose and method of the payment. Although not part of our original planned analysis, the tax-related information that emerged from our content analysis of the consent form language provided additional insights into researcher payment practices. Accordingly, we also recorded whether the payment section mentioned social security numbers (or other tax identification number) in connection with payments and whether it made any statements regarding the Internal Revenue Service or the tax status of payments. We found studies commonly offered payment, but did not distinguish between the purposes for which payment may be offered (i.e., compensation, reimbursement, incentive, or appreciation). We also found studies that excluded some participants from receiving payment or treated them differently from other participants in the study. Differential treatment was typically linked to US tax laws and other legal requirements. A number of US studies also discussed the need to collect Social Security numbers and income reporting based on US tax laws. Collectively, these practices disadvantage some participants and may interfere with efforts to conduct more inclusive research.
View
... Differences by HIV status also exist in demographic characteristics that influence health outcomes. HIV disproportionately affects minority and socioeconomically disadvantaged communities (31,32), resulting in differences in racial composition and healthcare coverage by HIV status. In 2019, an estimated 40% of PLWH in the US were non-Hispanic Black individuals, who account for only 12% of the general population (33,34). ...
Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states
Preprint
Full-text available
  • May 2024
Background Prostate cancer is projected to be the most common cancer among people living with HIV; however, incidence of prostate cancer has been reported to be lower in men with HIV compared to men without HIV with little evidence to explain this difference. We describe prostate cancer incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Methods Medicaid beneficiaries (N=15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and prostate cancer were identified using inpatient and other non-drug claims. We estimated cause-specific (csHR) and sub-distribution hazard ratios comparing incidence of prostate cancer by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions. Models were additionally stratified by age and race-ethnicity. Results There were 366 cases of prostate cancer observed over 299,976 person-years among beneficiaries with HIV and 17,224 cases over 22,298,914 person-years in beneficiaries without HIV. The hazard of prostate cancer was lower in men with HIV than men without HIV (csHR=0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR=0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR=0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR=1.17; 95% CI: 0.91, 1.50). Results were similar in models restricted to ages 50-64 and 40-49, except for a higher hazard of prostate cancer in Hispanic men with HIV in their 40s, while the hazard of prostate cancer was higher in men with HIV across all models for men aged 18-39. Conclusion Reported deficits in prostate cancer incidence by HIV status may be restricted to specific groups defined by age and race-ethnicity.
View
... Indeed, a recent modeling study comparing ART strategies among virally nonsuppressed patients with adherence barriers found that-with INSTI-based oral ART plus intensive adherence support-projected VS at 3 years would be merely 38% [16]. This VS rate is far short of the UNAIDS 95:95:95 targets, which call for 86% populationlevel viral suppression among all persons with HIV worldwide by 2025 [17]. For patients with NNRTI resistance and for whom oral ART remains a challenge, additional LA ART options are needed. ...
Case Series of People With HIV on the Long-Acting Combination of Lenacapavir and Cabotegravir: Call for a Trial
Article
Full-text available
  • Apr 2024
Background Injectable cabotegravir (CAB)/rilpivirine (RPV) is the only combination long-acting (LA) antiretroviral regimen approved for HIV. RPV may not be effective among individuals with non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance, which has >10% prevalence in many countries. Lenacapavir (LEN) is an LA capsid inhibitor given every 6 months, but has not been studied in combination with other LA agents. Methods We assembled a case series from 4 US academic medical centers where patients with adherence challenges were prescribed LEN subcutaneously every 26 weeks/CAB (+/− RPV) intramuscularly every 4 or 8 weeks. Descriptive statistics, including viral load (VL) outcomes, were summarized. Results All patients (n = 34: 76% male; 24% cis/trans female; 41% Black; 38% Latino/a; median age [range], 47 [28–75] years; 29% and 71% on CAB every 4 or 8 weeks) reported challenges adhering to oral ART. The reasons for using LEN/CAB with or without RPV were documented or suspected NNRTI mutations (n = 21, 59%), integrase mutations (n = 5, 15%), high VL (n = 6, 18%), or continued viremia on CAB/RPV alone (n = 4, 12%). Injection site reactions on LA LEN were reported in 44% (32% grade I, 12% grade 2). All patients but 2 (32/34; 94%) were suppressed (VL <75 copies/mL) after starting LEN at a median (range) of 8 (4–16) weeks, with 16/34 (47%) suppressed at baseline. Conclusions In this case series of 34 patients on LEN/CAB, high rates of virologic suppression (94%) were observed. Reasons for using LEN/CAB included adherence challenges and underlying resistance, mostly to NNRTIs. These data support a clinical trial of LEN/CAB among persons with NNRTI resistance.
View
The Danger of a Single Story: A Case for (Re)Centering Black Women and HIV in Higher Education
Article
  • Nov 2024
Although HIV rates are statistically stable, meaning the number of new acquisitions has remained relatively flat, the impact of the epidemic is uneven. Black women between the ages of 13 and 34 are more likely to acquire HIV, suggesting intervention during college is an ideal HIV mitigation strategy. Moreover, far too few Black women who could benefit from biomedical interventions have them or know about them. In this piece, I explore the current landscape and context of HIV and the college environment for Black women, revealing the social, cultural, and epistemic need to restory and better nuance the HIV crisis. I elucidate how and why the college context is a particularly vital space for HIV‐related health equity and the possibilities for transformation through teaching, research, practice, and policies around HIV and Black women.
View
An observational cohort study evaluating PrEP reach, engagement and persistence through a community‐based mobile clinic in Miami‐Dade County, Florida
Article
Full-text available
  • Oct 2024
Introduction Barriers to pre‐exposure prophylaxis (PrEP) access have limited its reach to priority populations. Community‐based mobile clinics have potential to broaden PrEP engagement. We evaluated reach and persistence for fixed and mobile clinic cohorts in Miami‐Dade County, Florida. Methods This observational cohort study analysed data from 1896 clients engaged through our fixed or mobile clinic from August 2018 to March 2023. Services were offered at no cost to clients. The same staff and package of barrier‐lowering strategies was deployed across fixed and mobile clinic sites. Chi‐square and Fisher's exact test or the Kruskal–Wallis test were used to test for differences in characteristics across sites as well as across services sought. Kaplan–Meier curves were generated to evaluate persistence on PrEP and in care, defined as completion of at least one clinic visit (including PrEP prescribing, for PrEP persistence, or for any reason, for persistence in care) within 24 weeks of the prior visit. Cox proportional hazards models were used to evaluate risk factors for discontinuation of PrEP or clinic care by 48 weeks by gender, race, ethnicity, insurance status and site. Results The fixed and mobile clinics reached 781 and 1109 clients, respectively, during the study period. The median client age was 35 years; the majority (70.4%) of clients were cisgender men, identified as Hispanic/Latino (62.5%) and were men who have sex with men (54.5%). The mobile clinic extended reach to a higher proportion of cisgender women (32.1% mobile vs. 12.9% for fixed clinic), Black clients (34.5% vs. 13.1%) and older clients (median 37 vs. 33 years) compared with the fixed setting. Uninsured individuals, men and those who initiated services in the mobile clinic were more likely to continue PrEP to 48 weeks (HR: 1.20, p = 0.01; HR: 2.02, p<0.01; HR: 1.68, p<0.01, respectively). Persistence did not differ by race or ethnicity. Conclusions A mobile clinic strategy for PrEP engagement can increase reach to key populations underrepresented in HIV prevention care including cisgender women and Black clients. Persistence in PrEP was increased for the mobile clinic cohort, suggesting an additional benefit to this modality beyond other barrier‐lowering strategies employed in our fixed and mobile clinics.
View
Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states
Article
Prostate cancer (PCa) incidence is reportedly lower in men with HIV compared to men without HIV for unknown reasons. We describe PCa incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Men (N = 15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and PCa were identified using non-drug claims. We estimated cause-specific (csHR) comparing incidence of PCa by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions, and stratified by age and race-ethnicity. Hazard of PCa was lower in men with HIV than men without HIV (csHR = 0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR = 0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR = 0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR = 1.17; 95% CI: 0.91, 1.50). Findings were similar in models restricted to men aged 50-64 and 40-49, but not in men aged 18-39. Reported deficits in PCa incidence by HIV status may be restricted to specific groups defined by age and race ethnicity.
View
AIDS Activism and the Pharmaceutical Industry
Article
Full-text available
  • Jun 2024
The intersection of AIDS activism and the pharmaceutical industry has been pivotal in remodeling public health responses and treatment accessibility for HIV/AIDS. In the Eighties and Nineteen Nineties, AIDS activists and considerable organizations like ACT UP played an essential role in the pharmaceutical industry's regulations and practices. these activists demanded quicker drug approval methods, low-cost medicinal drug pricing, and increased transparency in clinical trials. Their advocacy brought about extensive policy adjustments, which included the elevated approval process by using the U.S. Meals and Drug Administration (FDA) and the implementation of the 340B Drug Pricing application, which made medicines less expensive for underserved populations.The activism now not only compelled pharmaceutical industry to lower expenses but additionally stimulated the enterprise's research and improvement priorities, resulting in an extra�targeted attempt at HIV/AIDS remedies. Furthermore, the collaboration among activists, scientists, and healthcare providers fostered an environment conducive to large scientific breakthroughs, inclusive of the improvement of antiretroviral remedies (art), which has converted HIV/AIDS from a deadly disease to a doable, persistent situation.This dynamic interaction between activism and industry highlights the significance of civic engagement in shaping healthcare coverage and advancing scientific research
View
View
View
HIV prevalence estimates United States
  • Jan 2006
  • 1073-1076
  • Cdc
CDC. HIV prevalence estimates United States, 2006. MMWR 2008;57:1073-76.
Annual estimates of the resident population by sex and selected age groups for the United States
  • Apr 2000
  • U S Bureau
U.S. Census Bureau. Annual estimates of the resident population by sex and selected age groups for the United States: April 1, 2000 to July 1, 2008. NC-EST2008-02 2009.
Areas with concentrated poverty: 1999. Census
  • Jan 2000
  • U S Bureau
U.S. Census Bureau. Areas with concentrated poverty: 1999. Census 2000 Special Reports 2005.