In the South, Patients with HIV Face Additional Hurdles

New research finds patients with HIV living in 5 southern states had lower rates of viral suppression and linkage to care compared to people in northern states.

Morgan M. Philbin, PhD, MHS

New research makes the case that HIV disparities are not only dependent on individual actions and socioeconomic factors, but also on geography.

The study looked at outcomes for patients with HIV in 11 cities, 5 in southern states and 6 in non-southern states. Those in the southern states had lower rates of viral suppression and a higher likelihood of having CD4+ cell counts below 200 cells/µl. Southern patients were also less likely to be connected with regular HIV care, something the investigators suggested was linked with less robust social safety nets in those states.

“This study among hospitalized HIV-infected participants across 11 sites in the United States found that while participants living in southern sites had lower rates of problematic drug and alcohol use, they were less likely to report care engagement and more likely to have worse HIV outcomes,” wrote Morgan M. Philbin, PhD, MHS, and colleagues. Dr. Philbin is an assistant professor of sociomedical sciences at Columbia University.

The analysis is based on 1227 patients who participated in the Project HOPE study, and who were recruited prior to the study’s pre-screening process. The data showed that nearly two-thirds of participants who were recruited from the southern hospitals had a detectable viral load, while only half of those in non-southern states had not achieved viral suppression.

The sites in the southern cohort were in the states of Georgia, Maryland, Alabama, Texas, and Florida. The non-southern states were Massachusetts, Illinois, California, New York, and Pennsylvania. Two study sites in Pennsylvania were included, 1 in Pittsburgh and 1 in Philadelphia.

The majority of study participants were low income and ethnic/racial minorities, and most faced one or more economic hardship, such as unemployment, food insecurity, or lack of education.

“These problems may be particularly acute in southern sites, where social safety net programs to address these issues may be especially underfunded or unavailable,” the authors said. For instance, of the 5 southern states included in the study, only Maryland opted to expand its Medicaid program under the Affordable Care Act. All of the non-southern states did so.

Dr. Philbin told Contagion® that the complexity of factors suggests a wide-ranging approach is necessary to close the outcome gap.

“If public health practitioners only worked within their specific field, we would only be able to make incremental changes,” she said. “However, if we’re able to work with people in, for example, criminal justice, education, urban planning, and social work, and form coalitions that fight for structural-level policy changes, then we can maximize our impact.”

The study noted that the outcome gap could also have to do with social factors like attitudes about HIV, homosexuality, and race, as well as the prevalence of abstinence-only education in some areas.

“These contextual factors have been shown to be associated with suboptimal health care engagement, medication adherence, and awareness of HIV prevention measures such as pre-exposure prophylaxis,” the authors wrote.

The disparities may not only be linked to decisions and attitudes made at the state level. The authors noted differences in federal funding as well, pointing out a gap in the amount of money the federal government gives the states through its Ryan White HIV/AIDS Program.

“For instance, the amount the Ryan White Program provided per HIV-infected individual was, on average, $2912 in the southern sites in this study and $3250 in the non-southern sites,” the authors wrote, adding the caveat that overhead costs were lower in southern states.

Dr. Philbin said the research—​​​​​including this study—​​​​​make clear that major structural changes are necessary to truly solve the health disparity problem.

“I believe that we, as a public health community, need to move beyond research and focus on fighting for the policy changes that our work suggests are necessary and important,” she said.

The study was published June 16 in Clinical Infectious Diseases.