Evaluating the impact of neighborhood-level poverty on racial disparities in HIV outcomes

Background: Racial disparities in HIV outcomes persist despite the advent of highly active anti-retroviral therapy (HAART). Because poverty and resource distribution may play a role in racial health disparities, we examined the relationship between neighborhood-level poverty, virologic failure, and race. Methods: We evaluated patients in the Center for AIDS Research Clinical Cohort initiating HAART between 2000-2009. We dichotomized neighborhood poverty (the exposure variable) as US census tracts with < or ≥ 15% of residents living below the poverty line; multivariable logistic regression (adjusted for age, gender and initial viral load) assessed the impact of neighborhood poverty on the relationship between race and virologic failure (viral load>400 copies/mL, 12-18 months after HAART initiation). Results: Of 490 patients (37.3% white; 62.7% black), 24.7% experienced virologic failure (28.1% white; 71.9% black). A greater proportion of blacks than whites (16% vs. 12%; p<0.001) lived in neighborhoods with ≥15% poverty. In neighborhoods with <15% poverty, blacks were more likely to fail than whites (OR 3.21, 95% CI 1.60-6.47); blacks and whites failed at similar rates in neighborhoods with ≥15% poverty (OR 0.75, 95% CI 0.40-1.43). Blacks residing in neighborhoods with <15% poverty were as likely to experience virologic failure as blacks residing in higher poverty neighborhoods (OR 0.81, 95% CI 0.49-1.34). Conclusions: Blacks were more likely than whites to experience virologic failure in wealthier neighborhoods but were as likely to fail as blacks in poorer neighborhoods. Further studies should determine why improved HIV outcomes were not seen in blacks residing in neighborhoods with less poverty.