Structural barriers to HIV viral load suppression at an urban HIV/AIDS care center
Poor adherence to antiretroviral therapy (ART) and unsuppressed viral load (VL) continue to play a role in HIV-related morbidity, mortality, and subsequent transmission. Individual-level demographic and behavioral factors associated with adherence to ART are well documented; however, the role of structural-level factors on adherence is poorly understood.
We examined patients with ≥1 primary care visit in 2013 at a multi-site HIV care center in New York City. Individual-level variables were obtained from the electronic medical record. Structural-level variables (neighborhood poverty, neighborhood pharmacy density, and travel time to clinic) were obtained from U.S. Census American Community Survey data and Google Maps. Multilevel modeling was used to determine factors associated with unsuppressed VL, defined as VL > 200 copies/mL at most recent visit in 2013.
5232 patients were included in the analysis; 893 (17.1%) were unsuppressed. Factors associated with unsuppressed VL included younger age (18-34 vs. ≥55, AOR 2.8; 95% CI 2.2-3.6), black vs. white race (AOR 1.6; 95% CI 1.3-2.0), Medicaid managed care vs. commercial insurance (AOR 1.6; 95% CI 1.2-2.1), substance use (AOR 1.9; 95% CI 1.6-2.2), and high vs. low neighborhood poverty (AOR 1.4; 95% CI 1.1-1.8). Stable housing (AOR 0.6; 95% CI 0.5-0.8) and mental health diagnosis (AOR 0.8; 95% CI 0.7-0.9) were associated with lower odds of unsuppressed VL.
Neighborhood poverty may contribute to ART non-adherence and unsuppressed VL. Multilevel interventions focusing on structural factors may help increase rates of HIV VL suppression and lead to improvements in individual and public health outcomes.
Provision of health care to the public
Public health or related education
Public health or related organizational policy, standards, or other guidelines
Identify demographic, clinical, and behavioral factors associated with a lack of HIV viral load suppression at a large urban health center. Describe structural factors associated with a lack of HIV viral load suppression at a large urban health center. Discuss the role of neighborhood context in HIV viral load suppression.
Keyword(s): HIV/AIDS, Adherence
Qualified on the content I am responsible for because: I hold a MD and MPH and have over 10 years of experience in the field of public health and HIV.
Any relevant financial relationships? No
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