Structural barriers to comprehensive,coordinated HIV care: geographic accessibility in the US South*

Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30?min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70?min (IQR 64?min). For 368 counties in the top HIV prevalence quintile, median drive time is 50?min (IQR 61?min), exceeding 60?min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30?min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.     

Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review

Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.     

Prevention counseling should be ongoing. More education for docs needed

In rural Southern states such as South Carolina, the HIV/AIDS epidemic primarily affects low-income African American people who live miles from an urban health care clinic and from the high-tech prevention services available in large cities.     

Comparing neighborhood and state contexts for women living with and without HIV: understanding the Southern HIV epidemic

In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n?=?1,800) living with and without HIV in the Women’s Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants’ addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28–39% compared to 16–23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers.     

Links between sexual trauma exposure and Quality of Life (QoL) domains among people living with HIV in the Southern United States

ABSTRACT

People living with HIV (PLHIV) in the United States (US) are more likely to experience traumatic events than non-affected peers. Sexual violence is a unique trauma that has important implications for HIV-related treatment and care. The aim of the current study was to examine links between sexual violence and Quality of Life (QoL) among PLHIV in South Carolina – a Southern state that is disproportionately impacted by the HIV epidemic. Specifically, we surveyed 402 PLHIV about their past exposure to sexual traumas and their current QoL across multiple domains. Results indicated that women living with HIV were more likely to have experienced sexual trauma than men. Participants with histories of sexual trauma reported poorer overall QoL, as well as less satisfaction with their health. Multiple regression analyses indicated that exposure to sexual violence was associated with lower QoL in four of six domains, including psychological functioning, independence, social relationships, and environment. Sexual trauma was not associated with physical health QoL in the current study. Surprisingly, sexual trauma was associated with higher spiritual QoL. Findings support the need to screen PLHIV for sexual trauma exposure, adopt trauma-informed practices, and ensure that all PLHIV have access to comprehensive psychological services when indicated.     

Impact of nativity and race on "Stroke Belt" mortality.

The southeastern region of the United States has been recognized for 6 decades as an area of excess cerebrovascular mortality rates. While the reasons for the disease variation remain an enigma, South Carolina has consistently been the forerunner of the "Stroke Belt." To determine the effects of nativity (birthplace) on stroke mortality rates in South Carolina, proportional mortality ratios (PMRs) were calculated for stroke deaths in South Carolina during 1980-1996 according to birthplace and stratified by gender, race, age, and educational status. The analyses revealed a graded risk of stroke by birthplace, with the highest PMRs (95% CI) among individuals born in South Carolina (104.8 [103.4 to 106.3]), intermediate PMRs in those born in the Southeast other than South Carolina (92.5 [90.2 to 94.9]), and lowest PMRs for those born outside the Southeast (77.4 [74.9 to 80.1]). The lower stroke PMRs for individuals born outside the Southeast were more striking in blacks (51.8 [45.2 to 59.3]) than in whites (84.9 [82.0 to 88.0]) and for men (73.3 [69.5 to 77.3]) than women (83.5 [79.9 to 87.3]). The findings, particularly in blacks, were not explainable by gender, differences in age, and/or markers of educational and socioeconomic status. These findings suggest that nativity is a significant risk marker for the geographic variation in stroke mortality. Moreover, the regional disparities for nativity and subsequent stroke mortality appear to be greater in blacks than in whites and for men than for women. An understanding of factors linking birthplace to risk for cerebrovascular mortality could facilitate efforts directed at stroke prevention.     

Concurrent HIV/AIDS diagnosis increases the risk of short-term HIV-related death among persons newly diagnosed with AIDS, 2002-2005

Despite the overall effectiveness and availability of highly active antiretroviral therapy (HAART), 1500 HIV-related deaths still occur annually in New York City. In considering ways to further reduce deaths, we assessed the contribution of concurrent HIV/AIDS diagnosis to HIV-related mortality in New York City among persons newly diagnosed with AIDS. We used Cox regression to conduct a retrospective cohort analysis of HIV-related mortality among 15,211 residents age 13+ reported with AIDS to the population-based HIV/AIDS registry between January 2002 and June 2005. Concurrent HIV/AIDS diagnosis was defined as a diagnosis of AIDS occurring within 1 month of initial diagnosis of HIV. HIV-related mortality was 20.2% among persons diagnosed concurrently and 12.2% among those diagnosed nonconcurrently (p < 0.0001). Concurrent HIV/AIDS was associated with more than twice the risk of HIV-related death within the 4 months after diagnosis (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.94-2.65) but no increased risk thereafter (HR 1.12, 95% CI 0.77-1.61). Other significant predictors of death included injection drug use and birth in the Caribbean or Latin America. After 4 years 11.9% of all HIV-related deaths were attributable to a concurrent HIV/AIDS diagnosis. Public health initiatives that facilitate early diagnosis of HIV may reduce HIV-related mortality by giving people the opportunity to initiate care and begin treatment with HAART before immunosuppression places them at risk for opportunistic illness and death.     

Risk factors for HIV-AIDS among youth in Cape Town, South Africa

South Africa is in the midst of a devastating HIV-AIDS epidemic and most new HIV infections occur among young adults and adolescents. The current study examined risk behaviors and HIV risk factors among young people living in a Black South African township. Using community-based outreach methods of street intercept and facility-based surveying, 113 men and 115 women age 25 and younger responded to an anonymous survey. Results showed that men (68%) and women (56%) reported HIV-related high risk sexual behaviors. Although knowledge about HIV transmission was generally high, there was evidence that misconceptions about AIDS persist, particularly myths related to HIV transmission. For young men, HIV risk factors were associated with fewer years of education, lower levels of AIDS-related knowledge, condom attitudes, and Dagga (marijuana) use. Among young women, HIV risk factors were associated with beliefs that condoms get in the way of sex and rates of unprotected vaginal intercourse. Despite adequate general AIDS knowledge and risk sensitization, South African youth demonstrated high rates of sexual practices that place them at risk for HIV infection. There is an urgent need for behavioral interventions targeted to young South Africans living in the most economically disadvantaged areas.     

Association of Substance Use With Hospitalization and Virologic Suppression in a Southern Academic HIV Clinic

Background

Persons with HIV infection who do not achieve virologic suppression contribute significantly to the ongoing HIV epidemic and have an increased risk of clinical sequelae related to immunosuppression. The extent to which substance use and mental health diagnoses affect HIV outcomes and the care continuum has not been previously assessed at the Medical University of South Carolina (MUSC), a large academic HIV clinic.

Youth mortality due to HIV/AIDS in South Africa, 2001–2009: An analysis of the levels of mortality using life table techniques

South Africa has one of the highest HIV/AIDS prevalence rates in the world. It is estimated that 5.38 million South Africans are living with HIV/AIDS. In addition, new infections among adults aged 15+ were reportedly 316 900 in 2011. New infections among children (0–14 years old) was also high in 2011 at 63 600. This paper examines South Africa's mortality due to HIV/AIDS among the youth (15–34 years old). This age group is of fundamental importance to the economic and social development of the country. However, the challenges of youth development remain vast and incomparable. One of these challenges is the impact of HIV/AIDS on mortality. Life table techniques are used to estimate among others, sex differentials in death rates for the youth population, probability of dying from HIV/AIDS before the age of 35 and life expectancy should HIV/AIDS be eradicated from the population. The study used data from the National Registry of Deaths, as collated by Statistics South Africa from 2001 to 2009. Results show that youth mortality due to HIV/AIDS has remained consistently higher among older youths than in younger ones. By sex, mortality due to this cause has also remained consistent over the period, with mortality due to HIV/AIDS being higher among females than males. Cause-specific mortality rates and proportional mortality ratios reflect the increased mortality of older youth (especially 30–34 years old) and females within the South African population. Probability of dying from HIV/AIDS shows that over the period, fluctuations in likelihood of mortality have occurred, but for both males and females (of all age groups) the chances of dying from this cause decreased in 2007–2009.     

Psychological distress and engagement in HIV-related services among individuals seeking mental health care

In the US, HIV-related mental health care has been funded for its ability to help engage and retain individuals living with HIV into other components of HIV-related care and treatment. However, little is known empirically about the types of HIV prevention and care with which they are, or need to be, connected. To explore this, data were collected from 617 individuals upon their self-enrollment in HIV-related mental health care in a large US city with high rates of HIV infection. Nearly a third of the participants (n=195) were "minimally engaged" in care services, 53% were "moderately engaged" and 15.6% were "highly engaged". There were significant differences between level of care engagement according to one's ethnicity, X(2)(4, n=617)=38.05; p<.001; Cramer's V=.18, with African-Americans and Latinos more likely to be highly engaged in care services compared to their Caucasian counterparts. Furthermore, individuals who were highly engaged in services had significantly lower levels of depression than their less engaged peers, F(2, 614)=8.18; p<.001; eta(2)=.03. Results suggest that while ethnic minorities were engaged in a higher number of care services, they were enrolling in mental health care following enrollment in other care services. Given the numerous benefits of engaging in HIV-related mental health early in the course of infection, it is important that case managers and primary care physicians educate African-Americans and Latinos on the benefits of mental health care in order to facilitate earlier engagement in HIV-related mental health services.     

Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences

Many HIV-positive individuals face multiple barriers to care and therefore frequently experience unmet medical and support services needs. Rural areas often lack the infrastructure to support the delivery of comprehensive HIV services; however, few studies have examined service barriers faced by rural residents with HIV/AIDS, particularly in the South where two-thirds of people living with HIV/AIDS in rural areas reside. We surveyed North Carolina HIV/AIDS case managers (N = 111) employed at state-certified agencies regarding barriers to medical and support services that influence medication adherence for their rural and urban-living clients. For each of the seven barriers assessed (long travel for care, HIV-related stigma, and a lack of transportation; HIV-trained medical practitioners; housing; mental health services and substance abuse treatment), a substantial proportion of case managers (29-67%) reported it was a 'major problem'. For five of the seven barriers, rural case managers were significantly more likely to identify the barrier as a 'major problem'. Multivariate analysis revealed that rural case managers and case managers with more female clients reported a greater number of barriers. Because unmet medical and support service needs may result in poorer outcomes for HIV-positive individuals, barriers to these services must be identified and addressed, particularly in rural areas which may be highly underserved.     

Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa

Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with “care” and “capability” among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.     

Population Genetic Structure of Southern Flounder Inferred from Multilocus DNA Profiles

Determination of stock structure is an important component of fisheries management; incorporation of molecular genetic data is an effective method for assessing differentiation among putative populations. We examined genetic variation in Southern Flounder Paralichthys lethostigma within and between the U.S. South Atlantic and Gulf of Mexico basins to improve our understanding of the scale of population structure in this wide-ranging species. Analysis of amplified fragment length polymorphism (AFLP) fingerprints and analysis of mitochondrial DNA (mtDNA) control region sequences found clear divergence between ocean basins. Based on mtDNA sequences, no genetic differentiation was detected within the U.S. South Atlantic at spatial scales that were broad (among states: North Carolina, South Carolina, Georgia, and Florida) or fine (among estuarine regions within North Carolina). Increased genetic resolution was observed with AFLP fingerprint data, and we found significant subdivision between nearly all Southern Flounder geographic populations, suggesting the presence of finer-scale genetic population structure within the U.S. South Atlantic. However, AFLP genetic cluster analysis also revealed evidence for a high degree of mixing within the Atlantic basin; patterns of variation, which included genetic similarity between South Carolina and Gulf of Mexico samples, were not aligned closely with geography. We examined the partitioning of genetic variation among groups by using analyses of molecular variance and found no evidence that North Carolina Southern Flounder, which are managed on the state level as a unit stock, are differentiated from the remainder of U.S. South Atlantic Southern Flounder. Our findings indicate only weak structure and the potential for basinwide mixing among Atlantic Southern Flounder, suggesting that cooperation among U.S. South Atlantic states will be essential for the effective assessment of stock dynamics and future management plans.     

Rate of new HIV diagnoses among Latinos living in Florida: disparities by country/region of birth

HIV incidence in the USA is three times higher for Latinos than for non-Latino whites. Latinos differ in educational attainment, poverty, insurance coverage, and health-care access, factors that affect HIV knowledge, risk behaviors, and testing. The purpose of this study was to identify differences in demographics, risk factors, and rate of new HIV diagnoses by birth country/region among Latinos in Florida to guide the targeting of primary and secondary prevention programs. Using Florida HIV/AIDS surveillance data from 2007 to 2011 and the American Community Survey, we compared demographic and risk factors, and calculated annual and five-year age-adjusted rates of new HIV diagnoses for 5801 Latinos by birth country/region. Compared to US-born Latinos, those born in Cuba and South America were significantly more likely to report the HIV transmission mode of MSM; those born in the Dominican Republic (DR) heterosexual transmission; and those born in Puerto Rico injection drug use. Mexican- and Central American-born Latinos were more likely to be diagnosed with AIDS within a month of HIV diagnosis. The rate of new HIV diagnoses among Latinos declined 33% from 2007 to 2011. HIV diagnoses over time decreased significantly for Latinos born in Mexico and increased nonsignificantly for those born in the DR. Although this study was limited to Latinos living in Florida, results suggest that tailoring HIV primary prevention and testing initiatives to specific Latino groups may be warranted.     

HIV health literacy,sexual behaviour and self-reports of having tested for HIV among students

Responses to the HIV epidemic leading to an increase in the number of residential care facilities for children across sub-Saharan Africa have prompted concerns that large numbers of orphaned children are being placed in institutional care. There is little empirical research into the role that institutions are playing in the provision of care to children affected by HIV in the region. This paper draws on an exploratory study of the provision of residential care for children in the context of the HIV epidemic in South Africa. The analysis characterises the population of children in a small sample of residential care facilities in four provinces, and, after identifying a disproportionate number of HIV-positive children in care, examines the circumstances that led to their admission and the nature of HIV-related interventions in the facilities. The analysis reveals missed opportunities for non-institutional placements for HIV-positive children and identifies important gaps in the HIV prevention, treatment, care, and support interventions within the facilities. The article argues that a global and local preoccupation with orphans as being the children most severely affected by HIV, and as the primary category of children requiring alternative care as a result of the HIV epidemic, may have diverted attention away from the extent to which HIV-positive children populate institutions in South Africa. Furthermore, we suggest that adjustments are required to both decision-making regarding placement of HIV-positive children requiring alternative care and the provision of HIV-related interventions in residential facilities in order to ensure an adequate response to children's health and wellbeing.     

Behavioral Factors in Assessing Impact of HIV Treatment as Prevention

The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.     

Connecting The Dots: When the Risks of HIV/STD Infection Appear High But the Burden of Infection Is Not Known—The Case of Male Latino Migrants in the Southern United States

Between 1990 and 2000, the number of Latinos in Alabama, Arkansas, Georgia, North Carolina, South Carolina, and Tennessee, states that had no or small Latino populations in 1990, increased by more than 300% on average. Several of these states (referred to as rapid growth states) have high AIDS/STD case rates. Compared to Latinos in states with well-established Latino populations and Latinos nationwide, those in rapid growth states are more often males, young, foreign-born, and recent arrivals who travel without females. The typical Latino in rapid growth states is a young male migrant. Although these migrants may be at risk of HIV/STD infection, little is known about the risk factors that affect them. To clarify this picture, a database search was conducted to identify studies of HIV/STD infection and/or risk factors among rural and urban-based Latino migrants in the six rapid growth states. This qualitative review examines ten studies that were conducted in Alabama, Georgia, North Carolina, and South Carolina. Five of the studies screened for HIV and/or syphilis infection and provide some information on risk factors; five studies describe risk factors only. Most of those studies that describe risk factors provide evidence that male Latino migrants in rural and urban settings of rapid growth states are vulnerable to HIV/STD infection through heterosexual contacts. However, many of the studies fail to provide sufficient information on other risk factors, and all but one of the studies that screened migrants for HIV or STD infection were conducted between 1988 and 1991. There is an urgent need for updated information on HIV/STD infection and the social-behavioral and situational risk factors that affect male Latino migrants in rapid growth states of the South. Electronic Supplementary Material The online version of this article (doi:) contains supplementary material, which is available to authorized users. The findings reported here were presented in part at the 16th International AIDS Conference in Toronto, Canada (13–18 August 2006), abstract number TUPE0641, and the 19th Annual East Coast Migrant Stream Forum in Myrtle Beach, South Carolina (19–21 October 2006). The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Ethnic disparities among patients with systemic lupus erythematosus in South Carolina

OBJECTIVE: To evaluate whether ethnic disparities in mortality exist among hospitalized patients with systemic lupus erythematosus (SLE) in South Carolina, USA. METHODS: Administrative data were obtained on all SLE patients (ICD-9 code 710.0) hospitalized in South Carolina between 1996 and 2003. An SLE-specific comorbidity index validated as a predictor of hospital mortality was used as a measure of overall comorbidity. Cox proportional hazards models were used to compare mortality rates between Caucasians and African Americans. Post-hoc analyses focused on determining whether disparities were present across different risk strata. RESULTS: Of 6521 hospitalized patients with SLE (5728 female, 793 male), 1280 (19.6%) died. Annual mortality rates were 21.9% among Caucasians and 25.0% among African Americans. The comorbidity index score was significantly higher among African Americans [median 2.0 (interquartile range 0.0-4.0)] versus Caucasians [median 0.0 (IQR 0.0-3.0); p < 0.0001, Wilcoxon rank-sum test]; however, even after multivariate adjustment, African Americans had a 15% increased mortality risk (hazard ratio 1.15, 95% CI 1.02-1.29, p = 0.013). The disparity was strongest among those with less comorbidity (HR 1.39, 95% CI 1.05-1.81, p = 0.017). Among patients with low comorbidity index scores (n = 3485), the annual mortality rate was 8.1% among Caucasians and 9.7% among African Americans. No ethnic differences in mortality were seen for patients with higher comorbidity. CONCLUSION: In South Carolina, ethnic disparities in SLE mortality exist, predominantly among those with the least illness severity. Studies are planned to help clarify whether access and quality of care play a role.