Improving Outcomes Along the HIV Care Continuum: Paying Careful Attention to the Non-Biologic Determinants of Health

More and more, we realize that behavioral, social, economic, and environmental factors interact with biologic conditions and life circumstances to substantially influence health outcomes for individuals, families, and communities.¹ But recognizing the fact that health is much more than the mere absence of disease is not a new concept. In fact, the preamble to the constitution of the World Health Organization, adopted in 1946, states this premise explicitly.² In our own time, this notion of health as a complete and holistic state of well-being is most readily evident in the increasingly urgent calls to address the social determinants of health, especially as they relate to health disparities and inequities.

The current focus on health disparities and inequities across the continuum of human immunodeficiency virus (HIV) care—from timely diagnosis through regular receipt of optimal treatment resulting in viral suppression—is once again forcing us to confront the many factors beyond biology that affect health outcomes. Scientists from the U.S. Centers for Disease Control and Prevention (CDC) used national HIV surveillance data from 19 jurisdictions with complete reporting of CD4+ and viral load (VL) test results to assess state-level differences in HIV diagnosis, retention in care, and viral suppression. They found that while 80% of people who were diagnosed with HIV were linked to care within three months, in all 19 jurisdictions, a large percentage of people living with HIV (PLWH) were not receiving ongoing care; by jurisdiction, the percentage of people with a suppressed VL ranged from 14.3% to 55.7%, with an average of 43.4%.³ Although this analysis did not allow for the investigation of specific factors associated with disparities across the care continuum, the investigators noted that social and economic barriers, as well as behaviors, likely explain many of these differences.

An earlier analysis conducted by CDC used data from both the National HIV Surveillance System and the Medical Monitoring Project to estimate nationally, for various subpopulations, the percentages of PLWH who were aware of their HIV diagnosis, retained in care, prescribed antiretroviral therapy, and had achieved viral suppression. Their analysis found that the estimated percentages of black and Hispanic or Latino people who were aware of their HIV infection were lower than that of white people, and also revealed significant age disparities at each step of the HIV care continuum, with younger people less likely than older people to have received an HIV diagnosis or to have a suppressed VL.⁴

We know that a variety of factors can influence outcomes at each stage of the HIV care continuum, including poverty and lack of health insurance,⁵ homelessness,⁶ food insecurity,⁷ substance use,⁸ mental health problems and accumulated lifetime trauma,⁹ deficits in health literacy (e.g., not understanding the importance of adherence to antiretroviral medication),¹⁰ and stigma related to HIV and/or the behaviors placing one at risk for infection.¹¹ Recognizing that a single strategy or approach cannot address all of these barriers is a major reason why President Obama issued Executive Order 13649 on July 15, 2013, calling for the establishment of an HIV Care Continuum Initiative to “identify potential impediments to improving outcomes along the HIV care continuum” and “recommend ways to integrate (federal) efforts to improve outcomes.”¹²

In response to the Executive Order, leaders from across the federal government engaged in a process to actively review current programs, policies, and research findings. Based on this assessment, they developed an initial set of 21 specific federal actions to promote improvements along the HIV care continuum.¹³ These actions, which were released on World AIDS Day 2013, can be broadly summarized as follows:

• Develop and assess innovative models of HIV care, especially for vulnerable populations;

• Tackle misconceptions and stigma that act as barriers to HIV care;

• Strengthen the collection and use of data to improve HIV health outcomes;

• Prioritize research to address gaps in knowledge along the HIV care continuum; and

• Provide information, training, and technical assistance to strengthen comprehensive HIV services at state and local levels.

Truly, the many issues hindering the receipt of timely and comprehensive HIV care among vulnerable populations will not be easily resolved, but the previously outlined actions are already beginning to influence our public health priorities. For example, the Health Resources and Services Administration recently announced funding to support the identification and dissemination of best practices and effective models of HIV care for black men who have sex with men—a group disproportionately impacted by HIV disease.¹⁴ Additionally, in early spring 2014, CDC announced available funding for health departments to work collaboratively with community health centers to use state HIV surveillance data and health center electronic health record data to improve HIV health outcomes for PLWH, by expanding HIV linkage, retention, and reengagement services.¹⁵

These are two examples among many signifying an ongoing shift from older paradigms of HIV prevention and care that focused exclusively on the biologic determinants of health to newer—and admittedly more challenging—models that recognize the importance of addressing various social determinants that influence our collective ability to achieve healthy outcomes for individuals, families, and communities. As observed by other public health leaders, commenting on the increasing influence of social determinants of health, this paradigm shift does not minimize the need for high-quality biomedical services, but it will require that public health develop and sustain “strong governmental and intersectoral leadership and collaboration.”¹⁶ In short, if we want to improve outcomes along the HIV care continuum in the United States, we must be willing to embrace and reckon with all of the factors that contribute to health status, not just biology.