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. 2021 Jul 28;137(5):888–900. doi: 10.1177/00333549211029971

Linkage to HIV Medical Care and Social Determinants of Health Among Adults With Diagnosed HIV Infection in 41 States and the District of Columbia, 2017

Myrline Gillot 1,✉, Zanetta Gant 2, Xiaohong Hu 2, Anna Satcher Johnson 2
PMCID: PMC9379827  PMID: 34318733

Abstract

Objectives

To reduce the number of new HIV infections and improve HIV health care outcomes, the social conditions in which people live and work should be assessed. The objective of this study was to describe linkage to HIV medical care by selected demographic characteristics and social determinants of health (SDH) among US adults with HIV at the county level.

Methods

We used National HIV Surveillance System data from 42 US jurisdictions and data from the American Community Survey to describe differences in linkage to HIV medical care among adults aged ≥18 with HIV infection diagnosed in 2017. We categorized SDH variables into higher or lower levels of poverty (where <13% or ≥13% of the population lived below the federal poverty level), education (where <13% or ≥13% of the population had <high school diploma), and health insurance coverage (where <12% or ≥12% of the population lacked health insurance). We calculated prevalence ratios (PRs) and 95% CIs.

Results

Of 33 204 adults with HIV infection diagnosed in 2017, 78.4% were linked to HIV medical care ≤1 month after diagnosis. Overall, rates of linkage to care were significantly lower among men and women living in counties with higher versus lower poverty (PR = 0.96; 95% CI, 0.94-0.97), with lower versus higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94), and with lower versus higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

Conclusions

Increasing health insurance coverage and addressing economic and educational disparities would likely lead to better HIV care outcomes in these areas.

Keywords: human immunodeficiency virus, linkage to HIV medical care, social determinants of health, health disparity, HIV health care outcomes

More than 1.1 million people in the United States were living with HIV in 2016. 1 In 2017, almost 40 000 adults and adolescents received an HIV diagnosis. 2 Despite previous declines, the annual number of new HIV infections was stable from 2013 to 2016. 2 -4 To reduce HIV transmission in the United States, several federal initiatives were implemented, including Ending the HIV Epidemic: A Plan for America. 5 Components of these initiatives focus on efforts to increase linkage to HIV medical care and understand the social determinants of health (SDH) that affect HIV-related care outcomes. 2,6,7

After diagnosis, linkage to care is a crucial stage in the HIV care continuum. Although immediate referral to HIV care is recommended, linkage is often delayed for many people. A Centers for Disease Control and Prevention (CDC) report found lower linkage rates among Black/African American people (hereinafter referred to as Black people), adolescents and young adults aged 13-24, and males with infection attributed to male-to-male sexual conduct and injection drug use (MMSC/IDU). 8 Most research has focused on demographic characteristics such as race/ethnicity and age to describe differences in linkage to care and other HIV health outcomes; however, SDH can provide insight on other pertinent characteristics, which may help increase understanding about the effects of the shortage or absence of health and treatment resources on the HIV care continuum.

SDH are overlapping social structures and economic systems (eg, social and physical environments, health services, structural and societal factors) that contribute to health inequities. 9 Although several studies identified socioeconomic barriers among people with HIV including, but not limited to, poverty, 10 -14 lack of health insurance coverage, 15 -17 and low education level, 18 -20 few have explored associations between linkage to care and SDH in various geographic areas (urban, metropolitan, rural) of the United States. The objective of our study was to describe linkage to care among adults with diagnosed HIV by demographic and SDH characteristics at the county level.

Methods

HIV Surveillance Data

We analyzed data from CDC’s National HIV Surveillance System (NHSS) 21 for adults aged ≥18 with HIV diagnosed in 2017 to determine linkage to care within 1 month of diagnosis. 21 We measured linkage to care by documentation of ≥1 CD4+ T-lymphocyte test (CD4 test) (measured as a count in cells/μL or as a CD4 percentage of total lymphocytes) or ≥1 viral load test (measured as copies/mL) performed ≤1 month after diagnosis, the standard used by CDC. 3 Our analysis included data from 42 jurisdictions (41 states and the District of Columbia) with complete reporting of CD4 and viral load test results to CDC as of December 2018. Data from these jurisdictions represent 87.9% of all adults who received a diagnosis of HIV in the United States in 2017. We analyzed linkage to care for selected characteristics (sex at birth, age, race/ethnicity, and transmission category) and by population of residence (metropolitan [≥500 000 population], urban [50 000-499 999 population], or rural [<50 000 population]). We adjusted data in transmission category to account for people with missing data on risk factors. 22 We did not seek institutional review board approval for this study because our research was a public health activity and did not involve human subjects.

Census Data

We obtained county-level data for 3 SDH variables (federal poverty level [FPL], education level, and health insurance coverage) from the US Census Bureau’s American Community Survey (ACS) 5-year estimates. 23 We calculated the proportion of residents who were living below the FPL at any time during the 12 months before the survey response, the proportion of residents with less than a high school diploma, and the proportion of residents without health insurance or a health coverage plan.

Analysis

We linked NHSS data for adults aged ≥18 with HIV diagnosed in 2017 with ACS data by county of residence at diagnosis. We categorized SDH variables into 2 levels of poverty, education, and health insurance coverage using the median values of poverty, education, and health insurance coverage from all counties in the 42 areas as cut points. We based the cut points on the medians of the empirically derived quartiles for poverty level, education level, and health insurance coverage (13%, 12%, and 12%, respectively). We excluded cases or counties when no county information was available for the case, no SDH information was available for the county, or we could not match the county indicated in the surveillance data with a county indicated in the ACS.

We calculated prevalence ratios (PRs) and 95% CIs by using the SAS GENMOD procedure (SAS Institute, Inc) to assess significant differences in linkage to care between adults with HIV diagnosed in 2017 residing in counties at or above the SDH variable cut point and adults with HIV diagnosed in 2017 in counties below the SDH variable cut point. We assessed significance using 95% CIs, where we considered values significant if the 95% CIs did not include 1. Linkage to care within 1 month of diagnosis was the outcome category, and the low-level SDH groups (<13% living below FPL, <12% without health insurance, and <13% with <high school diploma) were the referent groups.

Results

Linkage to Care

Among adults in the 42 areas, 33 381 received an HIV diagnosis during 2017 and 33 204 (99%) met study inclusion criteria. Of the 33 204 adults included in analysis, 26 033 (78.4%) were linked to care ≤1 month after diagnosis (Table 1). Among men, by age group, the prevalence of linkage to care was lowest among men aged 18-24 (74.6%). By race/ethnicity, the prevalence of linkage was lowest among Black people (74.6%), and by transmission category, linkage was lowest among men with infection attributed to MMSC/IDU (75.5%). By county of residence, linkage was lowest among men in urban areas (77.1%).

Table 1.

HIV diagnoses and linkage to HIV medical care a within 1 month of diagnosis among adults aged ≥18, by sex at birth and selected characteristics, 41 states b and the District of Columbia, 2017 c

Characteristic Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%)
Males
Age at diagnosis, y
 18-24 6037 4501 (74.6) 1536 (25.4)
 25-34 10 015 7744 (77.3) 2271 (22.7)
 35-44 4922 3965 (80.6) 957 (19.4)
 45-54 3652 2982 (81.7) 670 (18.3)
 ≥55 2302 1881 (81.7) 421 (18.3)
Race/ethnicity
 American Indian/Alaska Native 121 101 (83.5) 20 (16.5)
 Asian 748 608 (81.3) 140 (18.7)
 Black/African American 10 615 7919 (74.6) 2696 (25.4)
 Hispanic/Latino d 7438 5896 (79.3) 1542 (20.7)
 Native Hawaiian/Other Pacific Islander 33 28 (84.8) 5 (15.2)
 White 7246 5937 (81.9) 1309 (18.1)
 Multiple races 727 584 (80.3) 143 (19.7)
Transmission category e
 Male-to-male sexual contact 22 262 17 496 (78.6) 4766 (21.4)
 Injection drug use 1066 815 (76.4) 252 (23.6)
 Male-to-male sexual contact and injection drug use 1094 826 (75.5) 268 (24.5)
 Heterosexual contact f 2480 1915 (77.2) 565 (22.8)
 Other g 25 20 (79.8) 5 (20.2)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 21 941 17 218 (78.5) 4723 (21.5)
 Urban (50 000-499 999) 3404 2624 (77.1) 780 (22.9)
 Rural (<50 000) 1583 1231 (77.8) 352 (22.2)
 Subtotal 26 928 21 073 (78.3) 5855 (21.7)
Females
Age at diagnosis, y
 18-24 818 627 (76.7) 191 (23.3)
 25-34 1726 1362 (78.9) 364 (21.1)
 35-44 1476 1140 (77.2) 336 (22.8)
 45-54 1232 998 (81.0) 234 (19.0)
 ≥55 1024 833 (81.3) 191 (18.7)
Race/ethnicity
 American Indian/Alaska Native 36 32 (88.9) 4 (11.1)
 Asian 97 73 (75.3) 24 (24.7)
 Black/African American 3795 2995 (78.9) 800 (21.1)
 Hispanic/Latino d 958 766 (80.0) 192 (20.0)
 Native Hawaiian/Other Pacific Islander 10 8 (80.0) 2 (20.0)
 White 1230 965 (78.5) 265 (21.5)
 Multiple races 150 121 (80.7) 29 (19.3)
Transmission category e
 Injection drug use 841 647 (76.8) 195 (23.2)
 Heterosexual contact f 5408 4292 (79.4) 1117 (20.6)
 Other g 26 22 (83.0) 5 (17.0)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 4983 3938 (79.0) 1045 (21.0)
 Urban (50 000-499 999) 894 716 (80.1) 178 (19.9)
 Rural (<50 000) 399 306 (76.7) 93 (23.3)
 Unknown
Subtotal 6276 4960 (79.0) 1316 (21.0)
Total 33 204 26 033 (78.4) 7171 (21.6)
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aLinkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte test or ≥1 viral load test ≤1 month after HIV diagnosis. Of 38 381 people with HIV diagnosed in 2017, 33 204 met inclusion criteria for this analysis.

bAlabama, Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

cData sources: Cohen et al 21 and US Census Bureau. 23

dHispanic/Latino can be of any race.

eData were adjusted to account for missing data on transmission category; therefore, values may not sum to row and column total.

fHeterosexual contact with a person known to have or to be at high risk for HIV infection.

gIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among women, by age group, the prevalence of linkage to care was lowest among women aged 18-24 (76.7%). By race/ethnicity, linkage was lowest among Asian people (75.3%), and by transmission category, linkage was lowest among women who injected drugs (76.8%). By county of residence, linkage was lowest among men in rural areas (76.7%).

Linkage to Care and FPL

Overall, among adults with HIV diagnosed in 2017, 21 000 (63.2%) resided in counties where ≥13% of the residents lived below the FPL (Table 2). The prevalence of linkage to care was lower among adults in counties with higher poverty than among adults in counties with lower poverty (77.1% vs 80.7%; PR = 0.96; 95% CI, 0.94-0.97).

Table 2.

Linkage to HIV medical care a within 1 month of HIV diagnosis, by federal poverty level (FPL) in county of residence, among adults aged ≥18, by sex at birth and selected characteristics, 41 states b and the District of Columbia, 2017 c

Characteristic Residence in counties where ≥13% of population lives below FPL Residence in counties where <13% of population lives below FPL Prevalence ratio d (95% CI)
Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%) Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%)
Males
Age at diagnosis, y
 18-24 4022 2973 (73.9) 1049 (26.1) 2015 1528 (75.8) 487 (24.2) 0.97 (0.95-1.01)
 25-34 6402 4862 (75.9) 1540 (24.1) 3613 2882 (79.8) 731 (20.2) 0.95 (0.93-0.97)
 35-44 3117 2449 (78.6) 668 (21.4) 1805 1516 (84.0) 289 (16.0) 0.94 (0.91-0.96)
 45-54 2177 1740 (79.9) 437 (20.1) 1475 1242 (84.2) 233 (15.8) 0.95 (0.92-0.98)
 ≥55 1370 1123 (82.0) 247 (18.0) 932 758 (81.3) 174 (18.7) 1.01 (0.97-1.05)
Race/ethnicity
 American Indian/Alaska Native 81 67 (82.7) 14 (17.3) 40 34 (85.0) 6 (15.0) 0.97 (0.83-1.15)
 Asian 326 247 (75.8) 79 (24.2) 422 361 (85.5) 61 (14.5) 0.89 (0.82-0.95)
 Black/African American 7373 5461 (74.1) 1912 (25.9) 3242 2458 (75.8) 784 (24.2) 0.98 (0.95-1.00)
 Hispanic/Latino e 4976 3879 (78.0) 1097 (22.0) 2462 2017 (81.9) 445 (18.1) 0.95 (0.93-0.97)
 Native Hawaiian/Other Pacific Islander 15 13 (86.7) 2 (13.3) 18 15 (83.3) 3 (16.7) 1.04 (0.78-1.39)
 White 3905 3158 (80.9) 747 (19.1) 3341 2779 (83.2) 562 (16.8) 0.97 (0.95-0.99)
 Multiple races 412 322 (78.2) 90 (21.8) 315 262 (83.2) 53 (16.8) 0.94 (0.88-1.01)
Transmission category f
 Male-to-male sexual contact 14 330 11 077 (77.3) 3254 (22.7) 7931 6420 (80.9) 1512 (19.1) 0.95 (0.94-0.97)
 Injection drug use 633 474 (75.0) 158 (25.0) 434 340 (78.5) 94 (21.5) 0.96 (0.89-1.02)
 Male-to-male sexual contact and injection drug use 586 429 (73.1) 158 (26.9) 508 398 (78.3) 110 (21.7) 0.93 (0.87-0.99)
 Heterosexual contact g 1521 1153 (75.8) 368 (24.2) 959 763 (79.5) 196 (20.5) 0.95 (0.91-0.99)
 Other h 18 15 (82.4) 3 (17.6) 8 6 (74.0) 2 (26.0) 1.11 (0.69-1.78)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 13 442 10 367 (77.1) 3075 (22.9) 8499 6851 (80.6) 1648 (19.4) 0.96 (0.94-0.97)
 Urban (50 000-499 999) 2398 1826 (76.1) 572 (23.9) 1006 798 (79.3) 208 (20.7) 0.96 (0.92-0.99)
 Rural (<50 000) 1248 954 (76.4) 294 (23.6) 335 277 (82.7) 58 (17.3) 0.92 (0.87-0.98)
Subtotal 17 088 13 147 (76.9) 3941 (23.1) 9840 7926 (80.5) 1914 (19.5) 0.96 (0.94-0.97)
Females
Age at diagnosis, y
 18-24 534 405 (75.8) 129 (24.2) 284 222 (78.2) 62 (21.8) 0.97 (0.90-1.05)
 25-34 1076 842 (78.3) 234 (21.7) 650 520 (80.0) 130 (20.0) 0.98 (0.93-1.03)
 35-44 908 692 (76.2) 216 (23.8) 568 448 (78.9) 120 (21.1) 0.97 (0.91-1.02)
 45-54 761 600 (78.8) 161 (21.2) 471 398 (84.5) 73 (15.5) 0.93 (0.88-0.98)
 ≥55 633 502 (79.3) 131 (20.7) 391 331 (84.7) 60 (15.3) 0.94 (0.88-0.99)
Race/ethnicity
 American Indian/Alaska Native 21 17 (81.0) 4 (19.0) 15 15 (100.0) 0 —
 Asian 44 31 (70.5) 13 (29.5) 53 42 (79.2) 11 (20.8) 0.89 (0.70-1.13)
 Black/African American 2510 1954 (77.8) 556 (22.2) 1285 1041 (81.0) 244 (19.0) 0.96 (0.93-0.99)
 Hispanic/Latino e 602 478 (79.4) 124 (20.6) 356 288 (80.9) 68 (19.1) 0.98 (0.92-1.05)
 Native Hawaiian/Other Pacific Islander 2 2 (100.0) 0 8 6 (75.0) 2 (25.0) —
 White 659 500 (75.9) 159 (24.1) 571 465 (81.4) 106 (18.6) 0.93 (0.88-0.99)
 Multiple races 74 59 (79.7) 15 (20.3) 76 62 (81.6) 14 (18.4) 0.98 (0.84-1.14)
Transmission category f
 Injection drug use 512 398 (77.8) 114 (22.2) 329 248 (75.4) 81 (24.6) 1.03 (0.95-1.11)
 Heterosexual contact g 3386 2632 (77.7) 754 (22.3) 2022 1659 (82.1) 363 (17.9) 0.95 (0.92-0.97)
 Other h 14 10 (76.5) 3 (23.5) 13 12 (89.8) 1 (10.2) 0.85 (0.60-1.20)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 2907 2254 (77.5) 653 (22.5) 2076 1684 (81.1) 392 (18.9) 0.96 (0.93-0.98)
 Urban (50 000-499 999) 667 528 (79.2) 139 (20.8) 227 188 (82.8) 39 (17.2) 0.96 (0.89-1.03)
 Rural (<50 000) 338 259 (76.6) 79 (23.4) 61 47 (77.0) 14 (23.0) 0.99 (0.86-1.15)
Subtotal 3912 3041 (77.7) 871 (22.3) 2364 1919 (81.2) 445 (18.8) 0.96 (0.93-0.98)
Total 21 000 16 188 (77.1) 4812 (22.9) 12 204 9845 (80.7) 2359 (19.3) 0.96 (0.94-0.97)
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aLinkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte test or ≥1 viral load test ≤1 month after HIV diagnosis. Of 38 381 people with HIV diagnosed in 2017, 33 204 met inclusion criteria for this analysis.

bAlabama, Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

cData sources: Cohen et al. 21

dCompares percentage linked to care within 1 month of HIV diagnosis.

eHispanic/Latino can be of any race.

fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with higher poverty than in counties with lower poverty (PR = 0.96; 95% CI, 0.94-0.97) by age, for males aged 35-44 (PR = 0.94; 95% CI, 0.91-0.96), 25-34 (PR = 0.95; 95% CI, 0.93-0.97), and 45-54 (PR = 0.95; 95% CI, 0.92-0.98); by race/ethnicity, for Asian (PR = 0.89; 95% CI, 0.82-0.95), Hispanic/Latino (PR = 0.95; 95% CI, 0.93-0.97), and White (PR = 0.97; 95% CI, 0.95-0.99) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.93; 95% CI, 0.87-0.99), males with MMSC (PR = 0.95; 95% CI, 0.94-0.97), and males with heterosexual contact (PR = 0.95; 95% CI, 0.91-0.99); and by population of residence, in rural (PR = 0.92; 95% CI, 0.87-0.98), metropolitan (PR = 0.96; 95% CI, 0.94-0.97), and urban (PR = 0.96; 95% CI, 0.92-0.99) areas.

Among females, linkage to care was lower in counties with higher poverty than in counties with lower poverty (PR = 0.96; 95% CI, 0.93-0.98) by age, for females aged 45-54 (PR = 0.93; 95% CI, 0.88-0.98) and ≥55 (PR = 0.94; 95% CI, 0.88-0.99); by race/ethnicity, for White (PR = 0.93; 95% CI, 0.88-0.99) and Black (PR = 0.96; 95% CI, 0.93-0.99) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.95; 95% CI, 0.92-0.97); and by population of residence, in metropolitan areas (PR = 0.96; 95% CI, 0.93-0.98).

Linkage to Care and Health Insurance Coverage

Overall, among adults with HIV diagnosed in 2017, 22 169 (66.8%) adults resided in counties with lower insurance coverage, where ≥12% of residents did not have health insurance (Table 3). Linkage to care was lower among adults in counties with lower health insurance coverage than among adults in counties with higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94).

Table 3.

Linkage to HIV medical care a within 1 month of HIV diagnosis, by health insurance coverage in county of residence among adults aged ≥18, by sex at birth and selected characteristics, 41 states b and the District of Columbia, 2017 c

Characteristic Residence in counties where ≥12% of population lacks health insurance Residence in counties where <12% of population lacks health insurance Prevalence ratio d (95% CI)
Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%) Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%)
Males
Age at diagnosis, y
 18-24 4121 2993 (72.6) 1128 (27.4) 1916 1508 (78.7) 408 (21.3) 0.92 (0.90-0.95)
 25-34 6713 5082 (75.7) 1631 (24.3) 3302 2662 (80.6) 640 (19.4) 0.94 (0.92-0.96)
 35-44 3324 2609 (78.5) 715 (21.5) 1598 1356 (84.9) 242 (15.1) 0.92 (0.90-0.95)
 45-54 2373 1871 (78.8) 502 (21.2) 1279 1111 (86.9) 168 (13.1) 0.91 (0.88-0.94)
 ≥55 1498 1215 (81.1) 283 (18.9) 804 666 (82.8) 138 (17.2) 0.98 (0.94-1.02)
Race/ethnicity
 American Indian/Alaska Native 93 74 (79.6) 19 (20.4) 28 27 (96.4) 1 (3.6) 0.83 (0.73-0.94)
 Asian 400 310 (77.5) 90 (22.5) 348 298 (85.6) 50 (14.4) 0.91 (0.85-0.97)
 Black/African American 7392 5428 (73.4) 1964 (26.6) 3223 2491 (77.3) 732 (22.7) 0.95 (0.93-0.97)
 Hispanic/Latino e 5590 4323 (77.3) 1267 (22.7) 1848 1573 (85.1) 275 (14.9) 0.91 (0.89-0.93)
 Native Hawaiian/Other Pacific Islander 15 12 (80.0) 3 (20.0) 18 16 (88.9) 2 (11.1) 0.90 (0.67-1.22)
 White 4126 3293 (79.8) 833 (20.2) 3120 2644 (84.7) 476 (15.3) 0.94 (0.92-0.96)
 Multiple races 413 330 (79.9) 83 (20.1) 314 254 (80.9) 60 (19.1) 0.99 (0.92-1.06)
Transmission category f
 Male-to-male sexual contact 15 064 11 553 (76.7) 3510 (23.3) 7198 5943 (82.6) 1255 (17.4) 0.93 (0.92-0.94)
 Injection drug use 571 425 (74.4) 146 (25.6) 496 390 (78.7) 106 (21.3) 0.95 (0.89-1.01)
 Male-to-male sexual contact and injection drug use 618 445 (72.1) 173 (27.9 477 381 (80.0) 95 (20.0) 0.90 (0.84-0.96)
 Heterosexual contact g 1761 1334 (75.8) 427 (24.2) 719 581 (80.8) 138 (19.2) 0.94 (0.90-0.98)
 Other h 16 13 (80.1) 3 (19.9) 10 8 (79.4) 2 (20.6) 1.01 (0.67-1.51)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 14 627 11 168 (76.4) 3459 (23.6) 7314 6050 (82.7) 1264 (17.3) 0.92 (0.91-0.94)
 Urban (50 000-499 999) 2245 1709 (76.1) 536 (23.9) 1159 915 (78.9) 244 (21.1) 0.96 (0.93-1.00)
 Rural (<50 000) 1157 893 (77.2) 264 (22.8) 426 338 (79.3) 88 (20.7) 0.97 (0.92-1.03)
Subtotal 18 029 13 770 (76.4) 4259 (23.6) 8899 7303 (82.1) 1596 (17.9 0.93 (0.92-0.94)
Females
Age at diagnosis, y
 18-24 565 419 (74.2) 146 (25.8) 253 208 (82.2) 45 (17.8) 0.90 (0.84-0.97)
 25-34 1154 883 (76.5) 271 (23.5) 572 479 (83.7) 93 (16.3) 0.91 (0.87-0.96)
 35-44 965 730 (75.6) 235 (24.4) 511 410 (80.2) 101 (19.8) 0.94 (0.89-0.99)
 45-54 807 640 (79.3) 167 (20.7) 425 358 (84.2) 67 (15.8) 0.94 (0.89-0.99)
 ≥55 649 499 (76.9) 150 (23.1) 375 334 (89.1) 41 (10.9) 0.86 (0.82-0.91)
Race/ethnicity
 American Indian/Alaska Native 27 24 (88.9) 3 (11.1) 9 8 (88.9) 1 (11.1) 1.00 (0.77-1.31)
 Asian 52 35 (67.3) 17 (32.7) 45 38 (84.4) 7 (15.6) 0.80 (0.64-1.00)
 Black/African American 2605 1995 (76.6) 610 (23.4) 1190 1000 (84.0) 190 (16.0) 0.91 (0.88-0.94)
 Hispanic/Latino e 682 535 (78.4) 147 (21.6) 276 231 (83.7) 45 (16.3) 0.94 (0.88-1.00)
 Native Hawaiian/Other Pacific Islander 5 3 (60.0) 2 (40.0) 5 5 (100.0) 0 —
 White 690 518 (75.1) 172 (24.9) 540 447 (82.8) 93 (17.2) 0.91 (0.86-0.96)
 Multiple races 79 61 (77.2) 18 (22.8) 71 60 (84.5) 11 (15.5) 0.91 (0.78-1.07)
Transmission category f
 Injection drug use 457 344 (75.1) 114 (24.9) 384 303 (78.9) 81 (21.1) 0.95 (0.88-1.03)
 Heterosexual contact g 3669 2817 (76.8) 852 (23.2) 1739 1475 (84.8) 265 (15.2) 0.91 (0.88-0.93)
 Other h 14 10 (75.7) 3 (24.3) 13 12 (90.6) 1 (9.4) 0.84 (0.59-1.18)
County of residence at diagnosis
 Metropolitan (≥500 000) 3198 2435 (76.1) 763 (23.9) 1785 1503 (84.2) 282 (15.8) 0.90 (0.88-0.93)
 Urban (50 000-499 999) 627 493 (78.6) 134 (21.4) 267 223 (83.5) 44 (16.5) 0.94 (0.88-1.01)
 Rural (<50 000) 315 243 (77.1) 72 (22.9) 84 63 (75.0) 21 (25.0) 1.03 (0.90-1.18)
Subtotal 4140 3171 (76.6) 969 (23.4) 2136 1789 (83.8) 347 (16.2) 0.91 (0.89-0.94)
Total 22 169 16 941 (76.4) 5228 (23.6) 11 035 9092 (82.4) 1943 (17.6) 0.93 (0.92-0.94)
Open in a new tab

aLinkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte test or ≥1 viral load test ≤1 month after HIV diagnosis. Of 38 381 people with HIV diagnosed in 2017, 33 204 met inclusion criteria for this analysis.

bAlabama, Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

cData source: Cohen et al. 21

dCompares percentage linked to care within 1 month of HIV diagnosis.

eHispanic/Latino can be of any race.

fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with lower health insurance coverage than in counties with higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94) by age, for males aged 18-24 (PR = 0.92; 95% CI, 0.90-0.95), 25-34 (PR = 0.94; 95% CI, 0.92-0.96), 35-44 (PR = 0.92; 95% CI, 0.90-0.95), and 45-54 (PR = 0.91; 95% CI, 0.88-0.94); by race/ethnicity, for American Indian/Alaska Native (PR = 0.83; 95% CI, 0.73-0.94), Asian (PR = 0.91; 95% CI, 0.85-0.97), Hispanic/Latino (PR = 0.91; 95% CI, 0.89-0.93), White (PR = 0.94; 95% CI, 0.92-0.96), and Black (PR = 0.95; 95% CI, 0.93-0.97) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.90; 95% CI, 0.84-0.96), males with MMSC (PR = 0.93; 95% CI, 0.92-0.94), and males with heterosexual contact (PR = 0.94; 95% CI, 0.90-0.98); and by population of residence, in metropolitan areas (PR = 0.92; 95% CI, 0.91-0.94).

Among females, linkage to care was lower in counties with lower health insurance coverage than in counties with higher health insurance coverage (PR = 0.91; 95% CI, 0.89-0.94) by age, for females aged 18-24 (PR = 0.90; 95% CI, 0.84-0.97), 25-34 (PR = 0.91; 95% CI, 0.87-0.96), 35-44 (PR = 0.94; 95% CI, 0.89-0.99), 45-54 (PR = 0.94; 95% CI, 0.89-0.99), and ≥55 (PR = 0.86; 95% CI, 0.82-0.91); by race/ethnicity, for Black (PR = 0.91; 95% CI, 0.88-0.94) and White (PR = 0.91; 95% CI, 0.86-0.96) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.91; 95% CI, 0.88-0.93); and by population of residence, in metropolitan areas (PR = 0.90; 95% CI, 0.88-0.93).

Linkage to Care and Education Level

Overall, among adults with HIV diagnosed in 2017, 16 372 (49.3%) adults resided in counties with lower education levels, where ≥13% of residents had less than a high school diploma (Table 4). Linkage to care was lower among adults in counties with lower education levels than among adults in counties with higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

Table 4.

Linkage to HIV medical care a within 1 month of HIV diagnosis, by education level of county of residence, among adults aged ≥18, by sex at birth and selected characteristics, 41 states b and the District of Columbia, 2017 c

Characteristic Residence in counties where ≥13% of population has <high school diploma Residence in counties where <13% of population has <high school diploma Prevalence ratiod (95% CI)
Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%) Total diagnoses, no. Linked to care within 1 month, no. (%) Not linked to care within 1 month, no. (%)
Males
Age at diagnosis, y
 18-24 2974 2192 (73.7) 782 (26.3) 3063 2309 (75.4) 754 (24.6) 0.98 (0.95-1.01)
 25-34 4990 3810 (76.4) 1180 (23.6) 5025 3934 (78.3) 1091 (21.7) 0.98 (0.95-1.00)
 35-44 2550 2020 (79.2) 530 (20.8) 2372 1945 (82.0) 427 (18.0) 0.97 (0.94-0.99)
 45-54 1768 1391 (78.7) 377 (21.3) 1884 1591 (84.4) 293 (15.6) 0.93 (0.90-0.96)
 ≥55 1087 888 (81.7) 199 (18.3) 1215 993 (81.7) 222 (18.3) 1.00 (0.96-1.04)
Race/ethnicity
 American Indian/Alaska Native 62 52 (83.9) 10 (16.1) 59 49 (83.1) 10 (16.9) 1.01 (0.86-1.18)
 Asian 336 255 (75.9) 81 (24.1) 412 353 (85.7) 59 (14.3) 0.89 (0.82-0.95)
 Black/African American 4961 3711 (74.8) 1250 (25.2) 5654 4208 (74.4) 1446 (25.6) 1.01 (0.98-1.03)
 Hispanic/Latino e 4820 3750 (77.8) 1070 (22.2) 2618 2146 (82.0) 472 (18.0) 0.95 (0.93-0.97)
 Native Hawaiian/Other Pacific Islander 9 7 (77.8) 2 (22.2) 24 21 (87.5) 3 (12.5) 0.89 (0.61-1.30)
 White 2870 2279 (79.4) 591 (20.6) 4376 3658 (83.6) 718 (16.4) 0.95 (0.93-0.97)
 Multiple races 311 247 (79.4) 64 (20.6) 416 337 (81.0) 79 (19.0) 0.98 (0.91-1.05)
Transmission category f
 Male-to-male sexual contact 11 233 8682 (77.3) 2551 (22.7) 11 029 8814 (79.9) 2215 (20.1) 0.97 (0.95-0.98)
 Injection drug use 504 377 (74.9) 127 (25.1) 563 438 (77.8) 125 (22.2) 0.96 (0.90-1.03)
 Male-to-male sexual contact and injection drug use 465 337 (72.4) 128 (27.6) 629 490 (77.8) 140 (22.2) 0.93 (0.87-0.99)
 Heterosexual contact g 1155 895 (77.5) 260 (22.5) 1325 1021 (77.0) 305 (23.0) 1.01 (0.96-1.05)
 Other h 12 10 (80.6) 2 (19.4) 13 10 (79.1) 3 (20.9) 1.02 (0.69-1.51)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 10 645 8231 (77.3) 2414 (22.7) 11 296 8987 (79.6) 2309 (20.4) 0.97 (0.96-0.99)
 Urban (50 000-499 999) 1538 1167 (75.9) 371 (24.1) 1866 1457 (78.1) 409 (21.9) 0.97 (0.94-1.01)
 Rural (<50 000) 1186 903 (76.1) 283 (23.9) 397 328 (82.6) 69 (17.4) 0.92 (0.87-0.97)
Subtotal 13 369 10 301 (77.1) 3068 (22.9) 13 559 10 772 (79.4) 2787 (20.6) 0.97 (0.96-0.98)
Females
Age at diagnosis, y
 18-24 402 304 (75.6) 98 (24.4) 416 323 (77.6) 93 (22.4) 0.97 (0.90-1.05)
 25-34 846 651 (77.0) 195 (23.0) 880 711 (80.8) 169 (19.2) 0.95 (0.91-1.00)
 35-44 709 550 (77.6) 159 (22.4) 767 590 (76.9) 177 (23.1) 1.01 (0.95-1.07)
 45-54 584 466 (79.8) 118 (20.2) 648 532 (82.1) 116 (17.9) 0.97 (0.92-1.03)
 ≥55 462 361 (78.1) 101 (21.9) 562 472 (84.0) 90 (16.0) 0.93 (0.88-0.99)
Race/ethnicity
 American Indian/Alaska Native 17 14 (82.4) 3 (17.6) 19 18 (94.7) 1 (5.3) 0.87 (0.68-1.11)
 Asian 36 22 (61.1) 14 (38.9) 61 51 (83.6) 10 (16.4) 0.73 (0.55-0.97)
 Black/African American 1830 1419 (77.5) 411 (22.5) 1965 1576 (80.2) 389 (19.8) 0.97 (0.94-0.99)
 Hispanic/Latino e 590 474 (80.3) 116 (19.7) 368 292 (79.3) 76 (20.7) 1.01 (0.95-1.08)
 Native Hawaiian/Other Pacific Islander 2 2 (100.0) 0 8 6 (75.0) 2 (25.0) —
 White 464 353 (76.1) 111 (23.9) 766 612 (79.9) 154 (20.1) 0.95 (0.89-1.01)
 Multiple races 64 48 (75.0) 16 (25.0) 86 73 (84.9) 13 (15.1) 0.88 (0.75-1.04)
Transmission category f
 Injection drug use 382 296 (77.6) 86 (22.4) 460 350 (76.2) 109 (23.8) 1.02 (0.94-1.10)
 Heterosexual contact g 2610 2028 (77.7) 582 (22.3) 2798 2264 (80.9) 534 (19.1) 0.96 (0.93-0.99)
 Other h 11 8 (72.3) 3 (27.7) 15 14 (90.8) 1 (9.2) 0.80 (0.54-1.18)
County of residence at diagnosis (population)
 Metropolitan (≥500 000) 2240 1741 (77.7) 499 (22.3) 2743 2197 (80.1) 546 (19.9) 0.97 (0.94-0.99)
 Urban (50 000-499 999) 441 341 (77.3) 100 (22.7) 453 375 (82.8) 78 (17.2) 0.93 (0.87-0.99)
 Rural (<50 000) 322 250 (77.6) 72 (22.4) 77 56 (72.7) 21 (27.3) 1.07 (0.92-1.24)
Subtotal 3003 2332 (77.7) 671 (22.3) 3273 2628 (80.3) 645 (19.7) 0.97 (0.94-0.99)
Total 16 372 12 633 (77.2 3739 (22.8) 16 832 13 400 (79.6) 3432 (20.4) 0.97 (0.96-0.98)
Open in a new tab

aLinkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte test or ≥1 viral load test ≤1 month after HIV diagnosis. Of 38 381 people with HIV diagnosed in 2017, 33 204 met inclusion criteria for this analysis.

bAlabama, Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

cData source: Cohen et al. 21

dCompares percentage linked to care within 1 month of HIV diagnosis.

eHispanic/Latino can be of any race.

fData were adjusted to account for missing data on transmission category; therefore, values may not sum to column total.

gHeterosexual contact with a person known to have or to be at high risk for HIV infection.

hIncludes people whose infection was attributed to hemophilia blood transfusion or perinatal exposure or whose risk factor was not reported or identified.

Among males, linkage to care was lower in counties with lower education levels than in counties with higher education levels (PR = 0.97; 95% CI, 0.96-0.98) by age, for males aged 35-44 (PR = 0.97; 95% CI, 0.94-0.99) and 45-54 (PR = 0.93; 95% CI, 0.90-0.96); by race/ethnicity, for Asian (PR = 0.89; 95% CI, 0.82-0.95), Hispanic/Latino (PR = 0.95; 95% CI, 0.93-0.97), and White (PR = 0.95; 95% CI, 0.93-0.97) males; by transmission category, for males with infection attributed to MMSC/IDU (PR = 0.93; 95% CI, 0.87-0.99) and MMSC (PR = 0.97; 95% CI, 0.95-0.98); and by population of residence, in rural (PR = 0.92; 95% CI, 0.87-0.97) and metropolitan (PR = 0.97; 95% CI, 0.96-0.99) areas.

Among females, linkage to care was lower in counties with lower education levels than in counties with higher education levels (PR = 0.97; 95% CI, 0.94-0.99) by age, for females aged ≥55 (PR = 0.93; 95% CI, 0.88-0.99); by race/ethnicity, for Asian (PR = 0.73; 95% CI, 0.55-0.97) and Black (PR = 0.97; 95% CI, 0.94-0.99) females; by transmission category, for infection attributed to heterosexual contact (PR = 0.96; 95% CI, 0.93-0.99); and by population of residence, in urban (PR = 0.93; 95% CI, 0.87-0.99) and metropolitan (PR = 0.97; 95% CI, 0.94-0.99) areas.

Discussion

For adults with diagnosed HIV in 2017 in the United States, our analysis found lower rates of linkage to care in the overall population and among males with infection attributed to MMSC/IDU, for adults residing in areas characterized by the 3 SDH extremes of higher poverty, lower health insurance coverage, and lower education levels. Linkage was lowest among males aged 45-54 in counties with lower health insurance coverage and lower education levels, among Asian and Hispanic/Latino males in counties with higher poverty and lower education levels, among males residing in rural areas with higher poverty and lower education levels, and among White and Black females in counties with higher poverty and lower health insurance coverage.

Few studies have examined SDH and linkage to care in the United States, and direct comparisons of findings are limited because of differences in the outcomes measured and populations observed. However, in general, we found that most studies support our overall findings of lower linkage to care among people residing in high-poverty areas and areas with low health insurance coverage. 24 -27 These findings may be attributed to factors such as lack of social support services, socioeconomic instability, and limited public transportation and highlight that structural and societal factors such as social and physical environments, and availability, cost of, and access to health services, may create barriers to HIV care. 24 -27 Identifying the limitations to accessing care and the SDH factors that may contribute to these limitations is critical and will provide insight on additional factors associated with lower rates of linkage to care in the United States.

For results across race/ethnicity, we found that Asian and Hispanic/Latino males residing in counties with higher poverty and lower education levels had lower rates of linkage to care. Several studies on HIV health outcomes among Asian people in the United States have suggested that cultural, behavioral, and belief factors must be addressed to increase linkage-to-care rates among Asian people in general. 28,29 A study of Latino men in large US cities found factors such as limited education, inadequate health insurance, language barriers, and migration contribute to poor health outcomes in the Hispanic/Latino population, which can directly and indirectly affect opportunities to be linked to HIV care. 30,31 Considering the heterogeneous nature of Asian and Latino populations, it may be beneficial to disaggregate these populations for better insight in future analyses.

In our study, linkage-to-care rates were low among White and Black females in counties with higher poverty and lower health insurance coverage. Although national surveillance data on health outcomes and SDH found lower linkage-to-care rates among White women in counties with lower poverty, additional studies are needed to provide better insight into the effect of SDH on care outcomes in this population. 14 Although recent studies have not analyzed SDH and linkage to care among Black women, some studies do support our findings of lower linkage-to-care rates among Black women in high-poverty areas. 13,32,33 A study of Florida residents found that non-initiation of care increased as poverty level increased and as the density of non-Hispanic Black people increased. 34 Limited access to quality health care, housing, transportation, and HIV education, in addition to stigma, discrimination, and fear, may directly affect linkage-to-care rates among Black women. 32,33

By population of residence, linkage to care was lowest among males residing in rural areas with higher poverty and lower education levels than among males in counties with lower poverty and higher education levels. People living in rural areas of the United States may be at a disadvantage for accessing and receiving HIV care, and HIV-related stigma is greater in rural areas than in large urban communities. 35,36 Although a study of care outcomes by geographic population found greater linkage-to-care rates among people in rural areas than in urban and metropolitan areas in the United States, 37 additional barriers such as living in an area of high poverty or low education generally affect other HIV-related outcomes, such as retention in care and adherence to treatment to attain viral suppression. 18

Linkage-to-care rates were lower among young adults aged 18-24 than among adults in other age groups. Surveillance studies have found that 44% of undiagnosed HIV infections and 21% of new HIV diagnoses in the United States are among adolescents and young adults, 1,2 and this group is less likely than other age groups to be retained in care and to be virally suppressed. 3,38 Adolescents and young adults often face challenges to testing, entry, and maintenance of HIV care, which include limited transportation, underemployment, stigma and fear, and low levels of family support, which affect their decision making on care options. 27,39 Understanding these barriers and other SDH factors is critical and will provide insight for work to improve linkage to care among young adults. 40 In addition, increasing the availability of adolescent-friendly, culturally competent, confidential, and convenient health services may facilitate access to HIV care for this population. 41

Limitations

Our analysis had several potential limitations. First, data were available from 42 jurisdictions with complete reporting of HIV-related laboratory data to CDC. These 42 areas represent 87.9% of all HIV diagnoses that occurred in the United States in 2017 and, as such, may not be representative of all people with diagnosed HIV infection in the United States. Third, because all people with HIV have not been tested and/or reported, the number and percentage of people linked to care may not be representative of all adults with diagnosed HIV infection in the 42 areas in 2017. Fourth, use of county-level aggregated data for this ecological analysis may not accurately reflect or represent the SDH environment at the individual level. Finally, although some SDH indicators may be correlated (eg, lack of education has been associated with both poverty and low income in the United States), 42,43 we did not analyze correlations between SDH indicators in our study.

Conclusions

Although health outcomes of people with HIV infection have improved in the past decade, some populations are disproportionately affected. 8 Prevention interventions need to be supplemented to address underlying factors such as poverty, lack of health insurance, and lack of education. A key strategy of the Ending the HIV Epidemic initiative is to reduce HIV transmission through interventions that improve rates of viral suppression. 4,5,7 Linkage to care is the gateway to receiving prompt and proper HIV treatment for the attainment and maintenance of viral suppression. Increasing low- to no-cost health insurance options among low-income populations would likely lead to better HIV care outcomes for these populations. In addition, increased use of peer navigators and allied health workers and the development of targeted campaigns may improve linkage-to-care rates among groups that are at high risk of having poor HIV health outcomes. Future studies are needed to analyze the relative effects of both county-level and individual poverty, education, and health insurance measures to inform whether variance in linkage is attributed to individual or aggregate county SDH, or both.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Footnotes

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Myrline Gillot, MPH https://orcid.org/0000-0003-1254-8068

Zanetta Gant, PhD, MS https://orcid.org/0000-0003-2558-8237

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