Abstract
The objective of this exploratory study was to examine sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression. Miami-Dade County has the highest HIV diagnosis rate in the United States. The study population included 6,489 clients enrolled in the Miami-Dade Ryan White Program (RWP) who received services during 2017 and RWP administrative data was analyzed. Sustained viral suppression (SVS) was defined as having all viral load tests during 2017 below 200 copies/ml. Multivariable multilevel logistic regression models accounted for clustering by medical case management site. Models were stratified by sex. Overall, a higher proportion of females did not achieve SVS (23.5%) than males (18.1%). For females (n=1,503), having acquired HIV perinatally and not having a partner or adult household member (in comparison to disclosing to a partner or adult household member) were associated with not achieving SVS. For males (n=4,986), lacking access to food, Black or Haitian race/ethnicity, problematic substance use, and unknown physician were associated with not achieving SVS. For both sexes, younger age, lower household income, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were associated with not achieving SVS. Elements of the transition from adolescent to adult HIV care that may differentially impact females should be explored further. Factors associated with disclosure also deserve additional analysis. Food security may be an area where male clients require additional support. Improving culturally specific care for Haitian and non-Hispanic Black male clients should be explored, particularly in the context of Miami-Dade County.
Keywords: sustained viral suppression, sex differences, women-centered care, Ryan White Program
INTRODUCTION
Antiretroviral therapy (ART) has dramatically improved the health of persons with HIV (PWH). Individuals with undetectable viral loads are at minimal risk of transmitting the virus to others and are less likely to acquire life-threatening opportunistic infections (CDC, 2018). Sustained viral suppression by taking ART as prescribed is the goal for PWH and is typically defined as having all viral load test results in a given year <200 HIV RNA copies/mL (Crepaz et al., 2018; CDC, 2018).
Previous research has shown that women are less likely to achieve sustained viral suppression (Crepaz et al., 2016). In a cohort of women with HIV in the US (n=921), increased age, substance use, and self-reported poor health were associated with a reduced likelihood of being virally suppressed (Blank et al., 2015). Women with HIV often delay entry into care and experience poorer care outcomes (Aziz & Smith, 2012). Relative to men, they face unique social and cultural challenges, have lower socioeconomic status, and may face issues such as substance use and domestic violence that impact their ability to maintain care (Aziz & Smith, 2012). The objective of the present work was to build upon the extant literature and inform practices of the Miami-Dade County Ryan White Program (RWP) by conducting an exploratory analysis of sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression among individuals enrolled in that program.
MATERIALS AND METHODS
The study population included clients 18 years or older enrolled (receiving medical case management or peer education and support services) in the Miami-Dade County RWP prior to January 1, 2017. Clients who died, were incarcerated, moved away, were no longer financially eligible, only received ancillary services, or had incomplete comprehensive health assessments were not eligible for inclusion (Trepka et al., 2020). The outcome was failure to achieve sustained viral suppression (SVS; above 200 copies/ml on any viral load tests in 2017). If an individual had only one viral load test in 2017 (or more than 1 but none were at least 3 months apart), we also used the last viral load test result in 2016 in an effort to assess consistent viral load suppression on at least two tests (Crepaz et al., 2018). Individuals with no viral load tests in 2017, or only one viral load test in 2017 and no tests in 2016, were excluded from analysis (Figure).
Figure 1.
Flowchart describing study sample.
Demographic characteristics included are shown in Table 1. Psychosocial characteristics were selected using the Behavioral Model for Vulnerable Populations (Gelberg et al., 2000) from the domains of need and vulnerable/enabling characteristics (additional details on the variables selected from these domains are available in Table 1). Covariates related to the neighborhood environment included neighborhood socioeconomic status (SES) and neighborhood instability/crime indices. Details of the construction of the two indices are described elsewhere (Trepka et al., 2020). To account for the healthcare environment, the volume of RWP clients served by an individual’s physician was included.
Table 1.
Characteristics of females and males living with HIV enrolled in the Ryan White Part A Program, Miami-Dade County, 2017
| Characteristics | Females | Males |
|---|---|---|
| N=1503 n (column %) |
N=4986 n (column %) |
|
| Demographic Characteristics | ||
| Age Group * | ||
| 18–24 years old | 36 (2.4) | 227 (4.6) |
| 25–34 years old | 187 (12.4) | 973 (19.5) |
| 35–49 years old | 567 (37.7) | 1936 (38.8) |
| 50+ years old | 713 (47.4) | 1850 (37.1) |
| Race/Ethnicity * | ||
| Haitian | 377 (25.1) | 333 (6.7) |
| Hispanic | 458 (30.5) | 3311 (66.4) |
| Non-Hispanic Black | 617 (41.1) | 962 (19.3) |
| White/Other | 51 (3.4) | 380 (7.6) |
| US Born * | ||
| No | 869 (57.8) | 3534 (70.9) |
| Yes | 634 (42.2) | 1452 (29.1) |
| Preferred Language * | ||
| English | 754 (50.2) | 1982 (39.8) |
| Spanish | 397 (26.4) | 2675 (53.7) |
| Haitian Creole | 335 (22.3) | 265 (5.3) |
| Other | 17 (1.1) | 64 (1.3) |
| Household Income, percent of Federal Poverty Level (FPL) * | ||
| <100% FPL | 768 (51.1) | 1904 (38.2) |
| 100–199% FPL | 546 (36.3) | 1756 (35.2) |
| 200%+ FPL | 189 (12.6) | 1326 (26.6) |
| Minors in Household * | ||
| No | 1082 (72.0) | 4725 (94.8) |
| Yes | 421 (28.0) | 261 (5.2) |
| Need Characteristics | ||
| Ever Received an AIDS Diagnosis * | ||
| Yes | 737 (49.0) | 1926 (38.7) |
| No | 766 (51.0) | 3060 (61.4) |
| Vulnerable/Enabling Characteristics | ||
| Perinatal Exposure * | ||
| Yes | 19 (1.3) | 25 (0.5) |
| No | 1484 (98.7) | 4961 (99.5) |
| Substance Use Problems (Affecting adherence or resulting in problems in daily activity, legal issues, or hazardous situations) * | ||
| Yes | 70 (4.7) | 302 (6.1) |
| No | 1433 (95.3) | 4684 (93.9) |
| Feeling Depressed/Anxious * | ||
| Yes | 262 (17.4) | 685 (13.7) |
| No | 1241 (82.6) | 4301 (86.3) |
| Disclosure * | ||
| Partner/adult in household knows status | 809 (53.8) | 2703 (54.2) |
| Partner/adult in household doesn't know status | 194 (12.9) | 363 (7.3) |
| No partner/adult household member | 500 (33.3) | 1920 (38.5) |
| Social Support System * | ||
| No | 210 (14.0) | 899 (18.0) |
| Yes | 1293 (86.0) | 4087 (82.0) |
| Ever Experienced Domestic Abuse * | ||
| Yes | 122 (8.1) | 157 (3.2) |
| No | 1381 (91.9) | 4829 (96.9) |
| Work Barriers to HIV-related Appointments * | ||
| Working and No Barriers | 701 (46.6) | 3132 (62.8) |
| Working and Barriers | 48 (3.2) | 113 (2.3) |
| Not Working | 754 (50.2) | 1741 (34.9) |
| Access to Transportation for Appointments * | ||
| No | 109 (7.3) | 466 (9.4) |
| Yes | 1394 (92.8) | 4520 (90.7) |
| Access to Food You Need | ||
| No | 19 (1.3) | 79 (1.6) |
| Yes | 1484 (98.7) | 4907 (98.4) |
| Experiencing Homelessness | ||
| Yes | 63 (4.2) | 259 (5.2) |
| No | 1440 (95.8) | 4727 (94.8) |
| Health Care Environment | ||
| Physician Ryan White Program Client Volume * | ||
| 1–9 clients | 56 (3.7) | 121 (2.4) |
| 10–29 clients | 59 (3.9) | 164 (3.3) |
| 30–99 clients | 403 (26.8) | 887 (17.8) |
| 100–199 clients | 486 (32.3) | 1453 (29.1) |
| 200+ clients | 417 (27.7) | 2092 (42.0) |
| Unknown physician | 82 (5.5) | 269 (5.4) |
| Neighborhood Environment | ||
| Neighborhood SES Index- Mean (SD)* | 0.83 (0.77) | 0.48 (0.87) |
| Neighborhood Instability/Crime Index- Mean (SD)* | 0.40 (0.84) | 0.50 (1.03) |
P-value <0.05.
Descriptive bivariate analyses, using chi square tests and t-tests, were conducted. To account for possible clustering according to the 11 medical case management sites where the clients received treatment, multilevel logistic regression (without cross-classification) treating medical case management site as level 2 and individuals as level 1 was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs). An estimate of the intraclass correlation coefficient (ICC) for medical case management site was estimated using an intercepts-only model. Adjusted, multivariable multilevel logistic regression models were used to control for covariates. To examine differences for males and females, models were stratified by sex at birth. SAS 9.4 was used for all analyses.
RESULTS
The research population consisted of 6,489 individuals enrolled in RWP in 2017 (1,503 females and 4,986 males). A description of the research population by sex is shown in Table 1. Compared to males with HIV, a significantly higher proportion of females with HIV were older, Haitian or non-Hispanic Black, and born in the United States. Females were more likely to have been infected with HIV perinatally, to have ever received an AIDS diagnosis, and to have experienced domestic abuse. While a higher proportion of females reported having a social support system, they also more frequently reported not disclosing their HIV status to a partner or other adult living in their household.
Overall, a higher proportion of females did not achieve SVS (23.5%, n=353) than males (18.1%, n=903). (The median number of viral load tests in 2017 was 3, with a range of 1 to 12.) The ICC for medical case management site was 0.11. Results of the stratified multilevel logistic regression models are shown in Table 2. For females (n=1,503), not having a partner or adult household member (in comparison to disclosing to a partner or adult household member; aOR=1.37, CI: 1.03-1.82) and perinatal exposure (aOR=3.33, CI: 1.08-10.28) were associated with higher odds of failure to achieve SVS (it should be noted there were only 19 females with perinatal exposure in the research population of 1,503). For males (n=4,986), being Haitian (aOR=2.31, CI: 1.49-3.58) or non-Hispanic Black (aOR=1.81, CI: 1.27-2.58), lacking access to food (aOR=2.23, CI: 1.34-3.71), substance use problems impacting adherence or daily life (aOR=1.56, CI:1.18-2.08), and unknown physician (aOR=1.81, CI: 1.29, 2.53) were associated with failure to achieve SVS. For both males and females, younger age, household income below 100% of the federal poverty level, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were significantly associated with not achieving SVS.
Table 2.
Unadjusted and adjusted odds ratios of failing to achieve sustained viral suppression among females and males living with HIV enrolled in the Ryan White Part A Program, Miami-Dade County, 2017
| Characteristics | Females N=1503 |
Males N=4986 |
||
|---|---|---|---|---|
| Unadjusted OR (95% CI) |
Adjusted OR (95% CI) |
Unadjusted OR (95% CI) |
Adjusted OR (95% CI) |
|
| Demographic characteristics | ||||
| Age Group | ||||
| 18–24 years old | 2.75 (1.35, 5.62) | 2.77 (1.34, 6.75) | 2.48 (1.80, 3.43) | 2.70 (1.88, 3.87) |
| 25–34 years old | 2.55 (1.78, 3.67) | 2.76 (1.81, 4.20) | 1.87 (1.52, 2.30) | 2.27 (1.81, 2.86) |
| 35–49 years old | 1.79 (1.36, 2.34) | 2.27 (1.67, 3.10) | 1.26 (1.06, 1.50) | 1.54 (1.27, 1.87) |
| 50+ years old | Ref | Ref | Ref | Ref |
| Race/Ethnicity | ||||
| Haitian | 1.14 (0.57, 2.28) | 1.64 (0.71, 3.82) | 2.12 (1.45, 3.10) | 2.31 (1.49, 3.58) |
| Hispanic | 0.67 (0.33, 1.33) | 0.92 (0.40, 2.08) | 0.95 (0.71, 1.29) | 1.08 (0.75, 1.54) |
| Non-Hispanic Black | 1.19 (0.60, 2.33) | 1.30 (0.61, 2.75) | 2.63 (1.91, 3.62) | 1.81 (1.27, 2.58) |
| White/Other | Ref | Ref | Ref | Ref |
| US Born | ||||
| No | 0.66 (0.52, 0.85) | 0.81 (0.53, 1.25) | 0.50 (0.43, 0.58) | 0.88 (0.69, 1.12) |
| Yes | Ref | Ref | Ref | Ref |
| Federal Poverty Level (FPL) | ||||
| <100% FPL | Ref | Ref | Ref | Ref |
| 100–199% FPL | 0.61 (0.47, 0.79) | 0.68 (0.50, 0.91) | 0.46 (0.39, 0.55) | 0.63 (0.52, 0.77) |
| 200%+ FPL | 0.22 (0.13, 0.38) | 0.25 (0.14, 0.45) | 0.35 (0.29, 0.43) | 0.53 (0.41, 0.67) |
| Minors in Household | ||||
| No | Ref | Ref | Ref | Ref |
| Yes | 1.07 (0.82, 1.39) | 0.84 (0.62, 1.15) | 1.13 (0.83, 1.55) | 1.00 (0.72, 1.41) |
| Need Characteristics | ||||
| Ever Received an AIDS Diagnosis | ||||
| Yes | 1.70 (1.32, 2.17) | 1.78 (1.36, 2.31) | 1.74 (1.49, 2.02) | 1.79 (1.51, 2.11) |
| No | Ref | Ref | Ref | Ref |
| Vulnerable/Enabling Characteristics | ||||
| Perinatal Exposure | ||||
| Yes | 6.40 (2.48, 16.53) | 3.33 (1.08, 10.28) | 4.61 (2.09, 10.23) | 1.79 (0.75, 4.25) |
| No | Ref | Ref | Ref | Ref |
| Substance Use Problems (Affecting adherence or resulting in problems in daily activity, legal issues, or hazardous situations) | ||||
| Yes | 2.35 (1.43, 3.87) | 1.13 (0.62, 2.05) | 2.78 (2.16, 3.58) | 1.56 (1.18, 2.08) |
| No | Ref | Ref | Ref | Ref |
| Feeling Depressed/Anxious | ||||
| Yes | 1.73 (1.29, 2.34) | 1.54 (1.10, 2.17) | 2.17 (1.81, 2.62) | 1.59 (1.29, 1.96) |
| No | Ref | Ref | Ref | Ref |
| Disclosure | ||||
| Partner/adult in household knows status | Ref | Ref | Ref | Ref |
| Partner/adult in household doesn't know status | 0.82 (0.55, 1.21) | 0.80 (0.52, 1.22) | 1.31 (1.002, 1.72) | 1.22 (0.91, 1.62) |
| No partner/adult household member | 1.18 (0.91, 1.53) | 1.37 (1.03, 1.82) | 1.02 (0.88, 1.19) | 1.03 (0.87, 1.23) |
| Social Support System | ||||
| No | 0.94 (0.66, 1.33) | 0.97 (0.66, 1.44) | 1.26 (1.05, 1.52) | 1.16 (0.95, 1.42) |
| Yes | Ref | Ref | Ref | Ref |
| Ever Experienced Domestic Abuse | ||||
| Yes | 1.30 (0.86, 1.96) | 0.86 (0.54, 1.38) | 2.40 (1.70, 3.38) | 1.35 (0.92, 1.99) |
| No | Ref | Ref | Ref | Ref |
| Work Barriers to HIV-related Appointments | ||||
| Working and No Barriers | Ref | Ref | Ref | Ref |
| Working and Barriers | 0.94 (0.43, 2.07) | 0.99 (0.43, 2.28) | 1.30 (0.79, 2.15) | 1.38 (0.82, 2.33) |
| Not Working | 1.50 (1.17, 1.93) | 1.12 (0.83, 1.52) | 2.11 (1.82, 2.46) | 1.20 (0.99, 1.46) |
| Access to Transportation for Appointments | ||||
| No | 1.59 (1.04, 2.43) | 1.43 (0.90, 2.30) | 1.49 (1.18, 1.88) | 1.18 (0.91, 1.52) |
| Yes | Ref | Ref | Ref | Ref |
| Access to Food You Need | ||||
| No | 1.81 (0.70, 4.66) | 1.35 (0.46, 3.98) | 3.83 (2.43, 6.05) | 2.23 (1.34, 3.71) |
| Yes | Ref | Ref | Ref | Ref |
| Experiencing Homelessness | ||||
| Yes | 3.36 (2.00, 5.64) | 2.27 (1.25, 4.13) | 3.59 (2.77, 4.67) | 1.98 (1.47, 2.65) |
| No | Ref | Ref | Ref | Ref |
| Health Care Environment | ||||
| Physician Ryan White Program Client Volume | ||||
| 1–9 clients | 1.44 (0.75, 2.79) | 1.14 (0.54, 2.42) | 0.98 (0.58, 1.65) | 0.89 (0.51, 1.55) |
| 10–29 clients | 0.97 (0.48, 1.98) | 0.88 (0.41, 1.93) | 1.25 (0.82, 1.90) | 0.98 (0.63, 1.54) |
| 30–99 clients | 1.35 (0.95, 1.92) | 1.22 (0.84, 1.79) | 1.56 (1.26, 1.93) | 1.25 (0.99, 1.57) |
| 100–199 clients | 1.61 (1.14, 2.27) | 1.38 (0.96, 2.00) | 1.42 (1.16, 1.75) | 1.15 (0.93, 1.43) |
| 200+ clients | Ref | Ref | Ref | Ref |
| Unknown physician | 1.96 (1.14, 3.37) | 1.47 (0.82, 2.64) | 2.52 (1.84, 3.45) | 1.81 (1.29, 2.53) |
| Neighborhood Environment | ||||
| Neighborhood SES Index- Mean (SD) | 1.19 (1.01, 1.40) | 1.02 (0.84, 1.25) | 1.33 (1.22, 1.45) | 1.09 (0.98, 1.20) |
| Neighborhood Instability/Crime Index- Mean (SD) | 1.20 (1.04, 1.39) | 1.08 (0.90, 1.28) | 1.11 (1.04, 1.19) | 1.03 (0.95, 1.12) |
DISCUSSION
The varying characteristics of female and male RWP clients (Table 1) highlight the differential impact of HIV by sex in Miami-Dade County. Factors associated with failure to achieve SVS in both sexes reflect longstanding disparities in HIV care and support the need for services offered by the Ryan White Program that address issues of poverty, homelessness, and depression to improve sustained viral suppression (Mandsager et al., 2018; HRSA 2022).
Not having a partner or adult household member in comparison to disclosing to a partner or adult household member and perinatally acquired HIV were associated with failure to achieve SVS among females. Our findings highlight the importance of disclosure and align with previous work. McDoom et al. found that among older Black women with HIV, HIV status disclosure was perceived to be a tool to improve their social support, which in turn improved their access to care (McDoom et al., 2015). Poor SVS outcomes among individuals with perinatally acquired HIV have been attributed to inadequate transitions from pediatric to adult care, difficult underlying social circumstances related to perinatal transmission, and ART resistance due to length of exposure to medication regimens (Agwu & Fairlie, 2013; Gilliam et al., 2011; Gray et al., 2019). The association of perinatal exposure with failure to achieve SVS among females but not males aligns with previous findings related to retention in care, an outcome that precedes SVS along the HIV care continuum (Trepka et al., 2020).
Non-Hispanic Black and Haitian race/ethnicity and inadequate access to food were associated with failure to achieve SVS among males. Disparities by race/ethnicity have been previously documented in analyses that were not stratified by sex (Crepaz et al., 2018; Crepaz et al., 2017; Crepaz et al., 2016). In Miami-Dade County, a majority of RWP male enrollees are Hispanic; our finding highlights the importance of culturally specific care and support for Haitian and non-Hispanic Black men. We did not observe an association between inadequate access to food and failure to achieve SVS among females. This difference may be due to programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which are available for women but not men. Clinicians and case managers serving male RWP clients at risk for food insecurity should screen for it regularly and connect eligible clients with programs that support food security.
One limitation of this study is its use of secondary administrative RWP data. Additionally, only individuals who were currently in care and had two viral load test results were included; this may have introduced selection bias and limits generalizability of study results to RWP clients retained in care. Furthermore, sensitive psychosocial variables may be underreported. A small sample of individuals with perinatal HIV were included in the analyses (resulting in OR estimates with limited precision), and a more detailed measure of the healthcare environment experienced by RWP clients was not available. Finally, our results are limited to observations made in the context of persons in treatment in the Ryan White Program in Miami-Dade County and may not be easily generalized beyond this group.
CONCLUSION
This exploratory study found differential factors impacting sustained viral suppression among males and females in Ryan White care in Miami-Dade County. Elements of the transition from adolescent to adult HIV care that may differentially impact females should be explored further. Factors associated with disclosure also deserve additional analysis. Food security may be an area where male clients require additional support. Improving culturally specific care for Haitian and non-Hispanic Black male clients should be explored, particularly in the context of Miami-Dade County.
Acknowledgements:
The authors wish to gratefully acknowledge Carla Valle-Schwenk, Ryan White Program Administrator, and the entire Ryan White Part A Program in the Miami-Dade County Office of Management and Budget, for their active assistance, cooperation and facilitation in the implementation of this study. The authors also gratefully acknowledge partial support by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Numbers U54MD012393 (Florida International University Research Center in Minority Institutions) and K01MD013770. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding
This research was supported in part by National Institute on Minority Health & Health Disparities (NIMHD) Awards R01MD013563, R01MD012421, 3R01MD013563-02S1, K01MD013770, and F31MD015234. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Conflicts of Interest: The authors declare no potential conflicts of interest.
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