A Census Tract-Level Examination of Diagnosed HIV Infection and Social Vulnerability Themes Among Black/African American, Hispanic/Latino, and White Adults, 2019—USA

André Dailey; Zanetta Gant; Xiaohong Hu; Shacara Johnson Lyons; Amanda Okello; Anna Satcher Johnson

doi:10.1007/s40615-023-01533-5

. 2023 Feb 17:1–24. Online ahead of print. doi: 10.1007/s40615-023-01533-5

A Census Tract-Level Examination of Diagnosed HIV Infection and Social Vulnerability Themes Among Black/African American, Hispanic/Latino, and White Adults, 2019—USA

André Dailey ^1,^✉, Zanetta Gant ¹, Xiaohong Hu ¹, Shacara Johnson Lyons ¹, Amanda Okello ¹, Anna Satcher Johnson ¹

PMCID: PMC9937524 PMID: 36808571

Abstract

Background

Assessing HIV diagnosis and the social vulnerability index (SVI) by themes (socioeconomic status, household composition and disability, minority status and English proficiency, and housing type and transportation) might help to identify specific social factors contributing to disparities across census tracts with high rates of diagnosed HIV infection in the USA.

Methods

We examined HIV rate ratios in 2019 using data from CDC’s National HIV Surveillance System (NHSS) for Black/African American, Hispanic/Latino, and White persons aged ≥ 18 years. NHSS data were linked to CDC/ATSDR SVI data to compare census tracts with the lowest SVI (Q1) and highest SVI (Q4) scores. Rates and rate ratios were calculated for 4 SVI themes by sex assigned at birth for age group, transmission category, and region of residence.

Results

In the socioeconomic theme analysis, we observed wide within-group disparity among White females with diagnosed HIV infection. In the household composition and disability theme, we observed high HIV diagnosis rates among Hispanic/Latino and White males who lived in the least socially vulnerable census tracts. In the minority status and English proficiency theme, we observed a high percentage of Hispanic/Latino adults with diagnosed HIV infection in the most socially vulnerable census tracts. In the housing type and transportation theme, we observed a high percentage of HIV diagnoses attributed to injection drug use in the most socially vulnerable census tracts.

Conclusion

The development and prioritization of interventions that address specific social factors contributing to disparities in HIV across census tracts with high diagnosis rates are critical to reducing new HIV infections in the USA.

Keywords: HIV, Disparities, Social vulnerability index themes, SVI themes, Census tracts

Introduction

Previous research has shown that disproportionately higher HIV diagnosis rates and percentages were among persons residing in the most socially vulnerable census tracts in the USA [1, 2]. Social vulnerability refers to the potential negative health effects on communities caused by external stressors [3]. In addition, racial/ethnic disparities in health are closely linked with social, economic, and/or environmental disadvantages (i.e., communities with the highest level of social vulnerability) that adversely affect groups of people who have systematically experienced greater obstacles to health based on their race/ethnicity group or other characteristics (e.g., religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location) historically linked to discrimination or exclusion [4].

Owing to a history of racial discrimination and residential segregation, some Black and Hispanic/Latino persons in the USA reside in census tracts with the highest social vulnerability [5]. The disproportionate impact of HIV on some subpopulations (e.g., Black and Hispanic/Latino persons) might be due to racial segregation and discrimination which have both been found to be more prevalent in socially vulnerable census tracts [1]. A study by the Centers for Disease Control and Prevention (CDC) found that in 2018, more than half of Black (52.2%) and Hispanic/Latino (51.5%) adults compared to 24.4% of White adults lived in the most socially vulnerable census tracts at the time of HIV diagnosis [1]. The development and prioritization of interventions that address social determinants of health (i.e., the conditions in which people are born, grow, live, work, and age) are critical to address the higher risk for HIV infection among Black and Hispanic/Latino persons living in census tracts with high levels of social vulnerability.

HIV typically has a positive gradient where higher social vulnerability is associated with increased risk for infection [1, 2]. Higher HIV rates are more prevalent among adults residing in the most socially vulnerable census tracts and among Black and Hispanic/Latino adults, which could lead to the erroneous inference that higher rates among Black and Hispanic/Latino adults are the primary explanation for both observed gradients. When social vulnerability and race/ethnicity are considered jointly, however, social vulnerability gradients are seen within each race/ethnicity group, and race/ethnicity disparities are seen across census tracts regardless of the level of social vulnerability [5]. The race/ethnicity disparities across census tracts could reflect differences among unmeasured social determinants of health factors (i.e., income, education, wealth, and childhood and neighborhood socioeconomic conditions), which vary systematically by race/ethnicity group and are important in explaining health differences across racial/ethnic groups [6, 7].

For the social vulnerability index (SVI), findings from previous studies are typically based on the overall ranking of 15 social factors that comprise the 4 social vulnerability themes: socioeconomic status, household composition and disability, minority status and English proficiency, and housing type and transportation. One study that assessed SVI based on the 4 themes and their individual factors found that counties with higher percentages of racial and ethnic minority residents and people living in crowded housing conditions were more likely to become areas with rapidly increasing COVID-19 incidence [8]. It is unknown from previous studies how each theme affects HIV diagnosis rates among racial/ethnic subpopulations.

Assessing HIV rate ratios (RRs) and the 4 SVI themes by race/ethnicity will provide an in-depth examination of the impact that each SVI theme has to identify social and vulnerable barriers to HIV prevention and care services and pinpoint additional opportunities for enhancing prevention and control efforts. This analysis examines diagnoses of HIV infection and social vulnerability themes for Black, Hispanic/Latino, and White adults using an intersectionality analytical framework [9]. This approach is useful for understanding the health inequities different subpopulations face—and by extension, aid in achieving health equity by better understanding which populations and areas have the greatest need and where to direct resources.

Methods

Data were obtained from CDC’s National HIV Surveillance System (NHSS) and the CDC/Agency for Toxic Substances and Disease Registry (ATSDR) SVI.

NHSS

Data for adults aged ≥ 18 years with HIV diagnosed during 2019 and reported to CDC through December 2020 were obtained from NHSS. HIV surveillance data were geocoded to the US census tract level based on a person’s residential address at the time of diagnosis and then linked at the census tract level to SVI indicators. Per federal guidelines, NHSS data collection is determined a public health activity and not human subject research; therefore, our study did not require institutional review board review or approval.

SVI

SVI data were obtained from the most recent CDC/ATSDR SVI (2018) [8]. The SVI uses the US Census Bureau’s American Community Survey (ACS) 2015–2019 5-year estimates data to determine the relative social vulnerability of every census tract. For the 15 population-based social factors, census tracts above the 90th percentile, or the most vulnerable 10%, are assigned a flag. The vulnerability index is created by counting the total number of flags in each census tract. The higher the count, the more vulnerable the population [10]. SVI scores and scores for 4 social vulnerability themes, ranging from 0 to 1, were generated for each census tract based on the 15 population-based social factors and were presented as percentile rankings by census tract (with higher scores representing greater vulnerability). The SVI scores for each of the 15 social factors were grouped into the 4 themes: (1) socioeconomic status, which was based on proportions of persons below poverty, unemployment, income, and lack of high school diploma; (2) household composition and disability, which was based on age (pediatric [≤ 17 years] and elderly [≥ 65 years] populations), civilians aged > 5 years with a disability, and single-parent households; (3) minority status and English proficiency, which was based on persons who do not identify as White, non-Hispanic/Latino and speak English “less than well”; and (4) housing type and transportation, which was based on proportions of persons in multi-unit structures, mobile homes, crowding, no household vehicle access, and institutionalized group quarters. Each census tract received a separate score for each theme, as well as an overall score. SVI scores were classified into quartiles per their distribution among all US census tracts.

Analysis

We used census-tract level NHSS data from all 50 states and the District of Columbia for Black, Hispanic/Latino, and White adults with HIV diagnosed during 2019 that were linked with SVI data. Analyses were limited to data for Black, Hispanic/Latino, and White adults because percentages and/or rates for American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and multiracial adults would have been based on small numbers. For each SVI theme, data were analyzed by sex assigned at birth (male, female) and assessed by age group (18‒24, 25‒34, 35‒44, 45‒54, ≥ 55); transmission category (male-to-male sexual contact [MMSC], injection drug use [IDU], male-to-male sexual contact and injection drug use [MMSC and IDU], heterosexual contact [i.e., with a person known to have, or with a risk factor for, HIV infection], and other [i.e., including hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified]); and the four US census regions (i.e., region of residence) (Northeast, Midwest, South, and West). To measure relative disparity, rates and RRs with 95% confidence intervals (CIs) were calculated to examine the relative difference comparing census tracts with the lowest SVI scores (quartile 1, Q1) to those with the highest SVI scores (quartile 4, Q4) by sex assigned at birth for age group and region of residence by the 4 SVI themes for Black, Hispanic/Latino, and White adults. Rates were considered significantly different if the 95% CIs of the RRs excluded one. Also, differences in the numbers of diagnoses across the quartiles were analyzed by sex assigned at birth and transmission category by the 4 SVI themes for Black, Hispanic/Latino, and White adults. HIV diagnosis rates were calculated per 100,000 persons. Rates and rate ratios were not calculated for transmission categories due to lack of population data. Data were statistically adjusted using multiple imputation techniques to account for missing HIV transmission categories [11]. By theme, SVI scores were missing for 910 persons (3.3%) for socioeconomic status (Black: 425 (3.3%), Hispanic/Latino: 204 (2.7%), and White: 270 (3.7%)); 899 persons (3.2%) for household composition and disability (Black: 430 (3.3%), Hispanic/Latino: 209 (2.8%), and White: 271 (3.7%)); 891 persons (3.2%) for minority status and English proficiency (Black: 421 (3.2%), Hispanic/Latino: 202 (2.7%), and White: 268 (3.6%)); and 903 persons (3.2%) for housing type and transportation (Black: 427 (3.3%), Hispanic/Latino: 206 (2.7%), and White: 270 (3.7%)). Cases or census tracts were excluded if (1) the address was nonresidential (e.g., military base, corrections facility), (2) no census tract was associated with the case, (3) no SVI information was available for the census tract, or (4) a census tract from the surveillance data could not be matched to a census tract provided by the SVI. SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used to conduct all analyses.

Results

In 2019, there were 13,037 Black, 7548 Hispanic/Latino, and 7361 White adults aged ≥ 18 years that received a diagnosis of HIV infection. By race/ethnicity and theme, the highest percentage of HIV diagnoses was among the following: Black adults (48.3%) in Q4 (highest vulnerability) census tracts for the socioeconomic status theme, Hispanic/Latino adults (68.1%) in Q4 census tracts for the minority status and English proficiency theme, and White adults (29.4%) in Q1 (lowest vulnerability) census tracts for the household composition and disability theme.

Socioeconomic Status

Table 1 presents HIV diagnoses and SVI by selected characteristics and region of residence for the socioeconomic status theme. Overall, by race/ethnicity and sex assigned at birth, the highest HIV diagnosis rates were among those who lived in Q4 census tracts—Black males (74.6) and females (22.9), Hispanic/Latino males (33.1) and females (5.4), and White males (13.1) and females (3.7).

Table 1.

Associations between socioeconomic status theme and diagnoses of HIV infection among Black, Hispanic/Latino, and White adults aged ≥ 18 years, by selected characteristics, and region of residence, 2019—census tract level, USA

	HIV diagnoses total		Quartile 1 (lowest vulnerability)			Quartile 2			Quartile 3			Quartile 4 (highest vulnerability)			Quartile 4 vs. quartile 1
	No.	%^a	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	RR^c	95% CI
Black/African American adults
Males
Age at diagnosis (Yrs)
18–24	2859	29.2	231	8.1	104.6	419	14.7	104.5	753	26.3	119.0	1353	47.3	131.3	1.3	1.1	1.4
25–34	3783	38.7	365	9.6	110.9	555	14.7	97.7	964	25.5	113.8	1777	47.0	135.6	1.2	1.1	1.4
35–44	1414	14.5	144	10.2	45.3	232	16.4	47.2	346	24.5	50.3	636	45.0	63.5	1.4	1.2	1.7
45–54	919	9.4	100	10.9	31.2	140	15.2	29.6	224	24.4	33.7	423	46.0	42.3	1.4	1.1	1.7
55+	809	8.3	66	8.2	14.6	124	15.3	17.4	166	20.5	15.2	423	52.3	23.0	1.6	1.2	2.0
Transmission category^d
Male-to-male sexual contact	7858	80.3	727	9.3	-	1189	15.1	-	2004	25.5	-	3656	46.5	-	-	-	-
Injection drug use	297	3.0	22	7.3	-	44	14.8	-	62	20.9	-	159	53.5	-	-	-	-
Male-to-male sexual contact and injection drug use	231	2.4	22	9.6	-	39	16.8	-	57	24.7	-	108	46.5	-	-	-	-
Heterosexual contact	1389	14.2	134	9.6	-	197	14.2	-	328	23.6	-	685	49.3	-	-	-	-
Other	9	0.1	2	16.0	-	1	14.9	-	1	13.8	-	5	52.1	-	-	-	-
Region of residence
Northeast	1142	11.7	89	7.8	33.0	160	14.0	36.4	278	24.3	41.6	598	52.4	61.4	1.9	1.5	2.3
Midwest	1586	16.2	131	8.3	47.3	193	12.2	49.3	346	21.8	59.7	876	55.2	73.6	1.6	1.3	1.9
South	6483	66.3	620	9.6	69.1	1011	15.6	68.8	1674	25.8	72.3	2909	44.9	82.5	1.2	1.1	1.3
West	573	5.9	66	11.5	33.8	106	18.5	30.6	155	27.1	42.7	229	40.0	46.8	1.4	1.1	1.8
Subtotal	9784	100.0	906	9.3	55.3	1470	15.0	55.6	2453	25.1	62.5	4612	47.1	74.6	1.4	1.3	1.5
Females
Age at diagnosis (Yrs)
18–24	430	13.2	29	6.7	14.1	48	11.2	13.2	89	20.7	14.9	250	58.1	23.6	1.7	1.1	2.5
25–34	862	26.5	61	7.1	18.4	112	13.0	20.0	206	23.9	23.8	456	52.9	31.5	1.7	1.3	2.2
35–44	736	22.6	49	6.7	14.2	110	14.9	20.9	201	27.3	26.4	362	49.2	30.7	2.2	1.6	2.9
45–54	618	19.0	50	8.1	14.5	87	14.1	16.7	150	24.3	19.7	316	51.1	26.9	1.8	1.4	2.5
55+	607	18.7	55	9.1	10.0	81	13.3	9.0	152	25.0	10.5	302	49.8	12.1	1.2	0.9	1.6
Transmission category^d
Injection drug use	256	7.9	23	9.0	-	30	11.6	-	56	21.7	-	142	55.6	-	-	-	-
Heterosexual contact	2982	91.7	218	7.3	-	405	13.6	-	739	24.8	-	1539	51.6	-	-	-	-
Other	15	0.5	3	21.8	-	3	23.1	-	3	22.4	-	5	32.7	-	-	-	-
Region of residence
Northeast	479	14.7	39	8.1	13.6	75	15.7	15.7	101	21.1	13.2	259	54.1	21.2	1.6	1.1	2.2
Midwest	465	14.3	40	8.6	13.7	48	10.3	11.8	97	20.9	15.6	269	57.8	18.6	1.4	1.0	1.9
South	2130	65.5	148	6.9	14.4	278	13.1	16.6	552	25.9	20.5	1086	51.0	26.0	1.8	1.5	2.1
West	179	5.5	17	9.5	9.8	37	20.7	11.6	48	26.8	13.8	72	40.2	13.7	1.4	0.8	2.4
Subtotal	3253	100.0	244	7.5	13.7	438	13.5	15.2	798	24.5	18.0	1686	51.8	22.9	1.7	1.5	1.9
Total^e	13,037	100.0	1150	8.8	33.6	1908	14.6	34.6	3251	24.9	38.9	6298	48.3	46.5	1.4	1.3	1.5
Hispanic/Latino adults
Males
Age at diagnosis (Yrs)
18–24	1360	20.5	135	9.9	38.2	236	17.4	38.8	389	28.6	40.8	556	40.9	36.0	0.9	0.8	1.1
25–34	2687	40.6	304	11.3	57.5	491	18.3	55.3	698	26.0	52.2	1131	42.1	55.2	1.0	0.8	1.1
35–44	1421	21.5	172	12.1	32.6	248	17.5	31.0	332	23.4	27.8	632	44.5	35.6	1.1	0.9	1.3
45–54	769	11.6	95	12.4	21.5	152	19.8	24.0	174	22.6	18.7	324	42.1	23.0	1.1	0.8	1.3
55+	382	5.8	42	11.0	8.1	68	17.8	9.1	89	23.3	8.2	170	44.5	10.0	1.2	0.9	1.7
Transmission category^d
Male-to-male sexual contact	5731	86.6	664	11.6	-	1055	18.4	-	1473	25.7	-	2396	41.8	-	-	-	-
Injection drug use	181	2.7	19	10.5	-	22	11.9	-	40	22.1	-	88	48.8	-	-	-	-
Male-to-male sexual contact and injection drug use	268	4.1	33	12.2	-	48	17.8	-	75	28.1	-	101	37.7	-	-	-	-
Heterosexual contact	436	6.6	32	7.4	-	71	16.2	-	93	21.3	-	225	51.7	-	-	-	-
Other	3	0.0	0	9.7	-	0	9.7	-	1	16.1	-	2	61.3	-	-	-	-
Region of residence
Northeast	1101	16.6	119	10.8	29.0	172	15.6	33.4	273	24.8	37.4	511	46.4	44.3	1.5	1.3	1.9
Midwest	565	8.5	77	13.6	26.8	114	20.2	30.7	137	24.2	28.5	227	40.2	35.5	1.3	1.0	1.7
South	3439	52.0	400	11.6	44.5	667	19.4	47.7	916	26.6	41.1	1359	39.5	44.6	1.0	0.9	1.1
West	1514	22.9	152	10.0	19.7	242	16.0	17.4	356	23.5	17.3	716	47.3	19.6	1.0	0.8	1.2
Subtotal	6619	100.0	748	11.3	31.6	1195	18.1	32.5	1682	25.4	30.6	2813	42.5	33.1	1.0	1.0	1.1
Females
Age at diagnosis (Yrs)
18–24	127	13.7	14	11.0	4.2	13	10.2	2.3	35	27.6	3.9	59	46.5	4.0	1.0	0.5	1.7
25–34	264	28.4	21	8.0	4.0	45	17.0	5.5	64	24.2	5.4	122	46.2	6.5	1.6	1.0	2.6
35–44	213	22.9	25	11.7	4.7	33	15.5	4.3	53	24.9	4.8	98	46.0	5.8	1.3	0.8	1.9
45–54	180	19.4	16	8.9	3.4	28	15.6	4.4	46	25.6	5.2	88	48.9	6.4	1.9	1.1	3.2
55+	145	15.6	7	4.8	1.1	17	11.7	1.9	36	24.8	2.8	81	55.9	4.1	3.7	1.7	8.0
Transmission category^d
Injection drug use	113	12.1	10	9.0	-	18	16.1	-	20	17.3	-	60	52.9	-	-	-	-
Heterosexual contact	813	87.6	73	9.0	-	118	14.5	-	214	26.4	-	386	47.4	-	-	-	-
Other	3	0.3	0	0.0	0.0	0	7.1	-	0	3.6	-	3	89.3	-	-	-	-
Region of residence
Northeast	223	24.0	21	9.4	4.9	28	12.6	5.5	49	22.0	6.9	120	53.8	9.6	1.9	1.2	3.1
Midwest	74	8.0	7	9.5	2.4	13	17.6	3.7	25	33.8	5.7	26	35.1	4.4	1.8	0.8	4.1
South	475	51.1	41	8.6	4.3	77	16.2	5.4	125	26.3	5.8	218	45.9	7.4	1.7	1.2	2.4
West	157	16.9	14	8.9	1.7	18	11.5	1.3	35	22.3	1.7	84	53.5	2.3	1.4	0.8	2.4
Subtotal	929	100.0	83	8.9	3.3	136	14.6	3.7	234	25.2	4.4	448	48.2	5.4	1.6	1.3	2.0
Total^e	7548	100.0	831	11.0	17.1	1331	17.6	18.1	1916	25.4	17.6	3261	43.2	19.4	1.1	1.0	1.2
White adults
Males
Age at diagnosis (Yrs)
18–24	851	13.8	186	21.9	8.3	209	24.6	9.0	214	25.1	9.3	199	23.4	13.1	1.6	1.3	1.9
25–34	2132	34.5	435	20.4	11.4	580	27.2	15.2	543	25.5	16.6	487	22.8	27.7	2.4	2.1	2.8
35–44	1254	20.3	297	23.7	7.3	331	26.4	9.6	315	25.1	11.4	267	21.3	18.7	2.5	2.2	3.0
45–54	1042	16.9	293	28.1	6.1	265	25.4	6.9	234	22.5	7.7	208	20.0	13.0	2.1	1.8	2.5
55+	902	14.6	273	30.3	2.5	244	27.1	2.6	190	21.1	2.5	170	18.8	4.4	1.8	1.5	2.1
Transmission category^d
Male-to-male sexual contact	4865	78.7	1255	25.8	-	1298	26.7	-	1154	23.7	-	965	19.8	-	-	-	-
Injection drug use	420	6.8	56	13.4	-	102	24.4	-	105	25.0	-	140	33.3	-	-	-	-
Male-to-male sexual contact and injection drug use	547	8.8	92	16.9	-	147	26.8	-	151	27.5	-	139	25.4	-	-	-	-
Heterosexual contact	343	5.6	80	23.2	-	81	23.5	-	86	25.0	-	84	24.6	-	-	-	-
Other	6	0.1	1	20.3	-	1	21.9	-	1	21.9	-	2	34.4	-	-	-	-
Region of residence
Northeast	779	12.6	242	31.1	3.9	239	30.7	5.2	151	19.4	5.7	128	16.4	12.1	3.1	2.5	3.8
Midwest	1190	19.3	292	24.5	4.1	318	26.7	5.0	278	23.4	6.0	258	21.7	12.6	3.1	2.6	3.6
South	3016	48.8	615	20.4	8.6	737	24.4	10.4	816	27.1	9.9	720	23.9	13.9	1.6	1.5	1.8
West	1196	19.3	335	28.0	6.2	335	28.0	6.8	251	21.0	7.1	225	18.8	12.0	1.9	1.6	2.3
Subtotal	6181	100.0	1484	24.0	5.7	1629	26.4	7.1	1496	24.2	7.9	1331	21.5	13.1	2.3	2.1	2.5
Females
Age at diagnosis (Yrs)
18–24	137	11.6	16	11.7	0.8	34	24.8	1.6	33	24.1	1.5	44	32.1	2.9	3.9	2.2	6.9
25–34	347	29.4	51	14.7	1.3	87	25.1	2.3	90	25.9	2.9	112	32.3	6.8	5.1	3.7	7.1
35–44	289	24.5	35	12.1	0.9	73	25.3	2.2	73	25.3	2.7	102	35.3	7.4	8.6	5.9	12.7
45–54	239	20.3	39	16.3	0.8	51	21.3	1.3	67	28.0	2.2	78	32.6	5.0	6.3	4.3	9.3
55+	168	14.2	28	16.7	0.2	40	23.8	0.4	48	28.6	0.5	49	29.2	1.1	4.8	3.0	7.7
Transmission category^d
Injection drug use	394	33.4	43	10.8	-	99	25.1	-	90	22.9	-	155	39.3	-	-	-	-
Heterosexual contact	783	66.3	126	16.1	-	185	23.7	-	220	28.1	-	229	29.3	-	-	-	-
Other	3	0.3	1	19.4	-	1	25.8	-	1	29.0	-	1	22.6	-	-	-	-
Region of residence
Northeast	162	13.7	45	27.8	0.7	40	24.7	0.8	35	21.6	1.2	40	24.7	3.6	5.4	3.5	8.2
Midwest	239	20.3	31	13.0	0.4	65	27.2	1.0	56	23.4	1.2	84	35.1	3.9	9.4	6.3	14.2
South	636	53.9	74	11.6	1.0	135	21.2	1.8	191	30.0	2.2	216	34.0	4.0	4.1	3.1	5.3
West	143	12.1	19	13.3	0.3	45	31.5	0.9	29	20.3	0.8	45	31.5	2.4	7.0	4.1	11.9
Subtotal	1180	100.0	169	14.3	0.6	285	24.2	1.2	311	26.4	1.6	385	32.6	3.7	5.9	4.9	7.1
Total^e	7361	100.0	1653	22.5	3.1	1914	26.0	4.1	1807	24.5	4.6	1716	23.3	8.3	2.7	2.5	2.8

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Hispanic/Latino persons can be of any race. Scores for social vulnerability indices represent percentile rankings by census tract, ranging from 0 to 1, with higher scores indicating greater vulnerability. Scores were categorized into quartiles based on distribution among all US census tracts

Socioeconomic status theme factors include proportions of persons below poverty, unemployed, income, and lack of high school diploma

Abbreviations: CI, confidence interval; RR, rate ratio

^aColumn percent

^bRow percent

^cRate ratios were calculated by dividing the rate of census tracts with the highest (quartile 4) vulnerability scores by the rate of census tracts with the lowest (quartile 1) scores. Rates are statistically different if the 95% confidence interval does not include one (1.0)

^dNumbers have been adjusted for missing transmission category

^eTotal includes cases without SVI ranks

When examining RRs for within-group comparisons by race/ethnicity and sex assigned at birth, the disparities in HIV diagnosis rates (i.e., higher likelihood in Q4 compared with Q1) were as follows: Black males (RR 1.4, CI 1.3–1.5) and females (RR 1.7, CI 1.5–1.9), Hispanic/Latino males (no disparity) and females (RR 1.6, CI 1.3–2.0), and White males (RR 2.3, CI 2.1–2.5) and females (RR 5.9, CI 4.9–7.1). When examining RRs for within-group comparisons for each race/ethnicity, by age group and region of residence, the highest disparities in HIV diagnosis rates were as follows: among Black adults, males aged ≥ 55 years (RR 1.6, CI 1.2–2.0) and females aged 35‒44 years (RR 2.2, CI 1.6–2.9), and males residing in the Northeast (RR 1.9, CI 1.5–2.3) and females residing in the South (RR 1.8, CI 1.5–2.1); among Hispanic/Latino adults, females aged ≥ 55 years (RR 3.7, CI 1.7–8.0), and adults residing in the Northeast (males: RR 1.5, CI 1.3–1.9; females: RR 1.9, CI 1.2–3.1); and among White adults, those aged 35–44 years (males: RR 2.5, 95% CI 2.2–3.0; females: RR 8.6, CI 5.9–12.7), and males residing in the Northeast (RR 3.1, CI 2.5–3.8) and females residing in the Midwest (RR 9.4, CI 6.3–14.3).

When examining within-group comparisons for each race/ethnicity, by transmission category and sex assigned at birth, the largest percentage of HIV diagnoses was in Q4 for both males and females with infection attributed to IDU (except Hispanic/Latino males, where the highest percentage was for heterosexual contact). The highest disparity (i.e., higher percentage in Q4 compared with Q1) of HIV diagnoses was adults with infection attributed to IDU (except Black females and Hispanic/Latino males, where the highest disparity was for heterosexual contact).

Household Composition and Disability

Table 2 presents HIV diagnoses and SVI by selected characteristics and region of residence for the household composition and disability theme. Results by age groups are not discussed as age was a primary component in defining this theme. Overall, by race/ethnicity and sex assigned at birth, the highest HIV diagnosis rates were among Black males and females (71.5 and 19.9, respectively), Hispanic/Latino females (5.4), and White females (2.2) who lived in Q4 census tracts. For Hispanic/Latino and White males (38.3 and 8.9, respectively), the highest diagnosis rates were among those who lived in Q1 census tracts. Negative gradients from Q1 to Q4 were observed among the following: Hispanic/Latino males in the South and West and White males in the South and West.

Table 2.

Associations between household composition and disability theme and diagnoses of HIV infection among Black, Hispanic/Latino, and White adults aged ≥ 18 years, by selected characteristics, and region of residence, 2019—census tract level, USA

	HIV diagnoses total		Quartile 1 (lowest vulnerability)			Quartile 2			Quartile 3			Quartile 4 (highest vulnerability)			Quartile 4 vs. quartile 1
	No.	%^a	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	RR^c	95% CI
Black/African American adults
Males
Age at diagnosis (Yrs)
18–24	2859	29.2	478	16.7	86.1	532	18.6	116.8	672	23.5	123.2	1076	37.6	146.4	1.7	1.5	1.9
25–34	3783	38.7	748	19.8	110.2	703	18.6	106.5	900	23.8	120.1	1313	34.7	135.6	1.2	1.1	1.3
35–44	1414	14.5	293	20.7	56.0	288	20.4	51.1	308	21.8	49.0	469	33.2	59.8	1.1	0.9	1.2
45–54	919	9.4	168	18.3	34.3	168	18.3	30.7	224	24.4	36.2	327	35.6	40.6	1.2	1.0	1.4
55+	809	8.3	126	15.6	18.2	173	21.4	21.4	181	22.4	17.8	299	37.0	19.0	1.0	0.8	1.3
Transmission category^d
Male-to-male sexual contact	7858	80.3	1474	18.8	-	1498	19.1	-	1835	23.4	-	2772	35.3	-	-	-	-
Injection drug use	297	3.0	48	16.3	-	53	17.9	-	68	23.1	-	118	39.8	-	-	-	-
Male-to-male sexual contact and injection drug use	231	2.4	45	19.3	-	45	19.4	-	53	23.0	-	83	35.8	-	-	-	-
Heterosexual contact	1389	14.2	243	17.5	-	265	19.1	-	328	23.6	-	508	36.6	-	-	-	-
Other	9	0.1	3	35.1	-	2	24.5	-	1	8.5	-	3	28.7	-	-	-	-
Region of residence
Northeast	1142	11.7	225	19.7	37.4	236	20.7	43.5	236	20.7	47.3	429	37.6	60.3	1.6	1.4	1.9
Midwest	1586	16.2	218	13.7	52.0	191	12.0	49.0	367	23.1	67.6	770	48.5	70.6	1.4	1.2	1.6
South	6483	66.3	1203	18.6	81.1	1292	19.9	74.3	1511	23.3	70.7	2212	34.1	77.6	1.0	0.9	1.0
West	573	5.9	167	29.1	38.4	145	25.3	39.8	171	29.8	45.2	73	12.7	33.6	0.9	0.7	1.2
Subtotal	9784	100.0	1813	18.5	61.7	1864	19.1	61.4	2285	23.4	64.2	3484	35.6	71.5	1.2	1.1	1.2
Females
Age at diagnosis (Yrs)
18–24	430	13.2	61	14.2	11.5	62	14.4	15.0	100	23.3	19.0	193	44.9	25.2	2.2	1.6	2.9
25–34	862	26.5	136	15.8	23.5	158	18.3	25.2	210	24.4	26.1	331	38.4	27.8	1.2	1.0	1.4
35–44	736	22.6	115	15.6	23.9	146	19.8	24.7	197	26.8	27.3	264	35.9	26.0	1.1	0.9	1.4
45–54	618	19.0	98	15.9	20.3	127	20.6	21.3	141	22.8	19.5	237	38.3	23.7	1.2	0.9	1.5
55+	607	18.7	103	17.0	12.6	106	17.5	10.3	173	28.5	12.9	208	34.3	9.4	0.7	0.6	0.9
Transmission category^d
Injection drug use	256	7.9	47	18.5	-	41	16.2	-	68	26.6	-	94	36.7	-	-	-	-
Heterosexual contact	2982	91.7	463	15.5	-	554	18.6	-	750	25.2	-	1133	38.0	-	-	-	-
Other	15	0.5	3	20.4	-	3	21.1	-	2	16.3	-	6	42.2	-	-	-	-
Region of residence
Northeast	479	14.7	82	17.1	13.4	97	20.3	16.0	114	23.8	19.0	181	37.8	19.3	1.4	1.1	1.9
Midwest	465	14.3	53	11.4	14.2	64	13.8	16.3	102	21.9	16.5	235	50.5	17.0	1.2	0.9	1.6
South	2130	65.5	336	15.8	21.8	392	18.4	20.5	542	25.4	21.8	794	37.3	21.9	1.0	0.9	1.1
West	179	5.5	42	23.5	11.4	46	25.7	13.3	63	35.2	15.3	23	12.8	9.5	0.8	0.5	1.4
Subtotal	3253	100.0	513	15.8	17.7	599	18.4	18.4	821	25.2	19.942	1233	37.9	19.9	1.1	1.0	1.2
Total^e	13,037	100.0	2326	17.8	39.9	2463	18.9	39.1	3106	23.8	40.5	4717	36.2	42.7	1.1	1.0	1.1
Hispanic/Latino adults
Males
Age at diagnosis (Yrs)
18–24	1360	20.5	346	25.4	40.3	327	24.0	37.2	367	27.0	37.8	278	20.4	36.6	0.9	0.8	1.1
25–34	2687	40.6	751	27.9	64.3	670	24.9	52.6	683	25.4	50.5	520	19.4	51.4	0.8	0.7	0.9
35–44	1421	21.5	369	26.0	36.9	381	26.8	32.5	380	26.7	30.8	254	17.9	28.4	0.8	0.7	0.9
45–54	769	11.6	238	30.9	29.5	168	21.8	17.8	190	24.7	19.7	149	19.4	21.2	0.7	0.6	0.9
55+	382	5.8	104	27.2	11.8	91	23.8	8.4	95	24.9	8.4	80	20.9	8.3	0.7	0.5	0.9
Transmission category^d
Male-to-male sexual contact	5731	86.6	1618	28.2	-	1424	24.8	-	1488	26.0	-	1061	18.5	-	-	-	-
Injection drug use	181	2.7	39	21.3	-	34	18.6	-	39	21.4	-	58	32.0	-	-	-	-
Male-to-male sexual contact and injection drug use	268	4.1	63	23.3	-	68	25.2	-	70	26.1	-	57	21.2	-	-	-	-
Heterosexual contact	436	6.6	88	20.2	-	111	25.5	-	117	26.9	-	105	24.1	-	-	-	-
Other	3	0.0	1	25.8	-	1	32.3	-	1	25.8	-	0	12.9	-	-	-	-
Region of residence
Northeast	1101	16.6	304	27.6	34.7	258	23.4	37.1	234	21.3	39.1	280	25.4	43.7	1.3	1.1	1.5
Midwest	565	8.5	141	25.0	34.2	145	25.7	30.7	140	24.8	28.1	129	22.8	32.3	0.9	0.7	1.2
South	3439	52.0	940	27.3	59.4	883	25.7	43.6	863	25.1	41.1	658	19.1	35.2	0.6	0.5	0.7
West	1514	22.9	423	27.9	22.9	351	23.2	16.2	478	31.6	19.5	214	14.1	15.0	0.7	0.6	0.8
Subtotal	6619	100.0	1808	27.3	38.3	1637	24.7	30.6	1715	25.9	30.3	1281	19.4	29.6	0.8	0.7	0.8
Females
Age at diagnosis (Yrs)
18–24	127	13.7	23	18.1	2.8	30	23.6	3.6	34	26.8	3.7	34	26.8	4.7	1.7	1.0	2.9
25–34	264	28.4	48	18.2	4.8	80	30.3	7.0	59	22.3	4.7	65	24.6	6.5	1.4	0.9	2.0
35–44	213	22.9	44	20.7	4.9	61	28.6	5.5	52	24.4	4.4	52	24.4	5.8	1.2	0.8	1.7
45–54	180	19.4	41	22.8	5.3	40	22.2	4.3	50	27.8	5.3	48	26.7	6.7	1.3	0.8	1.9
55+	145	15.6	26	17.9	2.5	30	20.7	2.4	44	30.3	3.4	42	29.0	3.7	1.5	0.9	2.4
Transmission category^d
Injection drug use	113	12.1	26	22.9	-	22	19.7	-	25	22.4	-	34	30.3	-	-	-	-
Heterosexual contact	813	87.6	156	19.2	-	218	26.8	-	212	26.1	-	207	25.4	-	-	-	-
Other	3	0.3	0	3.6	-	1	39.3	-	1	50.0	-	0	7.1	-	-	-	-
Region of residence
Northeast	223	24.0	51	22.9	6.0	42	18.8	6.1	49	22.0	8.0	76	34.1	10.2	1.7	1.2	2.4
Midwest	74	8.0	17	23.0	4.5	17	23.0	3.9	19	25.7	4.1	18	24.3	4.7	1.0	0.5	2.0
South	475	51.1	79	16.6	5.2	136	28.6	6.9	123	25.9	5.9	123	25.9	6.5	1.2	0.9	1.7
West	157	16.9	35	22.3	2.0	46	29.3	2.1	48	30.6	2.0	24	15.3	1.6	0.8	0.5	1.4
Subtotal	929	100.0	182	19.6	4.0	241	25.9	4.6	239	25.7	4.3	241	25.9	5.4	1.3	1.1	1.6
Total^e	7548	100.0	1990	26.4	21.5	1878	24.9	17.7	1954	25.9	17.3	1522	20.2	17.3	0.8	0.8	0.9
White adults
Males
Age at diagnosis (Yrs)
18–24	851	13.8	245	28.8	7.8	194	22.8	9.6	187	22.0	10.2	182	21.4	12.5	1.6	1.3	1.9
25–34	2132	34.5	660	31.0	16.2	487	22.8	15.0	477	22.4	16.1	422	19.8	17.6	1.1	1.0	1.2
35–44	1254	20.3	402	32.1	11.8	293	23.4	9.1	264	21.1	9.3	251	20.0	11.4	1.0	0.8	1.1
45–54	1042	16.9	353	33.9	9.5	242	23.2	6.4	220	21.1	6.7	185	17.8	7.3	0.8	0.6	0.9
55+	902	14.6	288	31.9	3.8	238	26.4	2.6	176	19.5	2.1	175	19.4	2.7	0.7	0.6	0.9
Transmission category^d
Male-to-male sexual contact	4865	78.7	1651	33.9	-	1142	23.5	-	1012	20.8	-	867	17.8	-	-	-	-
Injection drug use	420	6.8	69	16.3	-	109	26.0	-	86	20.5	-	140	33.2	-	-	-	-
Male-to-male sexual contact and injection drug use	547	8.8	139	25.4	-	121	22.1	-	136	24.9	-	133	24.3	-	-	-	-
Heterosexual contact	343	5.6	87	25.4	-	80	23.4	-	89	25.8	-	74	21.6	-	-	-	-
Other	6	0.1	3	39.1	-	1	14.1	-	2	25.0	-	1	20.3	-	-	-	-
Region of residence
Northeast	779	12.6	300	38.5	5.7	204	26.2	4.6	144	18.5	4.7	112	14.4	6.4	1.1	0.9	1.4
Midwest	1190	19.3	320	26.9	6.4	259	21.8	4.8	271	22.8	5.0	296	24.9	7.0	1.1	0.9	1.3
South	3016	48.8	825	27.4	13.2	702	23.3	9.8	667	22.1	9.1	695	23.0	10.1	0.8	0.7	0.8
West	1196	19.3	503	42.1	9.2	289	24.2	6.5	242	20.2	6.8	112	9.4	4.9	0.5	0.4	0.7
Subtotal	6181	100.0	1948	31.5	8.9	1454	23.5	6.8	1324	21.4	6.8	1215	19.7	8.0	0.9	0.8	1.0
Females
Age at diagnosis (Yrs)
18–24	137	11.6	19	13.9	0.6	29	21.2	1.6	33	24.1	2.0	46	33.6	3.3	5.4	3.2	9.2
25–34	347	29.4	59	17.0	1.5	83	23.9	2.7	88	25.4	3.0	110	31.7	4.5	2.9	2.1	4.0
35–44	289	24.5	54	18.7	1.7	69	23.9	2.2	74	25.6	2.6	86	29.8	3.8	2.3	1.6	3.2
45–54	239	20.3	41	17.2	1.1	62	25.9	1.6	55	23.0	1.7	77	32.2	3.0	2.6	1.8	3.9
55+	168	14.2	41	24.4	0.5	36	21.4	0.3	44	26.2	0.5	44	26.2	0.6	1.1	0.8	1.8
Transmission category^d
Injection drug use	394	33.4	58	14.7	-	99	25.1	-	101	25.5	-	130	32.9	-	-	-	-
Heterosexual contact	783	66.3	155	19.8	-	180	22.9	-	193	24.7	-	232	29.6	-	-	-	-
Other	3	0.3	1	25.8	-	1	16.1	-	0	9.7	-	1	45.2	-	-	-	-
Region of residence
Northeast	162	13.7	50	30.9	0.9	39	24.1	0.8	32	19.8	1.0	39	24.1	2.0	2.2	1.5	3.4
Midwest	239	20.3	28	11.7	0.6	49	20.5	0.9	65	27.2	1.1	94	39.3	2.0	3.7	2.4	5.6
South	636	53.9	94	14.8	1.5	156	24.5	2.1	159	25.0	2.0	207	32.5	2.7	1.8	1.4	2.3
West	143	12.1	42	29.4	0.8	35	24.5	0.8	38	26.6	1.0	23	16.1	1.0	1.2	0.7	2.0
Subtotal	1180	100.0	214	18.1	1.0	279	23.6	1.2	294	24.9	1.4	363	30.8	2.2	2.3	1.9	2.7
Total^e	7361	100.0	2162	29.4	4.9	1733	23.5	3.9	1618	22.0	4.1	1578	21.4	5.0	1.0	1.0	1.1

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Household composition and disability theme factors include proportions of persons aged ≥ 65 years, aged ≤ 17 years, aged > 5 years with a disability, and single-parent households

Abbreviations: CI, confidence interval; RR, rate ratio

^aColumn percent

^bRow percent

^dNumbers have been adjusted for missing transmission category

^eTotal includes cases without SVI ranks

When examining RRs for within-group comparisons by race/ethnicity and sex assigned at birth, the disparities in HIV diagnosis rates (i.e., higher likelihood in Q4 compared with Q1) were as follows: Black males (RR 1.2, CI 1.1–1.2) and females (RR 1.1, CI 1.0–1.1), Hispanic/Latino males (RR 0.8, CI 0.7–0.8) and females (RR 1.3, CI 1.1–1.6), and White males (RR 0.9, CI 0.8–1.0) and females (RR 2.3, CI 1.9–2.7). When examining RRs for within-group comparisons for each race/ethnicity, by region of residence, the highest disparities in HIV diagnosis rates were as follows: Among Black adults, those residing in the Northeast (males: RR 1.6, CI 1.4–1.9; and females: RR 1.4, CI 1.1–1.9); among Hispanic/Latino adults, those residing in the Northeast (males: RR 1.3, CI 1.1–1.5 and females: RR 1.7, CI 1.2–2.4); and among White adults, males in the South (RR 0.8, CI 0.7–0.8) and females in the Midwest (RR 3.7, CI 2.4–5.6).

When examining within-group comparisons for each race/ethnicity, by transmission category and sex assigned at birth, the largest percentage of HIV diagnoses was in Q4 for adults with infection attributed to IDU (except Black females, where the highest percentage was for heterosexual contact). The highest disparities (i.e., higher percentage in Q4 compared with Q1) of HIV diagnoses were adults with infection attributed to IDU (except Black females where the highest disparity was for both IDU and heterosexual contact).

Minority Status and English Proficiency

Table 3 presents HIV diagnoses and SVI by selected characteristics and region of residence for the minority status and English proficiency theme. Overall, by race/ethnicity and sex assigned at birth, the highest HIV diagnosis rates were among those who lived in Q4 census tracts—Black males (72.7) and females (23.7), Hispanic/Latino males (33.9) and females (5.1), and White males (15.6) and females (3.1).

Table 3.

Associations between minority status and English proficiency theme and diagnoses of HIV infection among Black, Hispanic/Latino, and White adults aged ≥ 18 years, by selected characteristics, and region of residence, 2019—census tract level, USA

	HIV diagnoses total		Quartile 1 (lowest vulnerability)			Quartile 2			Quartile 3			Quartile 4 (highest vulnerability)			Quartile 4 vs. quartile 1
	No.	%^a	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	RR^c	95% CI
Black/African American adults
Males
Age at diagnosis (Yrs)
18–24	2859	29.2	91	3.2	68.6	567	19.8	103.1	1006	35.2	125.6	1095	38.3	133.0	1.9	1.6	2.4
25–34	3783	38.7	142	3.8	92.6	692	18.3	109.5	1295	34.2	120.2	1535	40.6	125.6	1.4	1.1	1.6
35–44	1414	14.5	51	3.6	37.2	242	17.1	46.4	457	32.3	51.1	608	43.0	62.9	1.7	1.3	2.2
45–54	919	9.4	32	3.5	23.5	149	16.2	28.6	302	32.9	34.8	404	44.0	42.4	1.8	1.3	2.6
55+	809	8.3	31	3.8	13.2	132	16.3	14.5	257	31.8	18.1	362	44.7	23.5	1.8	1.2	2.6
Transmission category^d
Male-to-male sexual contact	7858	80.3	282	3.6	-	1469	18.7	-	2681	34.1	-	3151	40.1	-	-	-	-
Injection drug use	297	3.0	9	3.0	-	52	17.4	-	89	30.0	-	138	46.7	-	-	-	-
Male-to-male sexual contact and injection drug use	231	2.4	7	2.9	-	40	17.5	-	75	32.3	-	104	44.9	-	-	-	-
Heterosexual contact	1389	14.2	48	3.4	-	219	15.8	-	468	33.7	-	609	43.9	-	-	-	-
Other	9	0.1	1	12.8	-	2	22.3	-	4	41.5	-	2	20.2	-	-	-	-
Region of residence
Northeast	1142	11.7	25	2.2	25.0	100	8.8	37.2	237	20.8	40.1	764	66.9	54.1	2.2	1.5	3.2
Midwest	1586	16.2	105	6.6	45.5	401	25.3	56.0	649	40.9	65.4	391	24.7	76.1	1.7	1.3	2.1
South	6483	66.3	202	3.1	46.5	1246	19.2	61.4	2296	35.4	73.7	2478	38.2	92.6	2.0	1.7	2.3
West	573	5.9	15	2.6	51.7	35	6.1	29.0	135	23.6	37.2	371	64.7	41.1	0.8	0.5	1.3
Subtotal	9784	100.0	347	3.5	43.7	1782	18.2	56.8	3317	33.9	65.5	4004	40.9	72.7	1.7	1.5	1.9
Females
Age at diagnosis (Yrs)
18–24	430	13.2	15	3.5	14.0	75	17.4	14.6	135	31.4	17.2	191	44.4	23.0	1.6	1.0	2.8
25–34	862	26.5	22	2.6	17.1	126	14.6	20.2	278	32.3	24.7	409	47.4	30.8	1.8	1.2	2.8
35–44	736	22.6	17	2.3	13.7	96	13.0	17.1	248	33.7	24.9	361	49.0	31.9	2.3	1.4	3.8
45–54	618	19.0	16	2.6	12.3	108	17.5	19.1	193	31.2	19.5	286	46.3	25.6	2.1	1.3	3.5
55+	607	18.7	20	3.3	7.5	101	16.6	8.7	175	28.8	9.2	294	48.4	14.1	1.9	1.2	3.0
Transmission category^d
Injection drug use	256	7.9	6	2.4	-	42	16.5	-	80	31.4	-	122	47.6	-	-	-	-
Heterosexual contact	2982	91.7	80	2.7	-	460	15.4	-	944	31.7	-	1416	47.5	-	-	-	-
Other	15	0.5	4	24.5	-	4	24.5	-	4	27.9	-	3	23.1	-	-	-	-
Region of residence
Northeast	479	14.7	14	2.9	16.3	42	8.8	15.6	96	20.0	14.8	322	67.2	18.4	1.1	0.7	1.9
Midwest	465	14.3	31	6.7	16.1	107	23.0	14.0	183	39.4	15.5	133	28.6	21.3	1.3	0.9	2.0
South	2130	65.5	43	2.0	9.4	341	16.0	14.9	709	33.3	19.5	971	45.6	30.5	3.3	2.4	4.4
West	179	5.5	2	1.1	9.7	16	8.9	16.8	41	22.9	12.9	115	64.2	12.3	1.3	0.3	5.1
Subtotal	3253	100.0	90	2.8	11.9	506	15.6	14.8	1029	31.6	17.8	1541	47.4	23.7	2.0	1.6	2.5
Total^e	13,037	100.0	437	3.4	28.2	2288	17.6	34.9	4346	33.3	40.1	5545	42.5	46.2	1.6	1.5	1.8
Hispanic/Latino adults
Males
Age at diagnosis (Yrs)
18–24	1360	20.5	42	3.1	29.8	117	8.6	30.5	285	21.0	37.8	874	64.3	39.7	1.3	1.0	1.8
25–34	2687	40.6	63	2.3	37.2	196	7.3	44.6	543	20.2	51.8	1824	67.9	57.5	1.5	1.2	2.0
35–44	1421	21.5	33	2.3	21.0	103	7.2	25.4	260	18.3	27.7	988	69.5	35.1	1.7	1.2	2.4
45–54	769	11.6	25	3.3	20.2	63	8.2	20.4	132	17.2	18.5	525	68.3	23.0	1.1	0.8	1.7
55+	382	5.8	12	3.1	7.4	26	6.8	7.1	70	18.3	8.6	262	68.6	9.6	1.3	0.7	2.3
Transmission category^d
Male-to-male sexual contact	5731	86.6	151	2.6	-	442	7.7	-	1103	19.3	-	3896	68.0	-	-	-	-
Injection drug use	181	2.7	9	4.9	-	12	6.8	-	37	20.4	-	112	61.8	-	-	-	-
Male-to-male sexual contact and injection drug use	268	4.1	6	2.4	-	25	9.1	-	75	27.8	-	152	56.5	-	-	-	-
Heterosexual contact	436	6.6	9	2.0	-	26	5.9	-	75	17.2	-	312	71.6	-	-	-	-
Other	3	0.0	0	6.5	-	0	9.7	-	0	9.7	-	2	71.0	-	-	-	-
Region of residence
Northeast	1101	16.6	26	2.4	20.3	66	6.0	23.0	177	16.1	34.0	808	73.4	42.9	2.1	1.4	3.1
Midwest	565	8.5	47	8.3	19.7	106	18.8	29.7	147	26.0	34.3	255	45.1	33.7	1.7	1.3	2.3
South	3439	52.0	72	2.1	31.4	240	7.0	33.3	699	20.3	39.5	2334	67.9	47.9	1.5	1.2	1.9
West	1514	22.9	30	2.0	19.0	93	6.1	17.3	267	17.6	17.2	1076	71.1	18.9	1.0	0.7	1.4
Subtotal	6619	100.0	175	2.6	23.2	505	7.6	26.5	1290	19.5	30.2	4473	67.6	33.9	1.5	1.3	1.7
Females
Age at diagnosis (Yrs)
18–24	127	13.7	3	2.4	2.3	11	8.7	3.1	17	13.4	2.4	90	70.9	4.3	1.9	0.6	5.9
25–34	264	28.4	7	2.7	4.5	19	7.2	4.8	35	13.3	3.7	191	72.3	6.6	1.5	0.7	3.1
35–44	213	22.9	5	2.3	3.4	22	10.3	5.8	40	18.8	4.5	142	66.7	5.3	1.6	0.6	3.8
45–54	180	19.4	4	2.2	3.2	14	7.8	4.6	30	16.7	4.3	131	72.8	5.8	1.8	0.7	4.9
55+	145	15.6	2	1.4	1.1	6	4.1	1.4	20	13.8	2.1	114	78.6	3.5	3.3	0.8	13.2
Transmission category^d
Injection drug use	113	12.1	3	2.4	-	11	9.7	-	19	16.8	-	75	66.5	-	-	-	-
Heterosexual contact	813	87.6	18	2.2	-	61	7.5	-	123	15.1	-	590	72.6	-	-	-	-
Other	3	0.3	0	0.0	0.0	0	3.6	-	0	0.0	0.0	3	96.4	-	-	-	-
Region of residence
Northeast	223	24.0	6	2.7	4.7	16	7.2	5.7	22	9.9	4.2	174	78.0	8.8	1.9	0.8	4.2
Midwest	74	8.0	4	5.4	1.7	11	14.9	3.4	18	24.3	4.5	38	51.4	5.4	3.2	1.1	8.8
South	475	51.1	9	1.9	4.1	37	7.8	5.3	78	16.4	4.5	337	70.9	7.0	1.7	0.9	3.3
West	157	16.9	2	1.3	1.3	8	5.1	1.5	24	15.3	1.5	119	75.8	2.1	1.7	0.4	6.8
Subtotal	929	100.0	21	2.3	2.8	72	7.8	3.9	142	15.3	3.4	668	71.9	5.1	1.8	1.2	2.8
Total^e	7548	100.0	196	2.6	13.1	577	7.6	15.4	1432	19.0	16.9	5141	68.1	19.5	1.5	1.3	1.7
White adults
Males
Age at diagnosis (Yrs)
18–24	851	13.8	167	19.6	6.4	217	25.5	7.6	260	30.6	12.0	165	19.4	19.1	3.0	2.4	3.7
25–34	2132	34.5	383	18.0	10.4	546	25.6	14.6	566	26.5	16.3	552	25.9	30.7	3.0	2.6	3.4
35–44	1254	20.3	255	20.3	6.7	325	25.9	9.1	359	28.6	12.1	271	21.6	19.7	3.0	2.5	3.5
45–54	1042	16.9	205	19.7	4.5	274	26.3	6.7	301	28.9	9.4	220	21.1	15.1	3.3	2.8	4.0
55+	902	14.6	180	20.0	1.6	243	26.9	2.5	264	29.3	3.6	190	21.1	5.5	3.5	2.8	4.3
Transmission category^d
Male-to-male sexual contact	4865	78.7	891	18.3	-	1271	26.1	-	1389	28.6	-	1121	23.0	-	-	-	-
Injection drug use	420	6.8	105	25.0	-	112	26.6	-	98	23.3	-	90	21.5	-	-	-	-
Male-to-male sexual contact and injection drug use	547	8.8	120	21.9	-	128	23.4	-	171	31.3	-	110	20.2	-	-	-	-
Heterosexual contact	343	5.6	74	21.5	-	92	26.9	-	89	26.0	-	75	21.9	-	-	-	-
Other	6	0.1	1	10.9	-	2	26.6	-	3	45.3	-	1	15.6	-	-	-	-
Region of residence
Northeast	779	12.6	181	23.2	3.3	214	27.5	4.8	172	22.1	5.7	193	24.8	13.0	4.0	3.2	4.9
Midwest	1190	19.3	397	33.4	3.9	348	29.2	5.8	268	22.5	9.0	133	11.2	16.1	4.2	3.4	5.1
South	3016	48.8	491	16.3	6.4	801	26.6	8.8	925	30.7	11.8	674	22.3	21.6	3.4	3.0	3.8
West	1196	19.3	121	10.1	4.7	242	20.2	5.6	385	32.2	7.2	398	33.3	11.3	2.4	2.0	2.9
Subtotal	6181	100.0	1190	19.3	4.6	1605	26.0	6.7	1750	28.3	9.1	1398	22.6	15.6	3.4	3.2	3.7
Females
Age at diagnosis (Yrs)
18–24	137	11.6	31	22.6	1.3	38	27.7	1.4	37	27.0	1.8	21	15.3	2.6	2.0	1.2	3.5
25–34	347	29.4	82	23.6	2.2	74	21.3	2.0	112	32.3	3.4	72	20.7	4.3	1.9	1.4	2.7
35–44	289	24.5	55	19.0	1.4	67	23.2	1.9	83	28.7	2.9	78	27.0	6.2	4.3	3.1	6.1
45–54	239	20.3	58	24.3	1.3	64	26.8	1.5	50	20.9	1.6	63	26.4	4.6	3.7	2.6	5.3
55+	168	14.2	32	19.0	0.3	44	26.2	0.4	45	26.8	0.5	44	26.2	1.1	4.4	2.8	6.9
Transmission category^d
Injection drug use	394	33.4	93	23.7	-	100	25.3	-	104	26.3	-	90	22.9	-	-	-	-
Heterosexual contact	783	66.3	163	20.9	-	187	23.8	-	223	28.5	-	187	23.9	-	-	-	-
Other	3	0.3	1	45.2	-	1	29.0	-	0	12.9	-	0	9.7	-	-	-	-
Region of residence
Northeast	162	13.7	25	15.4	0.4	45	27.8	0.9	42	25.9	1.3	48	29.6	3.1	7.2	4.4	11.7
Midwest	239	20.3	89	37.2	0.8	64	26.8	1.0	51	21.3	1.6	32	13.4	3.7	4.4	3.0	6.6
South	636	53.9	126	19.8	1.6	160	25.2	1.7	187	29.4	2.3	143	22.5	4.5	2.9	2.3	3.7
West	143	12.1	18	12.6	0.7	18	12.6	0.4	47	32.9	0.9	55	38.5	1.6	2.3	1.4	3.9
Subtotal	1180	100.0	258	21.9	0.9	287	24.3	1.1	327	27.7	1.6	278	23.6	3.1	3.2	2.7	3.8
Total^e	7361	100.0	1448	19.7	2.7	1892	25.7	3.8	2077	28.2	5.3	1676	22.8	9.3	3.4	3.2	3.7

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Minority status and English proficiency theme factors include proportion of racial and ethnic minority residents and speak English “less than well”

Abbreviations: CI, confidence interval; RR, rate ratio.

^aColumn percent

^bRow percent

^dNumbers have been adjusted for missing transmission category

^eTotal includes cases without SVI ranks

When examining RRs for within-group comparisons by race/ethnicity and sex assigned at birth, the disparities in HIV diagnosis rates (i.e., higher likelihood in Q4 compared with Q1) were as follows: Black males (RR 1.7, CI 1.5–1.9) and females (RR 2.0, CI 1.6–2.5), Hispanic/Latino males (RR 1.5, CI 1.3–1.7) and females (RR 1.8, CI 1.2–2.8), and White males (RR 3.4, CI 3.2–3.7) and females (RR 3.2, CI 2.7–3.8). When examining RRs for within-group comparisons for each race/ethnicity, by age group and region of residence, the highest disparities in HIV diagnosis rates were as follows: among Black adults, males aged 18‒24 years (RR 1.9, CI 1.6–2.4) and females aged 35‒44 years (RR 2.3, CI 1.4–3.8), and males residing in the Northeast (RR 2.2, CI 1.4–3.2) and females residing in the South (RR 3.3, CI 2.4–4.4); among Hispanic/Latino adults, males aged 35‒44 years (RR 1.7, CI 1.2-2.4), and males residing in the Northeast (RR 2.1, CI 1.4–3.1) and females residing in the Midwest (RR 3.2, CI 1.1–8.8); and among White adults, those aged ≥55 years (males: RR 3.5, CI 2.8–4.3; and females: RR 4.4, CI 2.8–6.9), and males residing in the Midwest (RR 4.2, CI 3.4–5.1) and females residing in the Northeast (RR 7.2, CI 4.4–11.7).

When examining within-group comparisons for each race/ethnicity, by transmission category and sex assigned at birth, the largest percentage of HIV diagnoses was in Q4 for adults with infection attributed to IDU for Black males and females, heterosexual contact for Hispanic/Latino males and females, MMSC for White males, and heterosexual contact for White females. The highest disparity (i.e., higher percentage in Q4 compared with Q1) of HIV diagnoses was attributed to MMSC/IDU for Black males and IDU for females, heterosexual contact for Hispanic/Latino males and females, MMSC for White males, and heterosexual contact for White females.

Housing Type and Transportation

Table 4 presents HIV diagnoses and SVI by selected characteristics and region of residence for the housing type and transportation theme. Overall, by race/ethnicity and sex assigned at birth, the highest HIV diagnosis rates were among those who lived in Q4 census tracts—Black males (68.7) and females (22.7), Hispanic/Latino males (35.7) and females (5.5), and White males (10.9) and females (2.1).

Table 4.

Associations between housing type and transportation theme and diagnoses of HIV infection among Black, Hispanic/Latino, and White adults aged ≥ 18 years, by selected characteristics, and region of residence, 2019—census tract-level, USA

	HIV diagnoses total		Quartile 1 (lowest vulnerability)			Quartile 2			Quartile 3			Quartile 4 (highest vulnerability)			Quartile 4 vs. quartile 1
	No.	%^a	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	No.	%^b	Rate	RR^c	95% CI
Black/African American Adults
Males
Age at diagnosis (Yrs)
18–24	2859	29.2	406	14.2	111.7	649	22.7	132.1	787	27.5	131.4	915	32.0	110.2	1.0	0.9	1.1
25–34	3783	38.7	469	12.4	100.8	790	20.9	117.6	1094	28.9	129.9	1311	34.7	121.9	1.2	1.1	1.3
35–44	1414	14.5	196	13.9	43.2	287	20.3	50.6	383	27.1	58.0	492	34.8	60.3	1.4	1.2	1.6
45–54	919	9.4	125	13.6	26.3	189	20.6	33.6	258	28.1	40.2	315	34.3	40.3	1.5	1.2	1.9
55+	809	8.3	105	13.0	14.8	160	19.8	17.2	197	24.4	18.2	316	39.1	23.0	1.6	1.2	1.9
Transmission category^d
Male-to-male sexual contact	7858	80.3	1048	13.3	-	1705	21.7	-	2205	28.1	-	2621	33.4	-	-	-	-
Injection drug use	297	3.0	42	14.1	-	58	19.7	-	71	24.0	-	115	38.9	-	-	-	-
Male-to-male sexual contact and injection drug use	231	2.4	28	12.2	-	54	23.4	-	58	24.9	-	86	37.1	-	-	-	-
Heterosexual contact	1389	14.2	183	13.1	-	256	18.4	-	381	27.5	-	524	37.7	-	-	-	-
Other	9	0.1	1	7.4	-	2	23.4	-	4	38.3	-	3	27.7	-	-	-	-
Region of residence
Northeast	1142	11.7	110	9.6	38.3	171	15.0	38.5	325	28.5	48.8	518	45.4	54.5	1.4	1.2	1.7
Midwest	1586	16.2	262	16.5	55.6	414	26.1	67.7	448	28.2	66.3	422	26.6	61.8	1.1	1.0	1.3
South	6483	66.3	872	13.5	58.7	1399	21.6	73.7	1798	27.7	83.9	2149	33.1	80.2	1.4	1.3	1.5
West	573	5.9	57	9.9	25.7	91	15.9	34.3	148	25.8	43.5	260	45.4	46.0	1.8	1.3	2.4
Subtotal	9784	100.0	1301	13.3	52.7	2075	21.2	64.4	2719	27.8	71.1	3349	34.2	68.7	1.3	1.2	1.4
Females
Age at diagnosis (Yrs)
18–24	430	13.2	63	14.7	19.1	73	17.0	15.6	116	27.0	19.4	164	38.1	19.7	1.0	0.8	1.4
25–34	862	26.5	106	12.3	22.0	169	19.6	23.7	234	27.1	26.1	326	37.8	29.3	1.3	1.1	1.7
35–44	736	22.6	86	11.7	16.4	138	18.8	20.9	215	29.2	28.5	283	38.5	32.5	2.0	1.6	2.5
45–54	618	19.0	64	10.4	11.9	132	21.4	20.1	177	28.6	23.9	230	37.2	26.6	2.2	1.7	2.9
55+	607	18.7	70	11.5	7.9	122	20.1	9.9	161	26.5	10.9	237	39.0	13.2	1.7	1.3	2.2
Transmission category^d
Injection drug use	256	7.9	25	9.7	-	48	18.7	-	74	28.9	-	104	40.6	-	-	-	-
Heterosexual contact	2982	91.7	362	12.1	-	583	19.6	-	824	27.6	-	1132	38.0	-	-	-	-
Other	15	0.5	2	15.6	-	3	18.4	-	5	36.7	-	4	29.3	-	-	-	-
Region of residence
Northeast	479	14.7	41	8.6	13.4	66	13.8	12.7	134	28.0	16.8	233	48.6	20.6	1.5	1.1	2.1
Midwest	465	14.3	71	15.3	13.4	103	22.2	14.3	125	26.9	16.0	155	33.3	21.3	1.6	1.2	2.1
South	2130	65.5	258	12.1	15.0	441	20.7	19.7	598	28.1	23.5	767	36.0	25.1	1.7	1.5	1.9
West	179	5.5	19	10.6	9.1	24	13.4	9.4	46	25.7	13.5	85	47.5	15.1	1.7	1.0	2.7
Subtotal	3253	100.0	389	12.0	14.1	634	19.5	17.0	903	27.8	20.2	1240	38.1	22.7	1.6	1.4	1.8
Total^e	13,037	100.0	1690	13.0	32.3	2709	20.8	38.9	3622	27.8	43.7	4589	35.2	44.3	1.4	1.3	1.5
Hispanic/Latino adults
Males
Age at diagnosis (Yrs)
18–24	1360	20.5	175	12.9	36.5	221	16.3	31.1	402	29.6	42.1	519	38.2	39.5	1.1	0.9	1.3
25–34	2687	40.6	275	10.2	44.1	535	19.9	54.2	722	26.9	53.6	1092	40.6	59.0	1.3	1.2	1.5
35–44	1421	21.5	174	12.2	26.7	251	17.7	27.7	386	27.2	32.3	573	40.3	37.0	1.4	1.2	1.6
45–54	769	11.6	79	10.3	14.3	165	21.5	22.9	208	27.0	22.0	293	38.1	24.5	1.7	1.3	2.2
55+	382	5.8	61	16.0	9.5	59	15.4	6.9	106	27.7	9.4	144	37.7	10.0	1.1	0.8	1.4
Transmission category^d
Male-to-male sexual contact	5731	86.6	668	11.7	-	1059	18.5	-	1582	27.6	-	2282	39.8	-	-	-	-
Injection drug use	181	2.7	21	11.5	-	28	15.2	-	46	25.3	-	75	41.3	-	-	-	-
Male-to-male sexual contact and injection drug use	268	4.1	33	12.4	-	58	21.6	-	73	27.3	-	93	34.5	-	-	-	-
Heterosexual contact	436	6.6	42	9.6	-	86	19.9	-	122	28.0	-	171	39.2	-	-	-	-
Other	3	0.0	0	12.9	-	0	12.9	-	1	22.6	-	2	48.4	-	-	-	-
Region of residence
Northeast	1101	16.6	79	7.2	25.6	132	12.0	29.7	304	27.6	37.2	561	51.0	45.3	1.8	1.4	2.2
Midwest	565	8.5	85	15.0	25.5	139	24.6	29.2	178	31.5	35.2	153	27.1	32.9	1.3	1.0	1.7
South	3439	52.0	472	13.7	35.6	725	21.1	40.4	951	27.7	46.2	1195	34.7	49.9	1.4	1.3	1.6
West	1514	22.9	128	8.5	13.0	235	15.5	16.0	391	25.8	17.9	712	47.0	21.9	1.7	1.4	2.0
Subtotal	6619	100.0	764	11.5	25.9	1231	18.6	29.4	1824	27.6	32.8	2621	39.6	35.7	1.4	1.3	1.5
Females
Age at diagnosis (Yrs)
18–24	127	13.7	14	11.0	3.1	22	17.3	3.3	30	23.6	3.3	55	43.3	4.4	1.4	0.8	2.6
25–34	264	28.4	20	7.6	3.3	49	18.6	5.3	75	28.4	6.1	108	40.9	6.6	2.0	1.2	3.2
35–44	213	22.9	27	12.7	4.1	40	18.8	4.6	55	25.8	4.9	87	40.8	6.1	1.5	1.0	2.3
45–54	180	19.4	18	10.0	3.1	34	18.9	4.7	53	29.4	5.7	73	40.6	6.4	2.0	1.2	3.4
55+	145	15.6	19	13.1	2.5	22	15.2	2.2	30	20.7	2.3	71	49.0	4.2	1.7	1.0	2.8
Transmission category^d
Injection drug use	113	12.1	8	7.5	-	18	16.1	-	25	22.3	-	56	49.4	-	-	-	-
Heterosexual contact	813	87.6	90	11.0	-	148	18.2	-	218	26.8	-	337	41.4	-	-	-	-
Other	3	0.3	0	0.0	0.0	1	39.3	-	0	7.1	-	2	53.6	-	-	-	-
Region of residence
Northeast	223	24.0	14	6.3	4.5	21	9.4	4.7	53	23.8	6.4	130	58.3	9.9	2.2	1.3	3.9
Midwest	74	8.0	15	20.3	4.5	17	23.0	3.8	21	28.4	4.5	18	24.3	4.3	1.0	0.5	1.9
South	475	51.1	56	11.8	4.0	105	22.1	5.8	133	28.0	6.5	167	35.2	7.4	1.8	1.4	2.5
West	157	16.9	13	8.3	1.3	24	15.3	1.6	36	22.9	1.7	79	50.3	2.5	2.0	1.1	3.5
Subtotal	929	100.0	98	10.5	3.2	167	18.0	4.0	243	26.2	4.4	394	42.4	5.5	1.7	1.4	2.1
Total^e	7548	100.0	862	11.4	14.3	1398	18.5	16.7	2067	27.4	18.7	3015	39.9	20.8	1.5	1.3	1.6
White adults
Males
Age at diagnosis (Yrs)
18–24	851	13.8	173	20.3	8.3	192	22.6	9.4	206	24.2	10.3	237	27.8	10.4	1.3	1.0	1.5
25–34	2132	34.5	395	18.5	12.4	465	21.8	14.2	541	25.4	17.0	645	30.3	21.2	1.7	1.5	1.9
35–44	1254	20.3	252	20.1	7.2	299	23.8	9.6	302	24.1	11.0	357	28.5	15.4	2.2	1.8	2.5
45–54	1042	16.9	251	24.1	5.9	225	21.6	6.3	223	21.4	7.4	301	28.9	12.4	2.1	1.8	2.5
55+	902	14.6	228	25.3	2.4	215	23.8	2.5	205	22.7	2.7	229	25.4	3.7	1.6	1.3	1.9
Transmission category^d
Male-to-male sexual contact	4865	78.7	1024	21.0	-	1127	23.2	-	1166	24.0	-	1356	27.9	-	-	-	-
Injection drug use	420	6.8	86	20.4	-	82	19.5	-	90	21.5	-	146	34.7	-	-	-	-
Male-to-male sexual contact and injection drug use	547	8.8	98	18.0	-	112	20.5	-	137	25.0	-	182	33.3	-	-	-	-
Heterosexual contact	343	5.6	90	26.2	-	75	21.8	-	82	23.8	-	83	24.3	-	-	-	-
Other	6	0.1	1	21.9	-	1	9.4	-	2	32.8	-	2	34.4	-	-	-	-
Region of residence															-	-	-
Northeast	779	12.6	181	23.2	4.2	176	22.6	4.5	195	25.0	5.4	208	26.7	7.8	1.8	1.5	2.2
Midwest	1190	19.3	285	23.9	4.6	281	23.6	5.3	304	25.5	6.3	276	23.2	7.3	1.6	1.3	1.9
South	3016	48.8	619	20.5	7.6	722	23.9	9.3	707	23.4	11.3	841	27.9	15.2	2.0	1.8	2.2
West	1196	19.3	214	17.9	5.3	217	18.1	5.8	271	22.7	7.1	444	37.1	10.6	2.0	1.7	2.4
Subtotal	6181	100.0	1299	21.0	5.7	1396	22.6	6.8	1477	23.9	8.0	1769	28.6	10.9	1.9	1.8	2.0
Females
Age at diagnosis (Yrs)
18–24	137	11.6	27	19.7	1.4	34	24.8	1.8	32	23.4	1.7	34	24.8	1.5	1.1	0.6	1.7
25–34	347	29.4	61	17.6	1.9	88	25.4	2.7	91	26.2	3.0	100	28.8	3.5	1.8	1.3	2.5
35–44	289	24.5	39	13.5	1.1	77	26.6	2.5	80	27.7	3.0	87	30.1	4.0	3.7	2.5	5.4
45–54	239	20.3	43	18.0	1.0	73	30.5	2.0	40	16.7	1.3	79	33.1	3.4	3.4	2.3	4.9
55+	168	14.2	40	23.8	0.4	41	24.4	0.4	29	17.3	0.3	55	32.7	0.7	2.0	1.3	3.0
Transmission category^d
Injection drug use	394	33.4	61	15.6	-	92	23.4	-	99	25.2	-	134	34.0	-	-	-	-
Heterosexual contact	783	66.3	148	18.9	-	220	28.1	-	172	22.0	-	221	28.2	-	-	-	-
Other	3	0.3	1	25.8	-	1	35.5	-	1	25.8	-	0	9.7	-	-	-	-
Region of residence
Northeast	162	13.7	30	18.5	0.7	38	23.5	0.9	45	27.8	1.1	47	29.0	1.6	2.4	1.5	3.8
Midwest	239	20.3	49	20.5	0.8	67	28.0	1.2	55	23.0	1.1	65	27.2	1.6	2.1	1.5	3.1
South	636	53.9	108	17.0	1.3	176	27.7	2.2	153	24.1	2.3	179	28.1	3.0	2.4	1.9	3.1
West	143	12.1	23	16.1	0.6	32	22.4	0.9	19	13.3	0.5	64	44.8	1.5	2.7	1.7	4.4
Subtotal	1180	100.0	210	17.8	0.9	313	26.5	1.4	272	23.1	1.4	355	30.1	2.1	2.3	2.0	2.8
Total^e	7361	100.0	1509	20.5	3.3	1709	23.2	4.0	1749	23.8	4.6	2124	28.9	6.4	2.0	1.8	2.1

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Housing type and transportation theme factors include proportions of persons in multi-unit structures, mobile homes, crowding, no household vehicle access, and institutionalized group quarters

Abbreviations: CI, confidence interval; RR, rate ratio

^aColumn percent

^bRow percent

^dNumbers have been adjusted for missing transmission category

^eTotal includes cases without SVI ranks

When examining RRs for within-group comparisons by race/ethnicity and sex assigned at birth, the disparities in HIV diagnosis rates (i.e., higher likelihood in Q4 compared with Q1) were as follows: Black males (RR 1.3, CI 1.2–1.4) and females (RR 1.6, CI 1.4–1.8), Hispanic/Latino males (RR 1.4, CI 1.3–1.5) and females (RR 1.7, CI 1.4–2.1), and White males (RR 1.9, CI 1.8–2.0) and females (RR 2.3, CI 2.0–2.8). When examining RRs for within-group comparisons for each race/ethnicity, by age group and region of residence, the highest disparities in HIV diagnosis rates were as follows: Among Black adults, males aged ≥ 55 years (RR 1.6, CI 1.2–1.9) and females aged 45‒54 years (RR 2.2, CI 1.7–2.9), and males residing in the West (RR 1.8, CI 1.3–2.4) and females residing in the South (RR 1.7, CI 1.5–1.9); among Hispanic/Latino adults, those aged 45‒54 years (males: RR 1.7, CI 1.3–2.2; and females: RR 2.0, CI = 1.2–3.4), females aged 25‒34 years (RR 2.0, CI 1.2–3.2), and adults residing in the Northeast (males: RR 1.8, CI 1.4–2.2; and females: RR 2.2, CI 1.3–3.9); and among White adults, those aged 35–44 years (males: RR 2.2, CI 1.8–2.5; and females: RR 3.7, CI 2.5–5.4), and adults residing in the West (males: RR 2.0, CI 1.7–2.4; and females: RR 2.7, CI 1.7–4.4).

When examining within-group comparisons for each race/ethnicity, by transmission category and sex assigned at birth, the largest percentage of HIV diagnoses was in Q4 for adults with infection attributed to IDU. The highest disparity (i.e., higher percentage in Q4 compared with Q1) of HIV diagnoses was attributed to MMSC/IDU for Black males and IDU for females, heterosexual contact for Hispanic/Latino males and IDU for females, MMSC/IDU for White males, and IDU for White females.

Discussion

Overall, our findings of within-group disparities in HIV diagnosis rates and percentages in 2019 among Black, Hispanic/Latino, and White adults when comparing the highest SVI census tracts to the lowest SVI census tracts align with previous studies [1, 2]. In addition, our results indicated greater within-group disparities by SVI theme for the following subpopulations: White females with diagnosed HIV infection within the socioeconomic status theme, HIV diagnosis rates among Hispanic/Latino and White males who lived in the least socially vulnerable census tracts within the household composition and disability theme, percentage of Hispanic/Latino adults with a diagnosis of HIV infection in the most socially vulnerable census tracts within the minority status and English proficiency theme, and percentage of HIV diagnoses attributed to IDU in the most socially vulnerable census tracts within the housing type and transportation theme.

In the socioeconomic status theme, we found White females had the widest within-group disparity (HIV diagnoses among the most socially vulnerable census tracts compared to the least socially vulnerable census tracts) compared to other race/ethnicity and sex assigned at birth subpopulations. In considering both race/ethnicity and socioeconomic status, White females in the most socially vulnerable census tracts experience adverse health effects of more concentrated disadvantage such as lower levels of wealth and education resulting in a greater likelihood of living in a more disadvantaged neighborhood compared to White females in the least socially vulnerable census tracts [12]. In addition, White females living in the most socially vulnerable census tracts, which are oftentimes racially segregated communities comprising predominately Black persons [13, 14], may be indirectly subject to the effects of residential segregation (i.e., structural racism). Residential segregation is a contributing factor in higher rates of HIV diagnoses and poor health outcomes among Black persons because isolation limits access to important resources and affects neighborhood quality; populations residing in lower income and relatively more isolated areas experience greater vulnerability for poor health outcomes [13–15]. The adverse health effects of more concentrated disadvantage and potential indirect effects of residential segregation, which disadvantage White adults in the most socially vulnerable census tracts but not White adults in the least socially vulnerable census tracts, may partially explain the wide disparity among White females. We also saw a wide disparity among White males, but not to the same extent seen among females, which may be partially explained by experiences related to gender bias that are not captured by routinely collected socioeconomic measures such as income inequality.

The household composition and disability theme was the only theme to have race/ethnicity and sex assigned at birth subpopulations with a negative gradient—the rate of diagnosed HIV infections decreased as social vulnerability by household composition and disability increased. A previous study on disease testing rates by SVI themes had similar results [16]. The highest diagnosis rates for Hispanic/Latino and White males were among those who lived in the least socially vulnerable census tracts. A study in Massachusetts found that persons in the least socially vulnerable census tracts had higher access to testing resources compared to those in the most socially vulnerable census tracts [17]. Another study found urban areas had higher testing percentages and higher HIV diagnoses rates compared to rural areas [18], which usually contain the most socially vulnerable census tracts. HIV testing rates among Hispanic/Latino and White males are some of the lowest in the USA compared to other race/ethnicity and sex assigned at birth subpopulations [19], which indicate missed opportunities for testing. The combination of a high percentage of Hispanic/Latino and White males who have never tested for HIV infection, and higher testing percentages and access to HIV testing resources in the least socially vulnerable census tracts, may partially explain the higher HIV diagnoses rates among Hispanic/Latino and White males compared to those in the most socially vulnerable census tracts. More studies examining both race/ethnicity and household composition and disability are needed to better understand the effect of these SVI factors on diagnosis of HIV infections.

In the minority status and English proficiency theme, almost 70% of Hispanic/Latino adults with a diagnosis of HIV infection lived in the most socially vulnerable census tracts. In considering race/ethnicity and minority status/English proficiency, Hispanic/Latino adults tend to have limited English proficiency compared to Black and White adults [20]. Compared to the English-proficient population, persons with limited English proficiency are often less educated and more likely to live in poverty [21]. Hispanic/Latino adults are a heterogeneous group from different countries and cultures, and differences exist by origin of birth and region [22]. Approximately one-third (34%) of Hispanic/Latino persons residing in the USA are not US-born, and a high percentage are undocumented immigrants and thus experience medical, social, and economic marginalization [23]. In addition, many medical and social service agencies are unable to provide culturally and linguistically competent services to such a broad spectrum. As a result, Hispanic/Latino persons experience substantial health disparities because their access to medical care is suboptimal and they commonly present late in the course of their illness for medical care [20]. Residential segregation is a contributing factor in higher rates of HIV diagnoses and poor health outcomes, among Hispanic/Latino persons for which segregation has increased in the USA in recent years [12, 15]. There is an urgent need to identify and rapidly scale-up strategies to address the lack of culturally and linguistically competent services for Hispanic/Latino persons and integrate these strategies into HIV programs.

In the housing type and transportation theme, the largest percentage of HIV diagnoses was among persons who inject drugs for all race/ethnicity and sex assigned at birth subpopulations in the most socially vulnerable census tracts. It is recognized that many of the risks and harms accompanying injection drug use do not come from the actual act of injecting [24]. Rather, research shows that social, structural, and environmental factors create the conditions that shape harmful IDU practices (e.g., syringe sharing) and risk (e.g., of overdose) [24, 25]. In considering both IDU and housing type and transportation, microenvironmental influences including injection locations (physical) and relationship dynamics (social) have a role in IDU harm production [24]. For example, some persons in multi-unit structures, living in crowded housing where there are more people than bedrooms, and institutionalized group quarters, may not have the ability to exit or relocate (due to lack of transportation and/or financial and social support) from local drug scenes or housing settings that increases harms related to IDU. The risks and harms associated with IDU are heightened for those in the most socially vulnerable census tracts, as the social and structural inequities shaping their lives make safe injecting difficult [25]. For example, many of the most socially vulnerable census tracts are in rural communities that have experienced increases in non-prescription use of opioids and heroin that have led to increases in IDU as well as localized HIV outbreaks [26]. These outbreaks draw attention to the need for expanded mental health and substance use treatment services in medically underserved rural communities [27]. The risk of accelerated HIV transmission associated with opioid use in rural communities is well documented [28–33]. In addition, residents of and clinicians in less urbanized areas may have less awareness than their more urban counterparts of individual HIV risk and the benefits of prevention strategies, such as routine HIV testing and use of preexposure prophylaxis and syringe service programs (SSP) [34]. Rural areas also are more likely to lack the services and support required for HIV care and treatment and have greater HIV stigma in the community [34]. To reduce harmful IDU practices and HIV transmission associated with opioid use in the most socially vulnerable census tracts, in addition to providing treatment services, it is important to reorient attention toward social, structural, and spatial contexts that surround IDU [28].

Limitations

Our study had several limitations. First, diagnoses of HIV infection do not represent new infections. The time from infection to diagnosis varies by individual, and residence at the time of HIV diagnosis may not be the residence at the time infection was acquired. Second, data were limited to people whose residential addresses were complete in NHSS and could be geocoded to the census tract level. However, with 89% of residential addresses successfully geocoded, we expect our findings to be representative of the entire adult population who received an HIV diagnosis in the USA in 2019. Third, this is an ecological study, and conclusions and findings should be interpreted with caution and not inferred at the individual level. Our use of census tract to represent communities is noteworthy. Representing communities with larger geographic units (e.g., zip code or core-based statistical area) may obscure the heterogeneity of the studied community factors. Small geographic units (e.g., census tracts) provide more accurate estimates of community-level characteristics [35, 36]. Fourth, we used census tract-level data as a surrogate to represent the environment in which people with diagnosed HIV infection lived at the time of diagnosis. Fifth, only a relative disparity measure (RR) was included in analyses (i.e., no absolute disparity measure). Typically, health disparities are reported as relative measures (as ratios) derived by comparing groups with varying levels of health and aligns with similar analyses done using SVI [2, 37]. Finally, testing patterns are influenced by many factors, including the extent to which testing is routinely offered to specific groups and the availability of, and access to, medical care and testing services. Despite our robust approach, we cannot rule out other unexamined factors, and we cannot draw any causal links for our findings.

Conclusion

The development and prioritization of interventions that address varying social determinants of health factors are critical to address the higher risk for receiving a diagnosis of HIV infection among persons living in census tracts with high levels of social vulnerability. Additionally, more intersectionality research is needed as it is based on the premise that multiple factors uniquely combine to define a person’s experience or “unique social space” [38]. Expanded efforts should continue to address barriers affecting persons in the most socially vulnerable census tracts, the majority of whom are Black and Hispanic/Latino persons, as they may find it harder to obtain HIV prevention and care services due to a variety of factors including residential segregation, poverty, limited English proficiency, limited access to healthcare and transportation to services, housing insecurity, and other factors encompassing all SVI themes such as HIV stigma, racism, and discrimination [14, 39]. These barriers can be addressed through policy and programmatic efforts that support investments in communities of color and equitable redistribution of resources to resource-deprived communities [40]. Future research and efforts should be made to identify novel strategies and utilize known assets to address multiple social and structural factors to empower deprived communities while also providing greater access to healthcare and other resources.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of CDC.

Acknowledgements

The publication of this article was made possible with the contributions of the state and territorial health departments and the HIV surveillance programs that provided surveillance data to CDC. The authors thank CDC colleagues for their review of and feedback on this article.

Author Contribution

All the authors contributed to the research conception and design. Conceptualization: André Dailey. Methodology and analysis: Xiaohong Hu. Writing – original draft preparation: André Dailey, Zanetta Gant. Writing – review and editing: Shacara Johnson Lyons, Amanda Okello, Anna Satcher Johnson. All the authors read and approved the final manuscript.

Data Availability

Limited availability (due to confidentiality of the data).

Code Availability

SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used to conduct all analyses.

Declarations

Ethics Approval

Per federal guidelines, the National HIV Surveillance System (NHSS) is determined a public health activity and not human subject research; therefore, our study did not require institutional review board review or approval.

Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Competing Interests

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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24.Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376:268–84. doi: 10.1016/S0140-6736(10)60743-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
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28.Runfola JK, House J, Miller L, et al. Community outbreak of HIV infection linked to injection drug use of Oxymorphone — Indiana. MMWR Morb Mortal Wkly Rep. 2015;64:443–444. [PMC free article] [PubMed] [Google Scholar]
29.Lerner AM, Fauci AS. Opioid injection in rural areas of the United States: a potential obstacle to ending the HIV epidemic. JAMA. 2019;322:1041–1042. doi: 10.1001/jama.2019.10657. [DOI] [PubMed] [Google Scholar]
30.Evans ME, Labuda SM, Hogan V, et al. Notes from the field: HIV infection investigation in a rural area — West Virginia, 2017. MMWR Morb Mortal Wkly Rep. 2018;67:257–258. doi: 10.15585/mmwr.mm6708a6. [DOI] [PMC free article] [PubMed] [Google Scholar]
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33.Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Soc Sci Med. 2015;128:316–326. doi: 10.1016/j.socscimed.2014.12.031. [DOI] [PubMed] [Google Scholar]
34.Nelson JA, Kinder A, Johnson AS, et al. Differences in selected HIV care continuum outcomes among people residing in rural, urban, and metropolitan areas—28 US jurisdictions. Journal of Rural Health. 2018;34:63–70. doi: 10.1111/jrh.12208. [DOI] [PubMed] [Google Scholar]
35.Werner AK, Strosnider HM. Developing a surveillance system of sub-county data: finding suitable population thresholds for geographic aggregations. Spat Spatio-temporal Epidemiol. 2020;33:100339. doi: 10.1016/j.sste.2020.100339. [DOI] [PMC free article] [PubMed] [Google Scholar]
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39.Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010;1186:69–101. doi: 10.1111/j.1749-6632.2009.05339.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Limited availability (due to confidentiality of the data).

SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used to conduct all analyses.

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[CR21] 21.Batalova, J., Zong, J. Language diversity and english proficiency in the United States. Migration Information Source. https://www.migrationpolicy.org/article/language-diversity-and-english-proficiency-united-states-2015. Published November 2016. Accessed August 9, 2022.. Published November 2016. Accessed August 9, 2022.

[CR22] 22.Guarnaccia PJ, Martinez I, Acosta H. Chapter 2. Mental health in the Hispanic immigrant community an overview. J Immigr Refug Servi. 2005;3(1):21–46. doi: 10.1300/J191v03n01_02. [DOI] [Google Scholar]

[CR23] 23.Flores A. How the U.S. Hispanic population is changing. Pew Research Center. http://www.pewresearch.org/fact-tank/2017/09/18/how-the-u-s-hispanic-population-is-changing/. Published 2017. Accessed May 14, 2022.

[CR24] 24.Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, et al. HIV and risk environment for injecting drug users: the past, present, and future. Lancet. 2010;376:268–84. doi: 10.1016/S0140-6736(10)60743-X. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR25] 25.Boyd J, Fast D, Hobbins M, et al. Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: an ethno-epidemiological study. Harm Reduct J. 2017;14:31. doi: 10.1186/s12954-017-0159-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR26] 26.Peters PJ, Pontones P, Hoover KW, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015. New Engl J Med. 2016;375(3):229–239. doi: 10.1056/NEJMoa1515195. [DOI] [PubMed] [Google Scholar]

[CR27] 27.Lenardson JD, Gale JA. Research and policy brief. Distribution of substance abuse treatment facilities across the rural-urban continuum. Portland, ME: Maine Rural Health Research Center; 2008. Available at http://muskie.usm.maine.edu/Publications/rural/pb35bSubstAbuseTreatmentFacilities.pdf. Accessed September 15, 2022.

[CR28] 28.Runfola JK, House J, Miller L, et al. Community outbreak of HIV infection linked to injection drug use of Oxymorphone — Indiana. MMWR Morb Mortal Wkly Rep. 2015;64:443–444. [PMC free article] [PubMed] [Google Scholar]

[CR29] 29.Lerner AM, Fauci AS. Opioid injection in rural areas of the United States: a potential obstacle to ending the HIV epidemic. JAMA. 2019;322:1041–1042. doi: 10.1001/jama.2019.10657. [DOI] [PubMed] [Google Scholar]

[CR30] 30.Evans ME, Labuda SM, Hogan V, et al. Notes from the field: HIV infection investigation in a rural area — West Virginia, 2017. MMWR Morb Mortal Wkly Rep. 2018;67:257–258. doi: 10.15585/mmwr.mm6708a6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR31] 31.Bradley H, Hogan V, Agnew-Brune C, et al. Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary tale. Ann Epidemiol. 2019;34:12–17. doi: 10.1016/j.annepidem.2019.02.012. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR32] 32.NIH Office of AIDS Research. HIV and specific populations. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-older-people. 2021. Accessed June 14, 2022.

[CR33] 33.Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Soc Sci Med. 2015;128:316–326. doi: 10.1016/j.socscimed.2014.12.031. [DOI] [PubMed] [Google Scholar]

[CR34] 34.Nelson JA, Kinder A, Johnson AS, et al. Differences in selected HIV care continuum outcomes among people residing in rural, urban, and metropolitan areas—28 US jurisdictions. Journal of Rural Health. 2018;34:63–70. doi: 10.1111/jrh.12208. [DOI] [PubMed] [Google Scholar]

[CR35] 35.Werner AK, Strosnider HM. Developing a surveillance system of sub-county data: finding suitable population thresholds for geographic aggregations. Spat Spatio-temporal Epidemiol. 2020;33:100339. doi: 10.1016/j.sste.2020.100339. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR36] 36.Werner AK, Strosnider H, Kassinger C, Shin M, Workgroup S-CDP. Lessons learned from the environmental public health tracking sub-county data pilot project. J Publ Health Manag Pract JPHMP. 2018;24(5):E20. doi: 10.1097/PHH.0000000000000686. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR37] 37.Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of health disparities, health inequities, and social determinants of health to support the advancement of health equity. J Public Health Manag Pract. 2016 Jan-Feb;22 Suppl 1(Suppl 1):S33-42. 10.1097/PHH.0000000000000373. PMID: 26599027; PMCID: PMC5845853. [DOI] [PMC free article] [PubMed]

[CR38] 38.Bowleg L. When Black + lesbian + woman ≠ Black lesbian woman: the methodological challenges of qualitative and quantitative intersectionality research. Sex Roles. 2008;59:312–325. doi: 10.1007/s11199-008-9400-z. [DOI] [Google Scholar]

[CR39] 39.Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010;1186:69–101. doi: 10.1111/j.1749-6632.2009.05339.x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR40] 40.Dyer L, Chambers BD, Crear-Perry J, Theall KP, Wallace M. The index of concentration at the extremes (ICE) and pregnancy-associated mortality in Louisiana, 2016–2017. Maternal and Child Health Journal. 2022;26(4):814–822. doi: 10.1007/s10995-021-03189-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

A Census Tract-Level Examination of Diagnosed HIV Infection and Social Vulnerability Themes Among Black/African American, Hispanic/Latino, and White Adults, 2019—USA

André Dailey

Zanetta Gant

Xiaohong Hu

Shacara Johnson Lyons

Amanda Okello

Anna Satcher Johnson

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

NHSS

SVI

Analysis

Results

Socioeconomic Status

Table 1.

Household Composition and Disability

Table 2.

Minority Status and English Proficiency

Table 3.

Housing Type and Transportation

Table 4.

Discussion

Limitations

Conclusion

Disclaimer

Acknowledgements

Author Contribution

Data Availability

Code Availability

Declarations

Ethics Approval

Consent to Participate

Consent for Publication

Competing Interests

Footnotes

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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