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. 2023 Feb 24:1–18. Online ahead of print. doi: 10.1007/s10900-023-01191-y

A Census Tract-Level Examination of HIV Care Outcomes and Social Vulnerability Among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, 2018

Faith Elenwa 1,✉, Zanetta Gant 2, Xiaohong Hu 2, Anna Satcher Johnson 2
PMCID: PMC9950007  PMID: 36823280

Abstract

We examined the association between social vulnerability and HIV diagnoses, linkage to HIV medical care, and viral suppression among adults in the Southern U.S. Data from CDC’s National HIV Surveillance System (NHSS) were used to determine census tract-level HIV diagnosis rates and percentages of persons linked to care within one month and with viral suppression within six months of diagnosis among Black/African American, Hispanic/Latino, and White adults aged ≥ 18 years residing in the Southern U.S. in 2018. Census tract-level social vulnerability data were obtained from the 2018 CDC Social Vulnerability Index (SVI). Rate and proportion ratios were used to determine the difference between the lowest quartile of SVI scores (Q1) and the highest quartile (Q4) by age group, transmission category, and region of residence and stratified by sex assigned at birth. Areas with the highest social vulnerability (Q4) had the highest rates of HIV diagnoses (Black: 56.5, Hispanic/Latino: 27.2, and White: 10.3). Those in Q4 also had the lowest percentages of adults linked to care (Black: 76.1%, Hispanic/Latino: 81.2%, and White: 77.8%), and the lowest percentages of adults with viral suppression (Black: 59.8%, Hispanic/Latino: 68.4%, and White: 65.7%). This ecological study found an association between social vulnerability, HIV diagnoses, and poorer care outcomes among Black/African American, Hispanic/Latino, and White adults. Tailoring interventions and improving access for persons residing in areas with the highest social vulnerability is necessary to reduce HIV transmission and improve health outcomes in the Southern U.S.

Keywords: HIV, Diagnoses, Linkage to care, Viral suppression, Social vulnerability, South

Introduction

In 2018, the Southern United States (U.S.) accounted for 52% of all HIV diagnoses and the highest HIV rate at 15.6 cases per 100,000 persons compared to other U.S. regions [1]. The higher rate of HIV infections in the Southern U.S. is driven by several factors such as higher rates of sexually transmitted infections, higher unemployment, poverty, stigma, and reduced access to HIV care providers [2]. The Southern U.S. also has some of the poorest HIV outcomes, and individuals living with HIV still face limitations in managing their illness. Persons in the Southern U.S. have a low rate of early entry into care [3], which increases their likelihood of poorer HIV outcomes. Timely linkage to HIV medical care is particularly important as it allows individuals to start treatment early, increases their likelihood of attaining viral suppression, reduces the risk of transmission of HIV to partners, and improves survival [4, 5]. Disparities in HIV diagnoses exist between 9 southern states (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas), hereafter referred to as the Deep South, and the rest of the South. The Deep South contained 9 of the top 10 states with the highest HIV diagnosis rates in 2018 [6].

Existing literature shows that racial disparities persist in HIV diagnoses and HIV-related care outcomes [7]. In 2018, high rates of HIV diagnoses were observed among Black/African American persons (hereafter referred to as Black persons) (38.6 per 100,000) and Hispanic/Latino (16.7 per 100,000) [1]. For linkage to care, 77.1% Black, 82.4% Hispanic/Latino, and 82.6% of White persons were linked to care within one month of diagnosis [7]. Among persons aged 13 years and older with diagnosed HIV, 59.9% of Black, 63.7% of Hispanic/Latino, and 70.7% of White persons had viral suppression within six months of diagnosis during 2018 [7] These differences in outcomes may be exacerbated by community-level social and structural factors, such as social vulnerability. Social vulnerability, a multidimensional construct refers to factors that could potentially limit a community’s ability to prevent suffering during disasters, [8] and may contribute to disparities in HIV diagnoses and poorer care outcomes, as these social factors may influence the type of resources to which community members have access. Research has shown an association between poorer viral suppression and social factors such as lower levels of education, unemployment, income, housing status, and health insurance [9–12].

Past studies have examined the role of social factors on HIV [13–15]. However, very few studies have explored the role of a composite score that encompasses various social factors, on HIV. This paper evaluates the association between a composite score—social vulnerability index (SVI) and the following outcomes among Black, Hispanic/Latino, and White adults with HIV diagnosed in the Southern U.S. during 2018: HIV diagnoses, linkage to HIV medical care within 1 month of HIV diagnosis, and viral suppression within 6 months of HIV diagnosis.

Methods

Study Setting, Design, and Data Collection

HIV Surveillance Data

Data for adults aged ≥ 18 years with HIV diagnosed in 2018 were obtained from the National HIV Surveillance System (NHSS) and used to assess HIV diagnoses rates, percentages linked to care within one month of diagnosis, and percentages with viral suppression within six months of diagnosis among Black, Hispanic/Latino, and White adults in the Southern U.S. Linkage to HIV medical care within 1 month of HIV diagnosis was defined as having 1 or more CD4 (measured as count in cells/µL or percentage of total lymphocytes) or viral load tests performed ≤ 1 month after HIV diagnosis [16]. Viral suppression was defined as having any viral load test result of fewer than 200 copies/mL within 6 months of HIV diagnosis [16]. HIV cases were geocoded to the U.S. census tract level based on where a person lived at the time of their diagnosis. Our analysis included data from 14 Southern states and DC (excluding Kentucky and Arkansas) with complete reporting of CD4 and viral load test results as of December 2019. The U.S. Southern region was differentiated into two segments—the 9 jurisdictions in the “Deep South” and 6 jurisdictions were classified as “Other South”: Delaware, the District of Columbia, Maryland, Oklahoma, Virginia, and West Virginia [17].

Social Vulnerability Data

Social vulnerability data at the census tract level were obtained from the 2018 CDC SVI Database. The CDC SVI ranks each U.S. census tract using 15 population-based social factors grouped into four domains namely: socioeconomic status (poverty, employment, income, and education level); household composition (proportion of persons aged ≥ 65 years, persons ≤ 17 years, civilians with disability, and single-parent households); race/ethnicity/language (racial and ethnic minority residents and English language proficiency); and housing/transportation (multi-unit structures, crowding, no household vehicle access, mobile homes, and institutionalized group quarters). The 15 population-based measures were used to create overall SVI scores. SVI scores were ranked by percentile and overall SVI scores ranged from 0 to 1, with higher scores representing greater vulnerability. SVI scores were categorized into quartiles based on their distribution among the U.S. census tracts. HIV diagnoses data for persons with HIV diagnosed in the Southern U.S. and SVI data were linked together.

Analysis

Differences in HIV diagnosis rates and linkage to care and viral suppression percentages were calculated by age, region, and transmission category across quartiles and stratified by sex assigned at birth and race/ethnicity. For HIV diagnoses, we examined the rate ratios (RRs) and the associated 95% confidence intervals (CIs) between the lowest SVI scores (Quartile 1 or Q1) and the highest scores (Quartile 4 or Q4) by sex assigned at birth for age group, transmission category, and region of residence. For linkage to care and viral suppression, we examined proportion ratios (PRs) and 95% CIs between Q1 and Q4 by sex assigned at birth for age group, transmission category, and region of residence. CIs that excluded 1 were considered statistically significant. Statistical adjustment using multiple imputation techniques was applied to account for cases with missing HIV transmission categories [18]. SVI scores were missing for 159 Black (1.0%), 46 Hispanic/Latino (0.3%), and 69 White adults (0.4%). Analyses were conducted using SAS software (version 9.4; SAS Institute, Inc).

Results

HIV Diagnoses

In 2018 in the Southern U.S., there were 15,634 diagnoses of HIV infection among Black (8362), Hispanic/Latino (3805), and White (3467) adults (Deep South: 13,414; Other South: 2220) (Table 1). Overall, by race/ethnicity, the quartile with the highest SVI score (Q4) had the highest rates of HIV diagnoses (Black: 56.5, Hispanic/Latino: 27.2, and White: 10.3). Additionally, Black and White adults in Q4 were 1.5 and 2.0 times, respectively, as likely to receive an HIV diagnosis than those in Q1 (Black: CI: 1.35, 1.59 & White: CI: 1.84, 2.24). No differences were observed between Q4 and Q1 among Hispanic/Latino adults. By subpopulation, there was a higher likelihood of HIV diagnosis in Q4 compared with Q1 for the following: Black adults (except Black males aged 18‒24 and aged 55 + years where no differences were observed); Hispanic/Latino females aged 45‒54 years and both regions for females (i.e., the Deep South and Other South); and White adults. For all other subpopulations, no differences were observed.

Table 1.

Association between HIV Infection Diagnoses and Social Vulnerability Index among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, by Selected Characteristics, and Region of Residence—Census Tract-Level, 2018

Black/African American
Total Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
No %a No %b Rate No %b Rate No %b Rate No %b Rate RR 95% CIc
Male
 Age at diagnosis (yrs)
 18–24 1,787 29.0 151 8.4 123.4 266 14.9 121.1 493 27.6 131.5 832 46.6 151.0 1.2 1.03 1.46
 25–34 2,465 40.0 218 8.8 136.6 389 15.8 136.6 670 27.2 142.3 1,157 46.9 166.2 1.2 1.05 1.41
 35–44 887 14.4 82 9.2 48.7 127 14.3 49.9 232 26.2 58.1 429 48.4 77.5 1.6 1.26 2.02
 45–54 558 9.1 41 7.3 23.9 76 13.6 30.0 119 21.3 31.5 306 54.8 54.8 2.3 1.66 3.18
 55 +  460 7.5 49 10.7 22.2 51 11.1 14.2 106 23.0 17.4 249 54.1 25.0 1.1 0.83 1.53
 Transmission categoryd
 Male-to-male sexual contact 4,888 79.4 451 9.2 – 745 15.2 – 1,323 27.1 – 2,272 46.5 – – – –
 Injection drug use 150 2.4 8 5.1 – 19 12.6 – 36 23.8 – 84 55.8 – – – –
 Male-to-male sexual contact and injection drug use 100 1.6 8 7.9 – 16 15.7 – 25 24.6 – 49 49.0 – – – –
 Heterosexual contact 1,016 16.5 74 7.3 – 129 12.7 – 235 23.2 – 567 55.9 – – – –
 Other 3 0.1 0 5.9 – 0 11.8 – 1 35.3 – 2 47.1 – – – –
 Region
 Deep South 5104 82.9 382 7.5 69.3 697 13.7 68.2 1,303 25.5 73.5 2,621 51.4 88.8 1.3 1.15 1.43
 Other South 1053 17.1 159 15.1 54.4 212 20.1 60.5 317 30.1 69.1 352 33.4 87.1 1.6 1.33 1.93
 Subtotal 6157 100.0 541 8.8 64.2 909 14.8 66.2 1,620 26.3 72.6 2,973 48.3 88.6 1.4 1.26 1.51
Femal
 Age at diagnosis (yrs)
 18–24 298 13.5 19 6.4 16.9 40 13.4 18.9 62 20.8 16.8 173 58.1 30.5 1.8 1.13 2.91
 25–34 594 26.9 46 7.7 27.3 67 11.3 22.2 134 22.6 27.2 334 56.2 41.8 1.5 1.13 2.09
 35–44 525 23.8 34 6.5 17.7 61 11.6 20.4 148 28.2 33.0 274 52.2 41.8 2.4 1.66 3.38
 45–54 421 19.1 26 6.2 13.4 60 14.3 20.8 91 21.6 20.4 234 55.6 35.2 2.6 1.75 3.94
 55 +  367 16.6 21 5.7 7.8 46 12.5 9.9 85 23.2 10.6 205 55.9 14.9 1.9 1.22 3.00
 Transmission categoryd
 Injection drug use 127 5.8 7 5.6 – 16 12.5 – 29 22.5 – 73 57.6 – – – –
 Heterosexual contact 2072 93.9 138 6.6 – 258 12.4 – 489 23.6 – 1144 55.2 – – – –
 Other 7 0.3 1 19.7 – 0 3.0 – 2 30.3 – 3 45.5 – – – –
 Region
 Deep South 1781 80.8 83 4.7 13.4 195 10.9 16.7 387 21.7 19.2 1077 60.5 30.3 2.3 1.80 2.82
 Other South 424 19.2 63 14.9 19.7 79 18.6 19.9 133 31.4 24.8 143 33.7 28.3 1.4 1.07 1.94
 Subtotal 2205 100.0 146 6.6 15.6 274 12.4 17.5 520 23.6 20.4 1220 55.3 30.1 1.9 1.63 2.29
 Totale 8,362 100.0 687 8.2 38.6 1183 14.1 40.3 2,140 25.6 44.7 4193 50.1 56.5 1.5 1.35 1.59
Hispanic/Latino
Total Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
No %a No %b Rate No %b Rate No %b Rate No %b Rate RR 95% CIc
Male
 Age at diagnosis (yrs)
 18–24 642 19.4 57 8.9 49.4 104 16.2 50.5 172 26.8 52.0 301 46.9 53.9 1.1 0.82 1.45
 25–34 1284 38.9 154 12.0 96.9 220 17.1 74.8 344 26.8 72.8 553 43.1 69.3 0.7 0.60 0.85
 35–44 694 21.0 67 9.7 39.9 135 19.5 47.9 159 22.9 36.6 322 46.4 44.8 1.1 0.86 1.46
 45–54 472 14.3 50 10.6 34.8 71 15.0 32.7 116 24.6 35.1 230 48.7 41.5 1.2 0.88 1.62
 55 +  212 6.4 18 8.5 11.5 37 17.5 14.9 55 25.9 14.6 99 46.7 14.4 1.2 0.75 2.06
 Transmission categoryd
 Male-to-male sexual contact 2,858 86.5 311 10.9 – 498 17.4 – 727 25.4 – 1,286 45.0 – – – –
 Injection drug use 78 2.4 6 7.9 – 14 18.5 – 17 21.9 – 39 50.0 – – – –
 Male-to-male sexual contact and injection drug use 85 2.6 10 11.1 – 12 14.3 – 30 34.8 – 34 39.5 – – – –
 Heterosexual contact 282 8.5 20 6.9 – 43 15.2 – 72 25.5 – 146 51.7 – – – –
 Other 1 0.0 0 0.0 – 0 0.0 – 0 28.6 – 1 71.4 – – – –
 Region
 Deep South 3,083 93.3 309 10.0 51.5 512 16.6 47.0 782 25.4 44.7 1,446 46.9 46.0 0.9 0.79 1.01
 Other South 221 6.7 37 16.7 26.1 55 24.9 34.9 64 29.0 33.1 59 26.7 33.4 1.3 0.85 1.93
 Subtotal 3,304 100.0 346 10.5 46.6 567 17.2 45.5 846 25.6 43.5 1,505 45.6 45.4 1.0 0.87 1.09
Female
 Age at diagnosis (yrs)
 18–24 61 12.2 5 8.2 4.7 10 16.4 5.0 14 23.0 4.6 31 50.8 6.1 1.3 0.50 3.31
 25–34 138 27.5 10 7.2 6.3 18 13.0 6.5 30 21.7 7.2 77 55.8 11.0 1.7 0.90 3.37
 35–44 117 23.4 9 7.7 5.1 11 9.4 4.0 36 30.8 8.9 61 52.1 9.3 1.8 0.89 3.62
 45–54 115 23.0 6 5.2 3.8 14 12.2 6.2 28 24.3 8.8 65 56.5 12.3 3.2 1.38 7.37
 55 +  70 14.0 5 7.1 2.7 9 12.9 3.0 22 31.4 4.9 34 48.6 4.2 1.6 0.62 4.02
 Transmission categoryd
 Injection drug use 43 8.5 2 4.7 – 4 9.1 – 10 24.1 – 26 61.1 – – – –
 Heterosexual contact 457 91.2 33 7.2 – 58 12.7 – 120 26.2 – 241 52.7 – – – –
 Other 1 0.3 0 0.0 – 0 7.7 – 0 7.7 – 1 84.6 – – – –
 Region
 Deep South 466 93.0 30 6.4 4.7 55 11.8 4.9 124 26.6 7.2 252 54.1 8.2 1.7 1.20 2.55
 Other South 35 7.0 5 14.3 3.4 7 20.0 4.6 6 17.1 3.5 16 45.7 10.8 3.1 1.15 8.57
 Subtotal 501 100.0 35 7.0 4.5 62 12.4 4.9 130 25.9 6.9 268 53.5 8.4 1.9 1.31 2.66
 Totale 3,805 100.0 381 10.0 25.0 629 16.5 24.9 976 25.7 25.5 1,773 46.6 27.2 1.1 0.97 1.21
White
Total Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
No %a No %b Rate No %b Rate No %b Rate No %b Rate RR 95% CIc
Male
 Age at diagnosis (yrs)
 18–24 427 14.7 82 19.2 12.7 108 25.3 13.7 140 32.8 17.2 87 20.4 19.3 1.5 1.12 2.05
 25–34 995 34.2 219 22.0 21.3 247 24.8 21.1 251 25.2 21.7 260 26.1 37.7 1.8 1.48 2.12
 35–44 566 19.5 120 21.2 10.9 145 25.6 13.4 165 29.2 16.1 127 22.4 21.9 2.0 1.57 2.58
 45–54 524 18.0 134 25.6 10.2 144 27.5 11.6 126 24.0 10.7 109 20.8 16.2 1.6 1.24 2.05
 55 +  398 13.7 100 25.1 3.5 96 24.1 3.3 106 26.6 3.7 91 22.9 5.4 1.6 1.18 2.07
 Transmission category
 Male-to-male sexual contact 2,353 80.9 557 23.7 – 609 25.9 – 629 26.7 – 514 21.9 – – – –
 Injection drug use 139 4.8 14 10.0 – 20 14.6 – 39 28.0 – 62 44.4 – – – –
 Male-to-male sexual contact and injection drug use 205 7.0 44 21.3 – 49 23.9 – 57 28.1 – 50 24.6 – – – –
 Heterosexual contact 210 7.2 41 19.3 – 61 29.1 – 61 29.1 – 47 22.2 – – – –
 Other 3 0.1 0 7.7 – 1 23.1 – 1 38.5 – 1 30.8 – – – –
 Region
 Deep South 2,500 85.9 531 21.2 10.5 645 25.8 11.3 680 27.2 12.0 600 24.0 17.1 1.6 1.45 1.84
 Other South 410 14.1 124 30.2 6.6 95 23.2 6.4 108 26.3 8.0 74 18.0 13.2 2.0 1.51 2.68
 Subtotal 2,910 100.0 655 22.5 9.4 740 25.4 10.3 788 27.1 11.2 674 23.2 16.6 1.8 1.58 1.96
Female
 Age at diagnosis (yrs)
 18–24 66 11.8 10 15.2 1.7 17 25.8 2.3 18 27.3 2.3 20 30.3 4.6 2.7 1.27 5.78
 25–34 170 30.5 19 11.2 1.8 44 25.9 3.8 41 24.1 3.6 59 34.7 9.0 5.0 2.98 8.38
 35–44 134 24.1 19 14.2 1.7 16 11.9 1.5 41 30.6 4.0 56 41.8 9.8 5.8 3.48 9.84
 45–54 119 21.4 7 5.9 0.5 29 24.4 2.3 38 31.9 3.2 40 33.6 6.0 11.7 5.23 26.07
 55 +  68 12.2 14 20.6 0.4 16 23.5 0.5 17 25.0 0.5 20 29.4 1.0 2.2 1.12 4.41
 Transmission categoryd
 Injection drug use 152 27.3 13 8.5 – 34 22.0 – 46 30.2 – 54 35.5 – – – –
 Heterosexual contact 404 72.5 56 13.9 – 88 21.8 – 109 26.9 – 141 34.9 – – – –
 Other 1 0.2 0 0.0 – 1 50.0 – 1 41.7 – 0 8.3 – – – –
 Region
 Deep South 480 86.2 58 12.1 1.1 99 20.6 1.6 137 28.5 2.3 175 36.5 4.7 4.3 3.20 5.79
 Other South 77 13.8 11 14.3 0.6 23 29.9 1.5 18 23.4 1.3 20 26.0 3.3 5.8 2.78 12.11
 Subtotal 557 100.0 69 12.4 0.9 122 21.9 1.6 155 27.8 2.1 195 35.0 4.5 4.7 3.60 6.23
 Totale 3,467 100.0 724 20.9 5.1 862 24.9 5.8 943 27.2 6.5 869 25.1 10.3 2.0 1.84 2.24
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Hispanic/Latino persons can be of any race

CI = confidence interval; RR = rate ratio

Rates are per 100,000 population. SVI scores were grouped into quartiles according to their distribution among US census tracts. Rates were considered significantly different if the 95% CIs of the RRs excluded one

aColumn percent

bRow percent

c Two rates are statistically different if the 95% CI does not include one (1.0)

dTransmission category is classified based on a hierarchy of the risk factors most likely responsible for HIV transmission. Statistical adjustments were performed for missing HIV transmission categories. Due to lack of population data, rates and RRs for transmission categories were not calculated

e Total included 159 Black/African American, 46 Hispanic/Latino, and 69 White adults without SVI rankings

When examining RRs for within-group comparisons, the highest disparities in HIV diagnosis rates (i.e., higher likelihood in Quartile 4 compared with Quartile 1) by subpopulation were as follows: among Black adults aged 45‒54 years (males: RR = 2.3; CI: 1.66, 3.18; females: RR = 2.6; CI: 1.75, 3.94), and Black adults residing in the Other South for males (RR = 1.6; CI: 1.33, 1.93) and Deep South for females (RR = 2.3; CI: 1.80, 2.82); among Hispanic/Latino adults, females aged 45‒54 years (RR = 3.2; CI: 1.38, 7.37) and Hispanic/Latino females residing in the Other South (RR = 3.1; CI: 1.15, 8.57); and among White adults, males aged 35‒44 and females aged 45‒54 years (RR = 2.0; CI: 1.57, 2.581; RR = 11.7; CI: 5.23, 26.07, respectively) and White adults residing in the Other South (males: RR = 2.0; CI: 1.51, 2.68; females: RR = 5.8; CI: 2.78, 12.11).

Linkage to HIV Medical Care

Of the 15,634 diagnoses of HIV infection in the Southern U.S. in 2018, 12,385 (79.2%) were linked to HIV medical care within 1 month with 76.6% among Black (6407), 82.2% among Hispanic/Latino (3127), and 82.2% among White (2851) adults (Table 2). Overall, by race/ethnicity, adults with SVI scores in Q4 had the lowest percentages of linkage to care (Black: 76.1%, Hispanic/Latino: 81.2%, and White: 77.8%). Additionally, White adults in Q4 were less likely to be linked to care than those in Q1 (PR: 0.9, CI: 0.87, 0.96). No differences in linkage to care were observed between Q4 and Q1 for Black and Hispanic/Latino adults. By subpopulation, there was a lower likelihood of linkage to care in Q4 compared with Q1 for the following: Black males residing in the Other South; and White males with infection attributed to heterosexual contact, and White males and females residing in the Deep South. For all other subpopulations, no differences were observed.

Table 2.

Association between Linkage to HIV Medical Care and Social Vulnerability Index among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, by Selected Characteristics, and Region of Residence—Census Tract-Level, 2018

Black/African American
Total diagnoses Total linkage Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage
No %a No %b No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 1,787 29.0 1,347 75.4 151 113 74.8 266 210 78.9 493 372 75.5 832 621 74.6 1.0 0.90 1.10
 25–34 2,465 40.0 1,855 75.3 218 172 78.9 389 289 74.3 670 501 74.8 1,157 872 75.4 1.0 0.89 1.03
 35–44 887 14.4 697 78.6 82 64 78.0 127 104 81.9 232 178 76.7 429 342 79.7 1.0 0.90 1.16
 45–54 558 9.1 400 71.7 41 33 80.5 76 51 67.1 119 82 68.9 306 220 71.9 0.9 0.76 1.05
 55 +  460 7.5 362 78.7 49 41 83.7 51 38 74.5 106 87 82.1 249 193 77.5 0.9 0.80 1.07
 Transmission categorye
 Male-to-male sexual contact 4,888 79.4 3,720 76.1 451 355 78.5 745 573 76.9 1,323 1,009 76.2 2,272 1,717 75.6 1.0 0.91 1.02
 Injection drug use 150 2.4 107 71.4 8 6 76.3 19 12 64.6 36 25 69.2 84 62 73.7 1.0 0.64 1.46
 Male-to-male sexual contact and injection drug use 100 1.6 70 70.1 8 6 81.0 16 9 58.6 25 15 61.8 49 38 77.1 1.0 0.66 1.38
 Heterosexual contact 1,016 16.5 762 75.0 74 56 75.9 129 97 75.7 235 171 72.5 567 431 76.0 1.0 0.87 1.15
 Other 3 0.1 2 44.1 0 0 100.0 0 0 75.0 1 1 58.3 2 0 18.8 – – –
 Region
 Deep South 5,104 82.9 3,842 75.3 382 289 75.7 697 535 76.8 1,303 969 74.4 2,621 1,982 75.6 1.0 0.94 1.06
 Other South 1,053 17.1 819 77.8 159 134 84.3 212 157 74.1 317 251 79.2 352 266 75.6 0.9 0.82 0.98
 Subtotal 6,157 100.0 4,661 75.7 541 423 78.2 909 692 76.1 1620 1,220 75.3 2973 2,248 75.6 1.0 0.92 1.02
Female
 Age at diagnosis (yrs)
 18–24 298 13.5 228 76.5 19 15 78.9 40 34 85.0 62 51 82.3 173 125 72.3 0.9 0.71 1.18
 25–34 594 26.9 461 77.6 46 35 76.1 67 61 91.0 134 104 77.6 334 252 75.4 1.0 0.83 1.18
 35–44 525 23.8 422 80.4 34 25 73.5 61 54 88.5 148 120 81.1 274 216 78.8 1.1 0.87 1.32
 45–54 421 19.1 334 79.3 26 21 80.8 60 51 85.0 91 71 78.0 234 185 79.1 1.0 0.80 1.19
 55 +  367 16.6 301 82.0 21 19 90.5 46 38 82.6 85 70 82.4 205 165 80.5 0.9 0.76 1.04
 Transmission categorye
 Injection drug use 127 5.8 95 74.9 7 6 84.5 16 13 80.5 29 22 77.2 73 53 72.1 0.9 0.60 1.21
 Heterosexual contact 2072 93.9 1,645 79.4 138 108 78.3 258 225 87.2 490 392 80.1 1,144 887 77.6 1.0 0.90 1.09
 Other 7 0.3 6 93.9 1 1 92.3 0 0 100.0 2 2 95.0 3 3 96.7 – – –
 Region
 Deep South 1,781 80.8 1,393 78.2 83 65 78.3 195 166 85.1 387 308 79.6 1,077 826 76.7 1.0 0.87 1.10
 Other South 424 19.2 353 83.3 63 50 79.4 79 72 91.1 133 108 81.2 143 117 81.8 1.0 0.89 1.20
 Subtotal 2,205 100.0 1,746 79.2 146 115 78.8 274 238 86.9 520 416 80.0 1220 943 77.3 1.0 0.90 1.07
 Totalf 8,362 100.0 6407 76.6 687 538 78.3 1,183 930 78.6 2140 1,636 76.4 4193 3,191 76.1 1.0 0.93 1.01
Hispanic/Latino
Total diagnoses Total linkage Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage
No %a No %a No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 642 19.4 492 76.6 57 42 73.7 104 79 76.0 172 137 79.7 301 228 75.7 1.0 0.87 1.22
 25–34 1,284 38.9 1,045 81.4 154 125 81.2 220 181 82.3 344 281 81.7 553 449 81.2 1.0 0.92 1.09
 35–44 694 21.0 590 85.0 67 60 89.6 135 118 87.4 159 134 84.3 322 269 83.5 0.9 0.85 1.03
 45–54 472 14.3 415 87.9 50 45 90.0 71 63 88.7 116 103 88.8 230 199 86.5 1.0 0.87 1.07
 55 +  212 6.4 173 81.6 18 18 100.0 37 34 91.9 55 40 72.7 99 78 78.8 – – –
 Transmission categorye
 Male-to-male sexual contact 2858 86.5 2358 82.5 311 262 84.4 498 418 83.9 727 595 81.7 1286 1055 82.0 1.0 0.92 1.03
 Injection drug use 78 2.4 63 80.1 6 6 91.9 14 13 86.8 17 13 77.2 39 30 76.7 0.8 0.62 1.11
 Male-to-male sexual contact and injection drug use 85 2.6 60 70.2 10 7 74.7 12 11 87.7 30 23 76.4 34 19 57.0 0.8 0.48 1.22
 Heterosexual contact 282 8.5 234 83.0 20 15 76.4 43 34 79.9 72 64 89.8 146 118 81.1 1.1 0.82 1.38
 Other 1 0.0 1 100.0 0 0 - 0 0 - 0 0 100.0 1 1 100.0 – – –
 Region
 Deep South 3,083 93.3 2531 82.1 309 260 84.1 512 429 83.8 782 638 81.6 1446 1177 81.4 1.0 0.92 1.02
 Other South 221 6.7 184 83.3 37 30 81.1 55 46 83.6 64 57 89.1 59 46 78.0 1.0 0.78 1.18
 Subtotal 3,304 100.0 2,715 82.2 346 290 83.8 567 475 83.8 846 695 82.2 1505 1223 81.3 1.0 0.92 1.02
Female
 Age at diagnosis (yrs)
 18–24 61 12.2 52 85.2 5 4 80.0 10 9 90.0 14 10 71.4 31 28 90.3 1.1 0.72 1.78
 25–34 138 27.5 115 83.3 10 8 80.0 18 14 77.8 30 25 83.3 77 65 84.4 1.1 0.76 1.46
 35–44 117 23.4 97 82.9 9 8 88.9 11 9 81.8 36 31 86.1 61 49 80.3 0.9 0.70 1.17
 45–54 115 23.0 93 80.9 6 4 66.7 14 13 92.9 28 25 89.3 65 50 76.9 1.2 0.65 2.06
 55 +  70 14.0 55 78.6 5 5 100.0 9 5 55.6 22 20 90.9 34 25 73.5 – – –
 Transmission categorye
 Injection drug use 43 8.5 33 76.3 2 2 85.0 4 3 69.2 10 8 76.7 26 20 76.2 0.9 0.48 1.67
 Heterosexual contact 457 91.2 378 82.7 33 27 82.7 58 47 81.4 120 103 86.1 241 196 81.4 1.0 0.83 1.16
 Other 1 0.3 1 100.0 0 0 – 0 0 100.0 0 0 100.0 1 1 100.0 – – –
 Region
 Deep South 466 93.0 383 82.2 30 25 83.3 55 43 78.2 124 108 87.1 252 203 80.6 1.0 0.81 1.15
 Other South 35 7.0 29 82.9 5 4 80.0 7 7 100.0 6 3 50.0 16 14 87.5 – – –
 Subtotal 501 100.0 412 82.2 35 29 82.9 62 50 80.6 130 111 85.4 268 217 81.0 1.0 0.83 1.15
 Totalf 3,805 100.0 3,127 82.2 381 319 83.7 629 525 83.5 976 806 82.6 1,773 1440 81.2 1.0 0.92 1.02
White
Total diagnoses Total linkage Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage Diagnoses Linkage
No %a No %b No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 427 14.7 337 78.9 82 68 82.9 108 78 72.2 140 121 86.4 87 63 72.4 0.9 0.74 1.03
 25–34 995 34.2 840 84.4 219 191 87.2 247 206 83.4 251 212 84.5 260 215 82.7 0.9 0.88 1.02
 35–44 566 19.5 475 83.9 120 101 84.2 145 125 86.2 165 137 83.0 127 104 81.9 1.0 0.87 1.09
 45–54 524 18.0 445 84.9 134 113 84.3 144 127 88.2 126 112 88.9 109 85 78.0 0.9 0.82 1.05
 55 +  398 13.7 337 84.7 100 88 88.0 96 84 87.5 106 87 82.1 91 74 81.3 0.9 0.82 1.04
 Transmission categorye
 Male-to-male sexual contact 2,353 80.9 1,987 84.4 557 475 85.3 609 512 84.1 629 540 85.8 514 423 82.2 1.0 0.91 1.02
 Injection drug use 139 4.8 108 77.8 14 12 84.2 20 20 97.5 39 31 79.7 62 45 72.0 0.9 0.65 1.13
 Male-to-male sexual contact and injection drug use 205 7.0 165 80.4 44 37 84.4 49 37 74.8 57 49 85.7 50 38 74.8 0.9 0.72 1.09
 Heterosexual contact 210 7.2 172 81.8 41 37 91.6 61 51 83.4 61 48 78.4 47 35 75.6 0.8 0.68 0.99
 Other 3 0.1 2 84.6 0 0 100.0 1 0 66.7 1 1 90.0 1 1 87.5 0.9 0.00 –
 Region
 Deep South 2,500 85.9 2,099 84.0 531 464 87.4 645 535 82.9 680 576 84.7 600 488 81.3 0.9 0.89 0.98
 Other South 410 14.1 335 81.7 124 97 78.2 95 85 89.5 108 93 86.1 74 53 71.6 0.9 0.77 1.09
 Subtotal 2,910 100.0 2,434 83.6 655 561 85.6 740 620 83.8 788 669 84.9 674 541 80.3 0.9 0.89 0.98
Female
 Age at diagnosis (yrs)
 18–24 66 11.8 48 72.7 10 9 90.0 17 12 70.6 18 13 72.2 20 13 65.0 0.7 0.49 1.06
 25–34 170 30.5 129 75.9 19 15 78.9 44 33 75.0 41 36 87.8 59 41 69.5 0.9 0.66 1.17
 35–44 134 24.1 99 73.9 19 14 73.7 16 15 93.8 41 31 75.6 56 37 66.1 0.9 0.65 1.24
 45–54 119 21.4 86 72.3 7 6 85.7 29 19 65.5 38 28 73.7 40 29 72.5 0.8 0.59 1.21
 55 +  68 12.2 55 80.9 14 12 85.7 16 12 75.0 17 15 88.2 20 15 75.0 0.9 0.63 1.22
 Transmission categorye
 Injection drug use 152 27.3 102 67.3 13 9 72.9 34 26 76.4 46 34 73.7 54 31 57.6 0.8 0.53 1.18
 Heterosexual contact 404 72.5 314 77.7 56 47 83.1 88 65 73.8 109 89 81.8 141 104 73.7 0.9 0.76 1.03
 Other 1 0.2 1 83.3 0 0 – 1 1 83.3 1 0 80.0 0 0 100.0 – – –
 Region
 Deep South 480 86.2 364 75.8 58 48 82.8 99 76 76.8 137 109 79.6 175 124 70.9 0.9 0.74 1.00
 Other South 77 13.8 53 68.8 11 8 72.7 23 15 65.2 18 14 77.8 20 11 55.0 0.8 0.44 1.29
 Subtotal 557 100.0 417 74.9 69 56 81.2 122 91 74.6 155 123 79.4 195 135 69.2 0.9 0.74 0.99
 Totalf 3,467 100.0 2,851 82.2 724 617 85.2 862 711 82.5 943 792 84.0 869 676 77.8 0.9 0.87 0.96
Open in a new tab

Hispanic/Latino persons can be of any race

CI = confidence interval; PR = proportion ratio

SVI scores were grouped into quartiles according to their distribution among US census tracts. Proportions were considered significantly different if the 95% CIs of the PRs excluded one

aColumn percent

bDenominator of percent is total number of HIV diagnoses

cDenominator of percent is number of HIV diagnoses in the quarter

dTwo proportions are statistically different if the 95% CI does not include 1.0

eTransmission category is classified based on a hierarchy of the risk factors most likely responsible for HIV transmission. Statistical adjustments were performed for missing HIV transmission categories

f Total included 159 Black/African American, 46 Hispanic/Latino, and 69 White adults without SVI rankings

Viral Suppression

In 2018 in the Southern U.S., 10,205 (65.3%) adults had viral suppression within 6 months of HIV diagnosis with 61.5% among Black (5, 140), 70.4% among Hispanic/Latino (2680), and 68.8% among White (2385) adults (Table 3). Overall, by race/ethnicity, Q4 had the lowest percentages of adults with viral suppression (Black: 59.8%, Hispanic/Latino: 68.4%, and White: 65.7%). Additionally, Black and White adults in Q4 were less likely to have viral suppression than those in Q1 (Black: PR: 0.9, CI: 0.85, 0.95; White: PR: 0.9, CI: 0.84, 0.96). No differences in viral suppression were observed between Q4 and Q1 for Hispanic/Latino adults. By subpopulation, there was a lower likelihood of viral suppression in Q4 compared with Q1 for the following: among Black adults, males aged 45‒54 years, males with infection attributed to male-to-male sexual contact, females with infection attributed to heterosexual contact, and males residing in the Other South; among Hispanic/Latino adults, females aged 35‒44 years, both males and females aged 55 + , and females residing in the Deep South; and among White adults, males aged 25‒34 years, males with infection attributed to male-to-male sexual contact, and males residing in the Deep South. For all other subpopulations, no differences were observed.

Table 3.

Association between Viral Suppression and Social Vulnerability Index among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, by Selected Characteristics, and Region of Residence—Census Tract-Level, 2018

Black/African American
Total diagnoses Total viral suppression Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression
No %a No %b No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 1787 29.0 1,082 60.5 151 95 62.9 266 168 63.2 493 311 63.1 832 486 58.4 0.9 0.81 1.06
 25–34 2465 40.0 1,482 60.1 218 140 64.2 389 229 58.9 670 417 62.2 1,157 678 58.6 0.9 0.82 1.02
 35–44 887 14.4 544 61.3 82 53 64.6 127 85 66.9 232 134 57.8 429 263 61.3 0.9 0.79 1.13
 45–54 558 9.1 315 56.5 41 31 75.6 76 41 53.9 119 56 47.1 306 175 57.2 0.8 0.62 0.92
 55 +  460 7.5 274 59.6 49 34 69.4 51 34 66.7 106 61 57.5 249 141 56.6 0.8 0.66 1.01
 Transmission categorye
 Male-to-male sexual contact 4,888 79.4 2,983 61.0 451 297 65.8 745 467 62.6 1,323 821 62.1 2272 1345 59.2 0.9 0.84 0.97
 Injection drug use 150 2.4 69 46.3 8 5 59.2 19 9 48.7 36 14 39.2 84 39 47.1 0.8 0.42 1.50
 Male-to-male sexual contact and injection drug use 100 1.6 49 48.5 8 5 60.8 16 5 33.8 25 12 49.2 49 25 50.8 0.8 0.45 1.56
 Heterosexual contact 1,016 16.5 595 58.6 74 47 62.9 129 76 58.9 235 132 55.9 567 333 58.7 0.9 0.77 1.13
 Other 3 0.1 1 29.4 0 0 100.0 0 0 50.0 1 0 25.0 2 0 18.8 – – –
 Region
 Deep South 5,104 82.9 2988 58.5 382 231 60.5 697 421 60.4 1,303 763 58.6 2,621 1516 57.8 1.0 0.88 1.04
 Other South 1,053 17.1 709 67.3 159 122 76.7 212 136 64.2 317 216 68.1 352 227 64.5 0.8 0.75 0.94
 Subtotal 6,157 100.0 3,697 60.0 541 353 65.2 909 557 61.3 1,620 979 60.4 2,973 1,743 58.6 0.9 0.84 0.96
Female
 Age at diagnosis (yrs)
 18–24 298 13.5 199 66.8 19 15 78.9 40 30 75.0 62 41 66.1 173 113 65.3 0.8 0.64 1.07
 25–34 594 26.9 360 60.6 46 31 67.4 67 55 82.1 134 85 63.4 334 182 54.5 0.8 0.65 1.01
 35–44 525 23.8 356 67.8 34 23 67.6 61 46 75.4 148 97 65.5 274 185 67.5 1.0 0.78 1.28
 45–54 421 19.1 282 67.0 26 20 76.9 60 42 70.0 91 63 69.2 234 152 65.0 0.8 0.67 1.06
 55 +  367 16.6 246 67.0 21 16 76.2 46 34 73.9 85 58 68.2 205 131 63.9 0.8 0.65 1.09
 Transmission category
 Injection drug use 127 5.8 70 54.9 7 5 63.4 16 10 64.2 29 16 55.1 73 38 52.4 0.8 0.45 1.51
 Heterosexual contact 2072 93.9 1,368 66.1 138 99 72.2 258 197 76.2 490 327 66.7 1,144 723 63.2 0.9 0.78 0.98
 Other 7 0.3 5 74.2 1 1 92.3 0 0 100.0 2 2 80.0 3 2 63.3 – – –
 Region
 Deep South 1,781 80.8 1,127 63.3 83 58 69.9 195 142 72.8 387 247 63.8 1,077 660 61.3 0.9 0.76 1.02
 Other South 424 19.2 316 74.5 63 47 74.6 79 65 82.3 133 97 72.9 143 103 72.0 1.0 0.81 1.15
 Subtotal 2,205 100.0 1,443 65.4 146 105 71.9 274 207 75.5 520 344 66.2 1,220 763 62.5 0.9 0.78 0.97
 Totalf 8,362 100.0 5,140 61.5 687 458 66.7 1183 764 64.6 2140 1323 61.8 4193 2,506 59.8 0.9 0.85 0.95
Hispanic/Latino
Total diagnoses Total viral suppression Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. Quarter 1
Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression
No %a No %a No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 642 19.4 421 65.6 57 33 57.9 104 70 67.3 172 116 67.4 301 197 65.4 1.1 0.89 1.43
 25–34 1,284 38.9 903 70.3 154 108 70.1 220 163 74.1 344 234 68.0 553 389 70.3 1.0 0.89 1.13
 35–44 694 21.0 512 73.8 67 52 77.6 135 102 75.6 159 123 77.4 322 229 71.1 0.9 0.79 1.06
 45–54 472 14.3 350 74.2 50 39 78.0 71 59 83.1 116 88 75.9 230 160 69.6 0.9 0.75 1.06
 55 +  212 6.4 144 67.9 18 15 83.3 37 27 73.0 55 38 69.1 99 61 61.6 0.7 0.57 0.96
 Transmission categorye
 Male-to-male sexual contact 2,858 86.5 2,042 71.4 311 227 72.9 498 371 74.6 727 516 70.9 1286 904 70.3 1.0 0.89 1.04
 Injection drug use 78 2.4 39 50.4 6 4 56.5 14 9 62.5 17 10 60.8 39 16 41.5 0.7 0.34 1.61
 Male-to-male sexual contact and injection drug use 85 2.6 47 55.5 10 5 50.5 12 8 68.9 30 17 57.9 34 17 49.6 1.0 0.48 2.01
 Heterosexual contact 282 8.5 201 71.3 20 12 62.1 43 33 76.1 72 56 77.5 146 99 67.7 1.1 0.76 1.57
 Other 1 0.0 1 71.4 0 0 – 0 0 – 0 0 100.0 1 0 60.0 – – –
 Region
 Deep South 3,083 93.3 2,180 70.7 309 222 71.8 512 384 75.0 782 556 71.1 1446 993 68.7 1.0 0.88 1.03
 Other South 221 6.7 150 67.9 37 25 67.6 55 37 67.3 64 43 67.2 59 43 72.9 1.1 0.82 1.42
 Subtotal 3,304 100.0 2,330 70.5 346 247 71.4 567 421 74.3 846 599 70.8 1505 1036 68.8 1.0 0.89 1.04
Female
 Age at diagnosis (yrs)
 18–24 61 12.2 44 72.1 5 4 80.0 10 8 80.0 14 9 64.3 31 22 71.0 0.9 0.54 1.45
 25–34 138 27.5 101 73.2 10 8 80.0 18 13 72.2 30 20 66.7 77 57 74.0 0.9 0.66 1.30
 35–44 117 23.4 79 67.5 9 8 88.9 11 7 63.6 36 26 72.2 61 38 62.3 0.7 0.52 0.95
 45–54 115 23.0 85 73.9 6 3 50.0 14 11 78.6 28 26 92.9 65 44 67.7 1.4 0.60 3.07
 55 +  70 14.0 41 58.6 5 4 80.0 9 6 66.7 22 16 72.7 34 15 44.1 0.6 0.31 0.98
 Transmission category
 Injection drug use 43 8.5 26 61.6 2 2 85.0 4 3 87.2 10 6 60.2 26 15 55.9 0.7 0.34 1.29
 Heterosexual contact 457 91.2 323 70.6 33 25 76.7 58 42 71.7 120 91 75.8 241 160 66.6 0.9 0.70 1.07
 Other 1 0.3 1 92.3 0 0 – 0 0 – 0 0 100.0 1 1 100.0 – – –
 Region
 Deep South 466 93.0 324 69.5 30 24 80.0 55 39 70.9 124 92 74.2 252 165 65.5 0.8 0.67 1.00
 Other South 35 7.0 26 74.3 5 3 60.0 7 6 85.7 6 5 83.3 16 11 68.8 1.1 0.52 2.52
 Subtotal 501 100.0 350 69.9 35 27 77.1 62 45 72.6 130 97 74.6 268 176 65.7 0.9 0.70 1.04
 Totalf 3,805 100.0 2680 70.4 381 274 71.9 629 466 74.1 976 696 71.3 1773 1212 68.4 1.0 0.89 1.02
White
Total diagnoses Total viral suppression Quarter 1 (lowest vulnerability) Quarter 2 Quarter 3 Quarter 4 (highest vulnerability) Quarter 4 vs. quarter 1
Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression Diagnoses Viral suppression
No %a No %b No No %c No No %c No No %c No No %c PR 95% CId
Male
 Age at diagnosis (yrs)
 18–24 427 14.7 300 70.3 82 61 74.4 108 71 65.7 140 103 73.6 87 58 66.7 0.9 0.74 1.09
 25–34 995 34.2 714 71.8 219 172 78.5 247 174 70.4 251 176 70.1 260 179 68.8 0.9 0.79 0.98
 35–44 566 19.5 398 70.3 120 83 69.2 145 103 71.0 165 119 72.1 127 89 70.1 1.0 0.86 1.19
 45–54 524 18.0 368 70.2 134 101 75.4 144 104 72.2 126 82 65.1 109 73 67.0 0.9 0.75 1.05
 55 +  398 13.7 279 70.1 100 70 70.0 96 69 71.9 106 73 68.9 91 64 70.3 1.0 0.83 1.21
 Transmission categorye
 Male-to-male sexual contact 2,353 80.9 1,705 72.5 557 430 77.2 609 430 70.5 629 447 71.0 514 369 71.7 0.9 0.87 1.00
 Injection drug use 139 4.8 74 53.3 14 4 30.2 20 14 70.1 39 23 58.2 62 32 51.8 1.7 0.74 3.95
 Male-to-male sexual contact and injection drug use 205 7.0 132 64.4 44 23 53.4 49 34 69.7 57 40 69.3 50 31 62.1 1.2 0.82 1.65
 Heterosexual contact 210 7.2 146 69.4 41 30 72.7 61 43 70.0 61 43 70.3 47 30 65.1 0.9 0.68 1.19
 Other 3 0.1 2 57.7 0 0 100.0 1 0 33.3 1 1 70.0 1 0 50.0 – – –
 Region
 Deep South 2,500 85.9 1,775 71.0 531 397 74.8 645 453 70.2 680 483 71.0 600 414 69.0 0.9 0.86 0.99
 Other South 410 14.1 284 69.3 124 90 72.6 95 68 71.6 108 70 64.8 74 49 66.2 0.9 0.75 1.11
 Subtotal 2,910 100.0 2,059 70.8 655 487 74.4 740 521 70.4 788 553 70.2 674 463 68.7 0.9 0.86 0.99
Female
 Age at diagnosis (yrs)
 18–24 66 11.8 42 63.6 10 7 70.0 17 11 64.7 18 11 61.1 20 13 65.0 0.9 0.55 1.56
 25–34 170 30.5 100 58.8 19 12 63.2 44 30 68.2 41 26 63.4 59 28 47.5 0.8 0.49 1.16
 35–44 134 24.1 74 55.2 19 8 42.1 16 13 81.3 41 24 58.5 56 29 51.8 1.2 0.69 2.21
 45–54 119 21.4 65 54.6 7 5 71.4 29 15 51.7 38 14 36.8 40 26 65.0 0.9 0.54 1.53
 55 +  68 12.2 45 66.2 14 10 71.4 16 12 75.0 17 10 58.8 20 12 60.0 0.8 0.52 1.37
 Transmission categorye
 Injection drug use 152 27.3 70 45.8 13 7 51.9 34 19 57.0 46 17 36.1 54 26 47.4 0.9 0.50 1.66
 Heterosexual contact 404 72.5 256 63.4 56 35 62.9 88 62 70.2 109 68 62.9 141 82 58.4 0.9 0.73 1.19
 Other 1 0.2 0 33.3 0 0 – 1 0 33.3 1 0 20.0 0 0 100.0 – – –
 Region
 Deep South 480 86.2 279 58.1 58 33 56.9 99 67 67.7 137 75 54.7 175 98 56.0 1.0 0.76 1.28
 Other South 77 13.8 47 61.0 11 9 81.8 23 14 60.9 18 10 55.6 20 10 50.0 0.6 0.36 1.03
 Subtotal 557 100.0 326 58.5 69 42 60.9 122 81 66.4 155 85 54.8 195 108 55.4 0.9 0.72 1.14
 Totalf 3,467 100.0 2,385 68.8 724 529 73.1 862 602 69.8 943 638 67.7 869 571 65.7 0.9 0.84 0.96
Open in a new tab

Hispanic/Latino persons can be of any race

CI = confidence interval; PR = proportion ratio

SVI scores were grouped into quartiles according to their distribution among US census tracts. Proportions were considered significantly different if the 95% CIs of the PRs excluded one

aColumn percent

bDenominator of percent is total number of HIV diagnoses

cDenominator of percent is number of HIV diagnoses in the quarter

dTwo proportions are statistically different if the 95% CI does not include 1.0

eTransmission category is classified based on a hierarchy of the risk factors most likely responsible for HIV transmission. Statistical adjustments were performed for missing HIV transmission categories

f Total included 159 Black/African American, 46 Hispanic/Latino, and 69 White adults without SVI rankings

Discussion

In 2018 in the Southern U.S., we observed significant differences in rates of HIV diagnoses and some HIV-related care outcomes by SVI score. The highest diagnosis rates typically fell within census tracts with the highest vulnerability.

Black and White adults residing in the highest socially vulnerable tracts were more likely to receive an HIV diagnosis than those in the least socially vulnerable tracts. Among persons residing in the most socially vulnerable tracts, adults in all three racial/ethnic groups of all ages (excluding Black males aged 18‒24 and aged 55 + years) and those in both the Deep and Other South were more likely to receive an HIV diagnosis. Our findings are consistent with a recent study of Black adults with HIV that found higher rates of HIV diagnoses among those in communities with the highest social vulnerability compared to those with the lowest social vulnerability [19]. Another study exploring social vulnerability found an association between social vulnerability and increased COVID-19 case counts [20]. Previous studies on natural disasters have also found that groups with social and structural inequities are more prone to hazards and its negative effects [21]. Communities with better social conditions, that is those with ample resources, are more able to provide residents with access to a wide range of services such as knowledge of useful health information and the means to afford healthy lifestyles [22].

Hispanic/Latino males aged 25–34 years in communities with the highest social vulnerability were less likely to receive an HIV diagnosis than those in communities with low social vulnerability. This finding was unexpected, and it is possible that other social and structural factors not explored in this study could contribute to the high rates of HIV infections among this group of young Hispanic/Latino males. Another likely explanation could be that Hispanic/Latino males between 25 and 34 years old residing in the most socially vulnerable tracts in our study may have increased social support networks in their communities due to targeted interventions. Social support has been shown to be associated with past and future HIV testing and PrEP awareness, [23] which could contribute to lower rates of HIV infection.

We found that White adults in communities with the highest SVI were less likely to be linked to care within 1 month of diagnosis compared to those with the lowest SVI, whereas there was no significant difference in the highest and lowest SVI for Black and Hispanic/Latino adults. Differences may be less pronounced between Black and Hispanic/Latino adults in the highest and lowest SVI due to social determinants of health factors (SDOH). SDOH factors such as residential segregation, medical treatment, and psychosocial stressors affect Black and Hispanic/Latino adults more than White adults across all levels of SVI. For example, higher-income Black and Hispanic/Latino adults live in lower-income areas than White persons of similar economic status, and lower-income White persons live in higher-income areas than Black and Hispanic/Latino adults of similar economic status [24]. Segregation of Black and Hispanic/Latino adults is higher at all levels of income [24]. Residential segregation may play a role in racial disparities in HIV care outcomes by isolating individuals from access to important resources regardless of social vulnerability. Also, Black and Hispanic/Latino adults are less likely than White persons to receive high-quality medical treatment after they gain access to medical care, making the contribution of receiving medical care subpar [25]. Additionally, the subjective experience of discrimination is a neglected psychosocial stressor that can adversely affect the health of some racial/ethnic populations. Discrimination may contribute to the elevated risk of disease that is sometimes observed among Black and Hispanic/Latino adults regardless of social vulnerability [25]. Black and Hispanic/Latino adults have also been shown to be more likely to delay entry into HIV care and receive a diagnosis at a later stage of the disease compared to White persons [26, 27], which might partly explain why linkage to care remained uniform at all levels of social vulnerability throughout the Southern U.S. Existing literature also suggests that among Hispanic/Latino adults, stigma within the community, language barrier (i.e., lack of interpretive services), undocumented status (i.e., fear of deportation, paperwork requirements), and a challenging healthcare system (i.e., difficulties navigating the complex healthcare system), may account for some barriers to accessing HIV care services [28–30].

We found that Black and White adults were less likely to have viral suppression within 6 months of diagnosis when comparing the highest socially vulnerable census tracts to the lowest socially vulnerable census tracts. The evidence on a relationship between social vulnerability and viral suppression is mixed. Our findings for Black and White adults are consistent with a previous study that showed that neighborhoods with the worst socioeconomic context scores had poorer viral suppression than those with the best scores [31]. The authors suggested that limited job prospects, lower income, and stigma, reduced access to healthcare services, and substance use may act in synergy with each other and with other factors and influence health-seeking behavior and decisions; therefore, creating difficulties in engaging in HIV care which could lead to suboptimal HIV outcomes [31]. Conversely, our findings for Hispanic adults align with two studies in Brazil that found no association between social vulnerability and viral suppression within 6 months of Anti-retroviral therapy (ART) initiation [32, 33]; however, Pascom et al. reported that those residing in socially vulnerable neighborhoods were significantly more likely to present to care late and not be on ART [33].

By region of residence, we found strong associations between social vulnerability and HIV diagnoses for all three racial/ethnic groups (excluding Hispanic/Latino males in the Deep South or Other South). Our results suggest that the percentages of linkage to care and viral suppression were somewhat uniform across SVI tracts by region of residence throughout the Southern U.S. Literature on social determinants of health suggests that high rates of poverty, unemployment, institutionalized racism, conservative culture, and HIV-related stigma may play a role in the high HIV rates in the Southern U.S [2]. The Southern U.S., particularly the Deep South, typically experience high poverty rates, lack of health care services, shortage of healthcare personnel, and large proportion of uninsured persons, which make it challenging to access adequate HIV services [34]. Additionally, in the Deep South, health policies including those pertaining to HIV may be influenced by conservative politics and deep religiosity [35].

Limitations

This paper is subject to some limitations. First, the analyses were limited to 15 Southern jurisdictions with complete laboratory reporting during 2018; therefore, they may not be representative of all adults with diagnosed HIV in the Southern U.S. Second, this is an ecological study, so findings should be interpreted with caution because they may not apply at the individual level. Finally, HIV infection was geocoded to the U.S. census tract where a person lived at the time of their diagnosis; however, HIV infection might have occurred in a different place.

Conclusion

Reducing HIV infections and improving health outcomes in the Southern U.S. may require tailoring interventions to ameliorate social vulnerability. Improving economic opportunities, increasing access to public resources, and enhancing access to education could be beneficial especially for persons residing in communities identified as having limited resources. Future research should investigate why care outcomes such as linkage to care and viral suppression remain consistent across SVI tracts among Hispanic/Latino adults.

Acknowledgements

This project was supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the Centers for Disease Control and Prevention.

Funding

No funding was received for this work. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declarations

Conflict of interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Footnotes

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

Publisher's Note

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

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