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Association of neighborhood-level socioeconomic status (SES) with time from HIV
diagnosis to viral suppression among newly
HIV diagnosed New Yorkers, 2006–2010
Ellen Wiewel, CUNY School of Public Health, New York, NY
APHA abstract #300295, Session 4430.0, “Healthography: Spatial Data and HIV,” Tuesday, November 18, 2014
sph.cuny.eduwww.gc.cuny.edu
Presenter DisclosuresPresenter Disclosures
The following personal financial relationships with commercial interests relevant to this presentation existed
during the past 12 months:
Ellen Wiewel
No relationships to disclose
www.gc.cuny.edu
About the CUNY SPHAbout the CUNY SPHThe CUNY School of Public Health (CUNY SPH) is committed to teaching, research and service that creates a healthier New York City and helps promote equitable, efficient and evidence-based solutions to pressing health problems facing cities around the world.
The CUNY SPH is a CEPH-accredited school of public health which consists of four consortial campuses(Hunter College, Lehman College, Brooklyn College and the Graduate Center) and offers both master’s and doctoral degrees in public health.
www.gc.cuny.edu
About the Graduate CenterAbout the Graduate CenterThe Graduate Center (GC) is the principal doctorate-granting institution of the City University of New York. Offering more than thirty doctoral degrees from Anthropology to Urban Education, and fostering research in a wide variety of centers and institutes, the GC combines rigorous academic training in the humanities, sciences, and social sciences with globally significant research. It is home to a core faculty of approximately 150 teachers and mentors, virtually all senior scholars, and many leaders in their disciplines. This faculty is enhanced by more than 1,800 faculty from across the CUNY colleges, as well as from cultural, academic, and scientific institutions throughout New York City and beyond.
Through its extensive public programs including lectures, conferences, performances, exhibitions, and conversations, the Graduate Center also contributes to the intellectual and cultural life of New York City.
BackgroundBackground
• HIV viral suppression decreases the probability of onward transmission and is a goal of the National HIV/AIDS Strategy
• Population-based analyses of viral suppression have not examined the influence of neighborhood-level socioeconomic status (SES)
Poverty in New York CityPoverty in New York City
Figure 1b. Male HIV diagnosis rates
Text Explanation of MapText Explanation of Map
• NYC ZIP code map showing poverty rates
• Wide variation in poverty levels across NYC, from 0-10% in some ZIPs to ≥30% in others
• Clusters of high-poverty ZIPs in South Bronx, Upper Manhattan, and North and Central Brooklyn
ObjectiveObjective
• Determine whether neighborhood SES is associated with time from HIV diagnosis to viral suppression
Data SourcesData Sources
Data source
NYC HIV surveillance
registry 2006-2012
American Community
Survey 2007-2011
US Census 2010
Population All NYC HIV cases
Representative sample of US
population
Every US resident
Measures
Viral suppression,
demographics, place of
residence
PovertyUnemployment
Race/Ethnicity
Text Explanation of Data Text Explanation of Data Sources TableSources Table
• Table of three data sources and the measures gleaned from each
• Data sources include NYC HIV surveillance registry, American Community Survey, and US Census
Geographic InformationGeographic Information
• Geocoded patient address of residence to 2010 Census tract (CT; smaller than ZIP)
• CT-level data from ACS and Census linked to individual cases by their CT of residence
PopulationPopulation
• 17,825 total New York City residents ≥13 years old newly diagnosed with HIV in 2006-2010
• 12,547 (70%) in final analysis
–Criteria: Address geocodable to CT, diagnosis date accurate, patient domiciled and not institutionalized
–Resided in 1,133 / 2,168 NYC CTs (52%)
Outcome VariableOutcome Variable
• Time from HIV diagnosis to viral suppression
–Viral suppression definition: First viral load test after diagnosis that indicated ≤400 copies of HIV RNA/mL
–No viral load test = Not suppressed
Independent SES VariablesIndependent SES Variables
• Neighborhood poverty: Percent in a CT with incomes below the federal poverty threshold, categorized as 0-<10%, 10-<20%, 20-<30%, and ≥30%
• Neighborhood unemployment: Percent ≥16yo in a CT who were unemployed, divided by 10, modelled as continuous
CovariatesCovariates
• Neighborhood-level covariate: Percent black
• Individual-level covariates: Year of HIV diagnosis, ART eligibility (initial CD4), demographics (age group, sex, race/ethnicity, region of birth), HIV risk
Analytic MethodsAnalytic Methods
• % suppressed ≤12 mos after diagnosis
• Cox proportional hazards regression (time-to-event analysis), accounting for correlations of outcomes by CT, censoring at earlier of death or end of follow-up (12/31/2012)
ResultsResults
• 5,516 / 12,547 (44%) achieved viral suppression within 12 months of diagnosis
• Median time from diagnosis to suppression: 245 days (IQR: 114-646)
Proportional hazards regression of HIV viral suppression among Proportional hazards regression of HIV viral suppression among persons newly diagnosed with HIV in New York City in 2006-2010 persons newly diagnosed with HIV in New York City in 2006-2010
and followed through 2012, by characteristics of the neighborhood and followed through 2012, by characteristics of the neighborhood (Census tract) persons were living in at diagnosis(Census tract) persons were living in at diagnosis
Neighborhood-level variables HR (95% CI) AHR* (95% CI)Percent of population below federal poverty threshold in past 12 months
Low (<10%) 1.00 1.00Medium (10 to <20%) 0.98 (0.92-1.04) 0.99 (0.92-1.06)High (20 to <30%) 1.00 (0.94-1.07) 1.03 (0.95-1.11)Very high (≥30%) 0.95 (0.89-1.01) 1.01 (0.93-1.10)
Unemployment rate among population 16 years and over**
0.95 (0.92-0.99) 1.00 (0.95-1.05)
* Adjusting for both neighborhood-level SES variables, neighborhood-level percent black, and individual-level variables of year of diagnosis, ART eligibility, demographics (age group, sex, race/ethnicity, region of birth), and HIV risk.** Hazard ratios presented for unemployment represent the risk per 10-percentage-point increase in unemployment.
Text Explanation of TableText Explanation of Table
• Table of hazard ratios of viral suppression among residents of higher- vs. lower-poverty or -unemployment neighborhoods
• All adjusted HRs cross 1; time to suppression does not differ by neighborhood SES factors
Summary of FindingsSummary of Findings
• Neighborhood-level SES characteristics did not influence time from HIV diagnosis to viral suppression
LimitationsLimitations
• VL data only when persons sought care (median interval = every 3-4 months)
• Outmigration not ascertained
• No data on ART
• SES may influence intermediate outcomes between diagnosis and suppression – not measured here
StrengthsStrengths
• Among the first US analyses investigating neighborhood influence on HIV outcomes using surveillance data
• Laboratory-confirmed measure of viral suppression
• Address geocoded to CT, the optimal geographic unit for detection of disparities
ConclusionsConclusions
• Neighborhood SES not associated with time from HIV diagnosis to viral suppression in NYC
• NYC’s excellent HIV care and services, benefits for HIV-positive persons, and emphasis on linkage to care may mitigate effect of SES
AcknowledgmentsAcknowledgments
• Academic advisor and coauthor Luisa N. Borrell (CUNY School of Public Health)
• Coauthors Lucia V. Torian (NYC Department of Health), Andrew R. Maroko and Heidi E. Jones (CUNY School of Public Health)
• Heidi Westermann Gortakowski and Hani Nasrallah (both formerly of NYC Department of Health) for geocoding cases
• CUNY SPH Dean Dr. Ayman El-Mohandes & NYC Department of Health for travel stipends
