“Certain social and structural factors have contributed to Black people accounting for a higher proportion of new HIV infections than other races and ethnicities,” Joseph Logan, PhD, explains. “To achieve health equity and end the HIV epidemic, the nation must overcome the persistent barriers that have contributed to disparities for far too long. Understanding the social determinants of health is a key component in reducing HIV-related health inequities.”

For a study published in AIDS and Behavior, Dr. Logan and colleagues examined “three structural factors that might influence inequities in HIVrelated care outcomes,” including racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program use.

The investigators used three data sources to review linkage to HIV care within 1 month of diagnosis and viral suppression (ie, viral load <200 copies/mL) relative to these structural factors among 12,996 Black and White adults diagnosed with HIV in 2017 who were alive at the end of 2018. Participants lived in 38 US jurisdictions.

‘Stark’ Socioeconomic Differences for Black Vs White Patients

Compared with White participants, Black individuals had lower rates of linkage to care within 1 month after an HIV diagnosis (82.3% vs 75.8%) and viral suppression in 2018 (77.3% vs 67.8%). For both racial/ethnic groups, a greater number of people with HIV who lived in states with Medicaid expansion were linked to HIV care within 1 month following the diagnosis compared with patients with HIV who lived in states without Medicaid expansion.

“Structural factors intended to lessen the financial burden of HIV care and improve access were positively associated with being linked to HIV care within 1 month of diagnosis and achieving viral suppression for both Black and White people with HIV,” Dr Logan says.

However, the study results showed “stark differences” within the socioeconomic environments in which Black and White patients with HIV reside, according to Dr. Logan (Table). “We did not see a positive association between residing in a state with Medicaid expansion and achieving viral suppression in comparison with residing in a state without Medicaid expansion,” he says. “The strongest structural factor that was positively associated with achieving viral suppression was residing in a state where more than 50% of people living with HIV were receiving Ryan White HIV/AIDS Program services.”

Increasing Services for Patients & Conducting Additional Research

The researchers note that—to their knowledge—this study is the first to simultaneously analyze redlining (see Table footnote), Medicaid expansion, and utilization of the Ryan White HIV/AIDS Program in association with HIV care outcomes for Black and White patients in the United States. The results show that Black and White people with HIV reside in “very different socioeconomic environments, which might create unequal challenges related to receiving ongoing HIV care,” Dr. Logan says.

“Policies and programs that aim to reduce the financial burden of HIV care, like Medicaid expansion and the Ryan White HIV/AIDS Program, show promise for achieving favorable HIV care outcomes,” he continues. “However, while Medicaid expansion was positively associated with linking persons to HIV care within 1 month after diagnosis, this program was not associated with achieving viral suppression for the population in our study.”

Increasing the use of services available through the Ryan White program, such as referral to housing, transportation, mental health, and substance abuse services, could help reach the groups most impacted by HIV who also experience financial difficulties, Dr. Logan explains.

“Redlining was not definitively associated with HIV outcomes in this study,” he says. “However, more work is necessary to determine if redlining perpetuates circumstances such as poverty, which in turn might increase the risk for acquiring HIV or hinder the ability to sustain care. Nearly two-thirds of Black people with diagnosed HIV resided in census tracts where Black loan applicants were at least twice as likely to be rejected for a home loan compared with White applicants, even after accounting for the applicant’s sex at birth, gross annual income, and the loan amount. Not being able to build wealth or financial stability through homeownership while also needing ongoing HIV care might perpetuate ongoing financial disadvantages.”

Forthcoming research should address these disparities in other minority groups, Dr. Logan notes. “This study focused on HIV care disparities between Black and White people,” he says. “Future research is needed to assess the factors related to HIV care inequities and disparities between White people and other racial and ethnic minority groups who, traditionally, have been at a disadvantage in terms of obtaining healthcare.”