Our analysis of patterns and predictors of linkage to HIV care in TN between 2012 and 2016 highlights unsettling trends. First, despite concerted efforts from TDH, CDC and local partners, timely linkage to HIV care among people newly diagnosed with HIV in TN has not only failed to improve over time, but TN now unfortunately trails the nation in linking PLWH to care. Second, unacceptable racial disparities in linkage to care persist, as non-Hispanic Blacks remain much less likely to link to care than non-Hispanic Whites – even after accounting for a range of individual and structural factors that often are drivers of poor healthcare access and engagement. Our analysis does, however, identify some potential systematic and programmatic opportunities that could be targets for intervention to begin to change this trend as well as areas for further research.
It is well-documented that HIV disproportionately affects the Black community in the US at large – a disparity that persisted decades beyond the start of the HIV epidemic (13–15). Unfortunately, our study findings add to the body of literature highlighting a critical need to adopt new strategies to address these persistent and pervasive racial disparities in HIV outcomes. Today, the life-changing pandemic caused by the novel SARS-coronavirus has shone a floodlight on the power of structural racism to undermine public health as whole (26). Astoundingly, non-Hispanic Blacks have accounted for more than 70% of all COVID-19 deaths in certain US counties (Milwaukee), cities (Chicago), and states (Louisiana) (26). These trends have incited important discussions about systemic racial disparities in the US healthcare system, and may afford a critical opportunity to seriously consider how to address the structural factors driving such disparities in our healthcare system.
Some, like former president of the American Public Health Association, Dr. Camara Jones, have called on us to recognize structural racism as “a system of structuring opportunity and assigning value based on the social interpretation of how one looks;” and the root cause of all differences in any health outcome associated with race (27). As such, racism itself is an important social determinant of health, that necessitates a structural intervention (27). Acknowledging these complex dynamics, one city, Milwaukee, declared racism as a public health crisis in the summer of 2019 (28). Following this declaration, County officials committed to putting racial equity at the core of all city procedures to advocate for policies that improve health in communities of color, and to train their employees on how racism impacts residents (28). Several other studies have taken adopted other strategies to counter structural racism (such as Racial Equity Here in Albuquerque, Austin, Grand Rapids, Louisville, and Philadelphia) (29). Cities and counties in TN and other regions across the countries contending with profound racial disparities may also need to consider these novel structural approaches to not only effectively reduce these disparities, but also to ultimately end the HIV epidemic.
In addition to race/ethnicity, site of diagnosis has also been identified as a significant predictor of linkage to HIV care in several studies. Most have highlighted that while HIV testing in non-healthcare settings may have a higher positivity rate; linkage to care is lower at testing sites without co-located medical facilities (30–32). As in other studies, individuals in our cohort who tested positive for HIV at sites without co-located medical facilities such as correctional facilities and blood banks, were the least likely to link to HIV care (31, 33). Surprisingly, while outpatient facilities yielded the greatest numbers of incident diagnoses in this cohort, diagnosis at these sites were also associated with a 30% reduced risk of linkage to care compared to inpatient facilities. Higher likelihood of linkage to HIV care from inpatient facilities may also reflect the fact that patients diagnosed in these settings are more ill and in need of prompt ART, and thus more readily establish care after hospitalization. Linkage to care from both inpatient facilities and outpatient facilities was lowest in Shelby County, the County seat of Memphis, and TN’s only county targeted for EtE activities. Such findings represent an opportunity for improvement via review and optimization of linkage referrals at such sites, and implementation of new care delivery models, such as rapid ART initiation to promote earlier linkage to care, especially in this county (34).
Our analysis of county-level drivers of linkage to HIV also yielded some intriguing findings. One of the strongest county-level predictor of linkage to HIV care in TN was the average monthly number of mentally unhealthy days. In adjusted analysis, living in a county with more mentally unhealthy days was associated with a 40% reduction in risk of linkage to care. A rich body of data supports an association between community factors and important health outcomes (35–37). Much of this research has focused on poor socioeconomic status (SES) and other characteristics of neighborhood deprivation (18, 35, 37, 38). One study set in TN found that individuals living in neighborhoods with the most adverse socioeconomic features were least likely to achieve virologic suppression (18). Some authors hypothesize that the relationship between SES and health outcomes are mediated by distribution of stressors, which may be more prevalent in poorer neighborhoods and among racial and ethnic minorities (35, 39–41). Others propose that maladaptive response to stressors may disproportionately impact those with low SES due to greater perceived stress and limited resources to cope with stress (39). Importantly, in our analysis, this finding was strong, and independent of race. Another notable finding was a nearly 2-fold increase in the likelihood of linkage to care for individuals living in counties with higher rates of HIV due to IDU. However, given the low prevalence of IDU as a risk factor for new HIV infections in TN (5%), this finding might reflect services for this population within these communities.
Surprisingly, access to health insurance at the county level was not significantly associated with a linkage to care. While TN has not accepted federal Medicaid expansion, through the federally-supported Ryan White (RW) program TN is still able to provide coverage for medical services directly or indirectly associated with HIV/AIDS and related illnesses, as well as general insurance assistance (42). The TN HIV Drug Assistance Program (HDAP), also funded through RW, provides assistance for the purchase of HIV treatment regimens (42, 43). Across the country, recipients of these funds are more likely to succeed along the continuum of care, as compared to uninsured PLWH or those with other forms of healthcare coverage (44, 45). As such, the promotion and utilization of RW services in TN may be an important mechanism to address unmet mental health needs as described earlier in the discussion. Interestingly, unlike access to health insurance directly, the proportion of individuals in a county living with a disability was associated with a tremendous increase in the likelihood of linkage to care for an individual living in that county. This variable may be an important proxy for health insurance given that Americans with disabilities are eligible for Medicare coverage (46).
Our analysis has notable strengths and weaknesses. Our integration of individual-level surveillance with county-level census and publicly reported data allowed us to identify important individual and county-level risk factors for poor linkage to care, while accounting for many of the socioeconomic drivers of racial disparities in health. However, our use of such data also posed some limitations, as we could not incorporate important factors that are not readily collected in these data systems like individual level mental health, experiences with stigma, racism, and other barriers to healthcare access and earlier linkage to HIV care for individuals living with HIV in TN. Additionally, despite the improvements in HIV surveillance and data quality since 2012, our measures of linkage to care were reliant on the completeness of the mandatory reporting system which varies by site and could have introduced some bias.
In conclusion, in order to meet critical EtE target of reducing the number of new HIV infections in the US by 90% and move towards ending the epidemic, statewide linkage to care in TN needs to improve. Despite targeted efforts both broadly and in minority communities, linkage to HIV care did not improve substantially from 2012 to 2016. The pervasiveness of racial disparities that persist at both individual and county levels suggests the need for exploring structural interventions to address racism as a public health threat. In addition, optimizing outreach for young heterosexual men who may be overlooked by interventions targeting MSM, and addressing linkage to care processes from outpatient and community-based testing facilities through improved partnerships or co-location of testing and treatment services are potential areas for intervention. Further exploration of the role of poor community and individual mental health in this environment is needed to inform mental health interventions to improve engagement in HIV care.