Dissertations, Theses, and Capstone Projects

Date of Degree

2-2016

Document Type

Dissertation

Degree Name

D.P.H.

Program

Public Health

Advisor

Luisa N Borrell

Subject Categories

Community Health | Epidemiology | Health Services Research | Immune System Diseases | Infectious Disease | Survival Analysis | Virus Diseases

Keywords

HIV, multilevel analysis, neighborhood, health care facility, New York City

Abstract

Objective

To investigate the effect of individual, health care facility, and neighborhood characteristics on achievement and maintenance of HIV viral suppression, among New York City residents aged 13 years and older diagnosed with HIV between 2006 and 2012.

Methods

I used individual-level data from the New York City HIV surveillance registry and Case Surveillance-Based Sampling, facility-level data from the surveillance registry, and neighborhood-level data from the U.S. Census and American Community Survey. The outcomes of interest were first viral suppression after diagnosis (Aims 1 and 3; ≤400 copies/mL) and virologic failure after first suppression among persons who achieved suppression (Aim 2; viral load ≥1,000 copies/mL or no viral load test for 12 consecutive months). Aim 3 was limited to persons interviewed for Case Surveillance-Based Sampling. Multivariable proportional hazards regressions were used to assess the likelihood of suppression or failure for individual, facility, and neighborhood characteristics, accounting in Aims 1 and 2 for clustering of outcomes.

Results

Of 12,547 persons newly diagnosed with HIV in 2006–2010, 44% achieved suppression within 12 months of diagnosis. In adjusted analyses, persons 13-49 years old, men, blacks and Hispanics, US-born, heterosexuals, and persons diagnosed in 2006 and 2008 were less likely to achieve suppression than persons 60 years old and older, women, whites, foreign-born, men who have sex with men, and persons diagnosed in 2010, respectively. Suppression rates were also lower among persons who were not eligible for treatment, or who were diagnosed at facilities that diagnosed 10-74 patients per year, were screening/diagnosis/referral sites, or within one mile of the person’s home. No neighborhood factors were associated with suppression. Out of 8,927 persons newly diagnosed with HIV in 2006–2010 who achieved viral suppression, 18.2% experienced virologic failure within 12 months of suppression. After adjustment, the following groups were the least likely to maintain suppression: younger persons (≥60), blacks and Hispanics, US- and US-dependency born persons, heterosexuals and injection drug users, persons with CD4 counts ≥500 cells/mL at suppression, persons receiving care at facilities that were not large outpatient facilities or large private practices, and residents of high- or very-high-poverty neighborhoods. Suppression within 12 months of diagnosis was achieved by 65% of persons newly diagnosed with HIV in 2006–2012 and interviewed by Case Surveillance-Based Sampling (n=92). Perceived neighborhood social cohesion was not associated with suppression.

Conclusions

Persons who were younger, black or Hispanic, US-born, heterosexual, diagnosed in earlier years, not treatment-eligible, living within one mile of their health care facility, diagnosed or cared for at certain types of facilities such as those with fewer HIV-positive patients, and living in a higher-poverty neighborhood were less likely to achieve and/or maintain suppression. Assistance with post-diagnosis linkage to and retention in care, ART prescribing, or adherence that is targeted to groups with characteristics associated with poorer outcomes may improve achievement and maintenance of viral suppression in New York City.

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