A Qualitative Study of Transportation-Related Barriers to HIV Care in South Carolina.

OBJECTIVES: Addressing structural barriers to care for people living with human immunodeficiency virus (HIV) in the southern United States is critical to increase rates of viral suppression and to reduce existing HIV disparities. This qualitative study aimed to describe transportation-related barriers experienced by people living with HIV in South Carolina, understand perceived effects of transportation vulnerability on HIV care, and explore strategies used by individuals to overcome transportation-related challenges. METHODS: We conducted semistructured interviews with 20 people living with HIV from South Carolina who were either reengaging in HIV care after a prolonged absence (>9 months) or in care but with a detectable viral load (ie, >200 copies/mL). All people living with HIV reported transportation vulnerability. A deductive/inductive approach was used to identify transportation-related barriers perceived to negatively affect HIV care. We also identified strategies and resources described by people living with HIV as helpful in addressing transportation challenges. RESULTS: Participants described a range of transportation-related barriers to HIV care, including lack of access to reliable, safe, and affordable transportation, as well as stigma due to HIV and socioeconomic statuses. These barriers were reported to negatively affect engagement in care and worsen both physical and mental health. Participants indicated flexible clinic policies and instrumental support from family and friends were useful in overcoming barriers. CONCLUSIONS: This study offers insight for the development of transportation interventions to improve equitable access to HIV care for people living with HIV in South Carolina. It also calls attention to the ways in which transportation vulnerability, HIV-related stigma, and disability status intersect to create unique challenges for some people living with HIV.

Longitudinal assessments of viral rebound among people with HIV in South Carolina: a population-based cohort study.

Routinely monitoring viral rebound (VR) is important in the life course of people with HIV (PWH). This study examined risk factors for time to the first VR, the number of VRs and their association with VR history in men who have sex with men (MSM). It includes 8176 adult PWH diagnosed from January 2005 to December 2018, followed until July 2021. We used the Cox model for time to the first VR, the Poisson model for a number of VRs, and logistic regression for VR history in MSM. Younger individuals (50-59 years vs 18-29 years, aHR: 0.43, 95% CI: [0.34, 0.55]) were more likely to experience VR. Black individuals (Black vs White, IRR: 1.61, 95% CI [1.38, 1.88]) had more VR, while MSM (MSM vs Heterosexual, IRR: 0.68, 95% CI: [0.57, 0.81]) was negatively associated with number of VsR. Furthermore, individuals engaging illicit drug use (IDU) (aOR: 1.50, 95% CI: [1.03, 2.17]) were more likely to experience VR in the MSM subgroup. This study highlighted the alarming risk factors related to VR among PWH. Tailored intervention should also be deployed for young, Black MSM patients with substance use for more effective and targeted public health strategies concerning VR.

COVID-19 Breakthrough Infections Among People With HIV: A Statewide Cohort Analysis.

OBJECTIVES: This study aims to identify COVID-19 breakthrough infections among people with HIV (PWH) across different phases of the pandemic and explore whether differential immune dysfunctions are associated with breakthrough infections. DESIGN AND METHODS: This retrospective population-based cohort study used data from an integrated electronic health record (EHR) database in South Carolina (SC). Breakthrough infection was defined as the first COVID-19 diagnosis documented in the state agency after the date an individual was fully vaccinated (ie, 2 doses of Pfizer/BNT162b2 or Moderna/mRNA-1273, or 1 dose of Janssen/Ad26.COV2.S) through June 14, 2022. We analyzed the risk and associated factors of the outcome using Cox proportional hazards models. RESULTS: Among 7596 fully vaccinated PWH, the overall rate of breakthrough infections was 118.95 cases per 1000 person-years. When compared with the alpha-dominant period, the breakthrough infection rate was higher during both delta-dominant (HR: 1.50; 95% CI: 1.25 to 1.81) and omicron-dominant (HR: 2.86; 95% CI: 1.73 to 4.73) periods. Individuals who received a booster dose had a lower likelihood of breakthrough infections (HR: 0.19; 95% CI: 0.15 to 0.24). There was no association of breakthrough infections with degree of HIV viral suppression, but a higher CD4 count was significantly associated with fewer breakthroughs among PWH (>500 vs <200 cells/mm3: HR: 0.68; 95% CI: 0.49 to 0.94). CONCLUSIONS: In our PWH population, the incidence of breakthrough infections was high (during both delta-dominant and omicron-dominant periods) and mainly associated with the absence of a booster dose in patients older than 50 years, with comorbidities and low CD4 count.

Process evaluation and early outcomes of real-world implementation of a pharmacist-driven cabotegravir/rilpivirine long-acting injectable initiative.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Sexual orientation, gender identity and virologic failure among people with HIV: a cohort study in all of US research program.

BACKGROUND: Sexual and gender minorities (SGMs) are at higher risk of HIV incidence compared to their heterosexual cisgender counterparts. Despite the high HIV disease burden among SGMs, there was limited data on whether they are at higher risk of virologic failure, which may lead to potential disease progression and increased transmission risk. The All of Us (AoU) Research Program, a national community-engaged program aiming to improve health and facilitate health equity in the United States by partnering with one million participants, provides a promising resource for identifying a diverse and large volunteer TGD cohort. Leveraging various data sources available through AoU, the current study aims to explore the association between sexual orientation and gender identity (SOGI) and longitudinal virologic failure among adult people with HIV (PWH) in the US. METHODS: This retrospective cohort study used integrated electronic health records (EHR) and self-reported survey data from the All of Us (AoU) controlled tier data, version 7, which includes participants enrolled in the AoU research program from May 31, 2017, to July 1, 2022. Based on participants' sexual orientation, gender identity, and sex assigned at birth, their SOGI were categorized into six groups, including cisgender heterosexual women, cisgender heterosexual men, cisgender sexual minority women, cisgender sexual minority men, gender minority people assigned female at birth of any sexual orientation, and gender minority people assigned male at birth of any sexual orientation. Yearly virologic failure was defined yearly after one's first viral load testing, and individuals with at least one viral load test > 50 copies/mL during a year were defined as having virologic failure at that year. Generalized linear mixed-effects models were used to explore the association between SOGI and longitudinal virologic failure while adjusting for potential confounders, including age, race, ethnicity, education attainment, income, and insurance type. RESULTS: A total of 1,546 eligible PWH were extracted from the AoU database, among whom 1,196 (77.36%) had at least one viral failure and 773 (50.00%) belonged to SGMs. Compared to cisgender heterosexual women, cisgender sexual minority women (adjusted Odds Ratio [aOR] = 1.85, 95% CI: 1.05-3.27) were at higher risk of HIV virologic failure. Additionally, PWH who were Black vs. White (aOR = 2.15, 95% CI: 1.52-3.04) and whose insurance type was Medicaid vs. Private insurance (aOR = 2.07, 95% CI: 1.33-3.21) were more likely to experience virologic failure. CONCLUSIONS: Maintaining frequent viral load monitoring among sexual minority women with HIV is warranted because it allows early detection of virologic failure, which could provide opportunities for interventions to strengthen treatment adherence and prevent HIV transmission. To understand the specific needs of subgroups of SGMs, future research needs to examine the mechanisms for SOGI-based disparities in virologic failure and the combined effects of multi-level psychosocial and health behavior characteristics.

Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020.

This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.

Vaccination status and disease severity of COVID-19 in different phases of the pandemic.

This study aimed to explore the clinical profile and the impact of vaccination status on various health outcomes among COVID-19 patients diagnosed in different phases of the pandemic, during which several variants of concern (VOCs) circulated in South Carolina (SC). The current study included 861,526 adult COVID-19 patients diagnosed between January 2021 and April 2022. We extracted their information about demographic characteristics, vaccination, and clinical outcomes from a statewide electronic health record database. Multiple logistic regression models were used to compare clinical outcomes by vaccination status in different pandemic phases, accounting for key covariates (e.g. historical comorbidities). A reduction in mortality was observed among COVID-19 patients during the whole study period, although there were fluctuations during the Delta and Omicron dominant periods. Compared to non-vaccinated patients, full-vaccinated COVID-19 patients had lower mortality in all dominant variants, including Pre-alpha (adjusted odds ratio [aOR]: 0.33; 95%CI: 0.15-0.72), Alpha (aOR: 0.58; 95%CI: 0.42-0.82), Delta (aOR: 0.28; 95%CI: 0.25-0.31), and Omicron (aOR: 0.29; 95%CI: 0.26-0.33) phases. Regarding hospitalization, full-vaccinated parties showed lower risk of hospitalization than non-vaccinated patients in Delta (aOR: 0.44; 95%CI: 0.41-0.47) and Omicron (aOR: 0.53; 95%CI: 0.50-0.57) dominant periods. The findings demonstrated the protection effect of the COVID-19 vaccines against all VOCs, although some of the full-vaccinated population still have symptoms to varying degrees from COVID-19 disease at different phases of the pandemic.

Use of machine learning approaches to predict transition of retention in care among people living with HIV in South Carolina: a real-world data study.

Maintaining retention in care (RIC) for people living with HIV (PLWH) helps achieve viral suppression and reduce onward transmission. This study aims to identify the best machine learning model that predicts the RIC transition over time. Extracting from the enhanced HIV/AIDS reporting system, this study included 9765 PLWH from 2005 to 2020 in South Carolina. Transition of RIC was defined as the change of RIC status in each two-year time window. We applied seven classifiers, such as Random Forest, Support Vector Machine, eXtreme Gradient Boosting and Long-short-term memory, for each lagged response to predict the subsequent year's RIC transition. Classification performance was assessed using balanced prediction accuracy, the area under the curve (AUC), recall, precision and F1 scores. The proportion of the four categories of RIC transition was 13.59%, 29.78%, 9.06% and 47.57%, respectively. Support Vector Machine was the best approach for every lag model based on both the F1 score (0.713, 0.717 and 0.719) and AUC (0.920, 0.925 and 0.928). The findings could facilitate the risk augment of PLWH who are prone to follow-up so that clinicians and policymakers could come up with more specific strategies and relocate resources for intervention to keep them sustained in HIV care.

Multi-level Factors Associated with HIV Late Presentation with Advanced Disease and Delay Time of Diagnosis in South Carolina, 2005-2019.

This study explored individual- and county-level risk factors of late presentation with advanced disease (LPAD) among people with HIV (PWH) and their longer delay time from infection to diagnosis in South Carolina (SC), using SC statewide Enhanced HIV/AIDS Reporting System (eHARS). LPAD was defined as having an AIDS diagnosis within three months of initial HIV diagnosis, and delay time from HIV infection to diagnosis was estimated using CD4 depletion model. 3,733 (41.88%) out of 8,913 adult PWH diagnosed from 2005 to 2019 in SC were LPAD, and the median delay time was 13.04 years. Based on the generalized estimating equations models, PWH who were male (adjusted prevalence ratio [aPR]: 1.22, 95% CI: 1.12 ∼ 1.33), aged 55+ (aPR: 1.76, 95% CI: 1.62 ∼ 1.92), were Black (aPR: 1.09, 95% CI: 1.03 ∼ 1.15) or Hispanic (aPR: 1.42, 95% CI: 1.26 ∼ 1.61), and living in counties with a larger proportion of unemployment individuals (aPR: 1.02, 95% CI: 1.01 ∼ 1.03) were more likely to be LPAD. Among PWH who were LPAD, Hispanic (adjusted beta: 1.17, 95% CI: 0.49 ∼ 1.85) instead of Black (adjusted beta: 0.11, 95% CI: -0.30 ∼ 0.52) individuals had significant longer delay time compared to White individuals. Targeted and sustained interventions are needed for older, male, Hispanic or Black individuals and those living in counties with a higher percentage of unemployment because of their higher risk of LPAD. Additionally, specific attention should be paid to Hispanic individuals due to their longer delay time to diagnosis.

The dynamic risk factors of cardiovascular disease among people living with HIV: a real-world data study.

BACKGROUND: This study aims to investigate the incidence and dynamic risk factors for cardiovascular diseases (CVD) among people living with HIV (PLWH). METHODS: In this population-based statewide cohort study, we utilized integrated electronic health records data to identify adult (age ≥ 18) who were diagnosed with HIV between 2006 and 2019 and were CVD event-free at the HIV diagnosis in South Carolina. The associations of HIV-related factors and traditional risk factors with the CVD incidence were investigated during the overall study period, and by different follow-up periods (i.e., 0-5yrs, 6-10yrs 11-15yrs) using multivariable logistic regression models. RESULTS: Among 9,082 eligible participants, the incidence of CVD was 18.64 cases per 1000 person-years. Overall, conventional risk factors, such as tobacco use, hypertension, obesity, chronic kidney disease (CKD), were persistently associated with the outcome across all three groups. While HIV-related factors, such as recent CD4 count (e.g., > 350 vs. <200 cells/mm3: adjusted odds ratio [aOR] range: 0.18-0.25), and percent of years in retention (e.g., 31-75% vs. 0-30%: aOR range: 0.24-0.57) were associated with lower odds of CVD incidence regardless of different follow up periods. The impact of the percent of days with viral suppression gradually diminished as the follow-up period increased. CONCLUSIONS: Maintaining an optimal viral suppression might prevent CVD incidence in the short term, whereas restoring immune recovery may be beneficial for reducing CVD risk regardless of the duration of HIV diagnosis. Our findings suggest the necessity of conducting more targeted interventions during different periods of HIV infection.

Which Features of Telehealth in HIV Care Are Most Important? A Mixed-Methods Study With HIV Care Providers and People Living With HIV in South Carolina.

ABSTRACT: Telehealth was rapidly implemented in HIV care during COVID-19 yet remains understudied. To assess the importance of telehealth features, we conducted a mixed-methods study with HIV care providers and people living with HIV. Qualitative interviews and ranking exercises revealed heterogeneity in preference-relevant features of telehealth in HIV care.

Impact of enacted stigma on mental health, substance use, and HIV-related behaviors among sexual minority men in Zambia.

Sexual minority men (SMM) in Zambia face significant challenges including stigma, discrimination, and mental health issues, which further impact their HIV-related risk behaviors. This study aimed to investigate the associations between enacted stigma, substance abuse, HIV-related behaviors, and mental health (i.e., depression, anxiety, and post-traumatic stress disorder [PTSD] symptoms) among SMM in Zambia. SMM aged 18-35 years who reported having multiple and/or concurrent sexual partners or low and/or inconsistent condom use in the past three months were recruited from four districts in Zambia between February and November 2021. Participants completed an anonymous interviewer-administered survey. Key variables of interest were compared between participants with higher vs. lower levels of enacted stigma. Independent samples t-tests were used for continuous variables, and chi-squared tests were used for categorical variables. A total of 197 eligible SMM participated in the study (mean age = 24.41 years). Participants with a higher level of enacted stigma showed a higher level of anxiety symptoms (χ2 = 12.91, p ≤ .001), PTSD symptoms (χ2 = 7.13, p < .01), tobacco use (χ2 = 10.47, p < .01), cannabis use (χ2 = 5.90, p < .05), and a higher number of sexual partners (t = 1.99, p < .05) in the past three months. Stigma reduction interventions may help mitigate substance abuse, HIV-related behaviors, and adverse mental health outcomes among SMM in Zambia. Health care providers, especially psychiatric-mental health nurses, can incorporate strategies for recognizing and addressing stigma into their practice through training and integrate multiple resources to create an inclusive and non-judgmental environment for SMM to improve their well-being.

Disparities in Telehealth Use in HIV Care During the COVID-19 Pandemic: Study Findings from South Carolina.

Background: Telehealth was adopted to maintain HIV care continuity during the COVID-19 pandemic; however, its use was unequally distributed. This study examined variation in HIV care visit patterns and whether telehealth use was associated with viral suppression. Methods: Electronic health record (EHR) data from a large HIV clinic in South Carolina was analyzed using multivariable logistic regression to characterize variation in telehealth use, having a viral load (VL) test, and viral suppression in 2022. Results: EHR data from 2,375 people living with HIV (PWH) between March 2021 and March 2023 showed telehealth use among 4.8% of PWH. PWH who are 50+ years and non-Hispanic Black had lower odds of telehealth use (odds ratio [OR] 0.59, 95% confidence interval [CI 0.40-0.86]; OR 0.58, 95% CI [0.37-0.92] respectively). Telehealth use was not associated with viral suppression and VL testing. Conclusion: Telehealth disparities in HIV care affected older and non-Hispanic Black PWH, requiring tailored strategies to promote telehealth among them.

Sexual orientation and gender identity measures and viral suppression for people living with HIV: a protocol for a population-based cohort study.

INTRODUCTION: The measure of sexual orientation and gender identity (SOGI) data in electronic health records (EHR) has been critical for addressing health disparities and inequalities, especially for HIV care. Given that gender and sexual minorities (eg, transgender, men who have sex with men and intersex) are key groups in people living with HIV (PLWH), SOGI data can facilitate a more accurate understanding about the HIV outcomes (eg, viral suppression) among this key group and then lead to tailored therapeutic services. The two-step SOGI collection method as an emerging gender measurement can be used to measure SOGI status in medical settings. Using the statewide cohort of PLWH in South Carolina (SC), this project aims to: (1) integrate statewide PLWH cohort data with their birth certificate data to evaluate SOGI measurements from multiple EHR sources; and (2) examine differences in viral suppression based on SOGI measurements. METHODS AND ANALYSIS: Our EHR database includes several HIV data sources with patients' gender information, such as SC Department of Health and Environmental Control Centre (DHEC), Health Sciences South Carolina (HSSC) and Prisma as well as birth certificate data to retrieve the sex at birth. The SC Enhanced HIV/AIDS Reporting System (e-HARS) from DHEC will provide longitudinal viral load information to define a variety of viral suppression status. Datasources like the SC office of Revenue and Fiscal Affairs (RFA) will extract longitudinal EHR clinical data of all PLWH in SC from multiple health systems; obtain data from other state agencies and link the patient-level data with county-level data from multiple publicly available data sources. ETHICS AND DISSEMINATION: The study was approved by the Institutional Review Board at the University of South Carolina (Pro00129906) as a Non-Human Subject study. The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media.

COVID-19 breakthrough infections among people living with and without HIV: A statewide cohort analysis.

OBJECTIVES: This study aims to characterize and compare COVID-19 breakthrough infections between people living with and without HIV across different phases of the pandemic. METHODS: Using statewide HIV cohort data, the study population included adult residents in South Carolina (SC) (>18 years old) who were fully vaccinated between January 02, 2021 and April 14, 2022 when Alpha, Delta, and Omicron variants were circulating in SC. We used the Cox proportional hazard model to investigate the association between HIV infection and breakthrough infection, adjusting for relevant covariates. RESULTS: Among 2,144,415 vaccinated individuals, 8,335 were people living with HIV (PLWH) and 2,136,080 were people without HIV (PWoH). After propensity score matching, HIV infection was not significantly associated with breakthrough infection rate. However, when comparing breakthrough infections among individuals without any booster dose, PLWH had a higher risk of breakthrough infections (adjusted Hazard Ration: 1.19; 95% confidence interval: 1.03-1.39). Compared to PWoH, PLWH with high levels of clusters of differentiation 4 (CD4) count or viral suppression were not associated with breakthrough infections. CONCLUSIONS: Our findings do not support a broad conclusion that COVID-19 vaccine effectiveness is lower among PLWH, while we did find that PLWH had a higher risk of breakthrough infection compared to PWoH if they did not receive a booster dose.

Suicide Ideation and Attempt Among People With HIV: A Statewide Population-level Cohort Analysis Between 2005 and 2020.

BACKGROUND: Risk factors for suicidality among people with HIV (PWH) may evolve over their disease course, particularly as they develop comorbidities such as mental health disorders over time. SETTING: This study compared the leading risk factors of suicide ideation/attempt among PWH in South Carolina across different combination antiretroviral therapy (cART) eras. METHODS: A statewide cohort of PWH who were diagnosed between 2005 and 2016, with a follow-up record until 2020, was involved in the study. A Cox proportional hazards model was used to examine the association of suicide ideation/attempt and predictors, including demographics, HIV-related characteristics, and mental health conditions. RESULTS: Among 8567 PWH, the incidence of suicide ideation/attempt increased from 537.7 per 100,000 person-years [95% confidence interval (CI): 460.2 to 615.1] in the early cART cohort (2005-2008) to 782.5 (95% CI: 697.6 to 867.4) in the late cART cohort (2009-2016). Leading risk factors of suicide ideation/attempt changed across the cART cohort. In the early cART cohort, PWH with suicide ideation/attempt were more likely to be White and diagnosed with bipolar disorder ( P' s < 0.05). In the late cART cohort, suicide ideation/attempt was positively associated with transmission through injection drug use, anxiety, posttraumatic stress disorder, schizophrenia, and personality disorder ( P' s < 0.05). CONCLUSIONS: Mental health conditions have emerged as more prominent risk factors for suicide ideation/attempt in the late cART cohort. Enhanced access to psychiatric care could facilitate the early identification of mental health conditions, enabling timely counseling or psychosocial interventions that may mitigate mental health issues and, consequently, reduce the likelihood of suicide ideation/attempts among PWH.

COVID-19 Testing Among People with HIV: A Population Level Analysis Based on Statewide Data in South Carolina.

People with HIV (PWH) are at an elevated risk of developing severe COVID-19 outcomes because of compromised immunity and more comorbidities. However, existing literature suggests a lower rate of COVID-testing among PWH. This study aimed to explore the temporal trend of county-level COVID-19 testing rate and multi-level predictors of COVID-19 ever-testing among PWH in South Carolina (SC). Leveraging linked statewide HIV and COVID-19 datasets, we defined the study population as all adult (18 + years) PWH who were alive on March 2020 and living in SC. PWH with a COVID-19 testing record between March 2020 and October 2021 were defined as COVID-19 ever-testers. Logistic regression and generalized mixed models were used to investigate the association of PWH's demographic profile, HIV clinical characteristics (e.g., CD4 count, viral load), comorbidities, and social factors with COVID-19 testing among PWH. Among 15,660 adult PWH, 8,005 (51.12%) had ever tested for COVID-19 during the study period (March 2020-October 2021). PWH with older age, being male, and Hispanics were less likely to take COVID-19 testing, while men who have sex with men or injection drug users were more likely to take COVID-19 testing. PWH with higher recent viral load (10,000-100,000 copies/ml vs. <200 copies/ml: adjusted odds ratio [AOR]: 0.64, 95%CI: 0.55-0.75) and lower CD4 counts (> 350 cells/mm3 vs. <200 cells/mm3: AOR: 1.25, 95%CI: 1.09-1.45) had lower odds for COVID-19 testing. Additionally, PWH with lower comorbidity burden and those living in rural areas were less likely to be tested for COVID-19. Differences in COVID-19 test-seeking behaviors were observed among PWH in the current study, which could help provide empirical evidence to inform the prioritization of further disease monitoring and targeted intervention. More efforts on building effective surveillance and screening systems are needed to allow early case detection and curbing disease transmission among older, male, Hispanic, and immune-suppressed PWH, especially in rural areas.

Residential Segregation and County-Level COVID-19 Booster Coverage in the Deep South: Surveillance Report and Ecological Study.

BACKGROUND: COVID-19 had a greater impact in the Deep South compared with other regions in the United States. While vaccination remains a top priority for all eligible individuals, data regarding the progress of booster coverage in the Deep South and how the coverage varies by county and age are sparse. Despite existing evidence of racial and ethnic disparities in COVID-19 vaccinations at the individual level, there is an urgent need for evidence at the population level. Such information could highlight vulnerable communities and guide future health care policy-making and resource allocation. OBJECTIVE: We aimed to evaluate county-level COVID-19 booster coverage by age group in the Deep South and explore its association with residential segregation. METHODS: An ecological study was conducted at the population level by integrating COVID-19 vaccine surveillance data, residential segregation index, and county-level factors across the 418 counties of 5 Deep South states from December 15, 2021, to October 19, 2022. We analyzed the cumulative percentages of county-level COVID-19 booster uptake by age group (eg, 12 to 17 years, 18 to 64 years, and at least 65 years) by the end of the study period. The longitudinal relationships were examined between residential segregation, the interaction of time and residential segregation, and COVID-19 booster coverage using the Poisson model. RESULTS: As of October 19, 2022, among the 418 counties, the median of booster uptake was 40% (IQR 37.8%-43%). Compared with older adults (ie, at least 65 years; median 63.1%, IQR 59.5%-66.5%), youth (ie, 12 to 17 years; median 14.1%, IQR 11.3%-17.4%) and adults (ie, 18 to 64 years; median 33.4%, IQR 30.5%-36.5%) had lower percentages of booster uptake. There was geospatial heterogeneity in the county-level COVID-19 booster coverage. We found that higher segregated counties had lower percentages of booster coverage. Such relationships attenuated as time increased. The findings were consistent across the age groups. CONCLUSIONS: The progress of county-level COVID-19 booster coverage in the Deep South was slow and varied by age group. Residential segregation precluded the county-level COVID-19 booster coverage across age groups. Future efforts regarding vaccination strategies should focus on youth and adults. Health care facilities and resources are needed in racial and ethnic minority communities.