Understanding Local Spatial Variation Along the Care Continuum: The Potential Impact of Transportation Vulnerability on HIV Linkage to Care and Viral Suppression in High-Poverty Areas, Atlanta, Georgia.

BACKGROUND: Engagement in care is central to reducing mortality for HIV-infected persons and achieving the White House National AIDS Strategy of 80% viral suppression in the US by 2020. Where an HIV-infected person lives impacts his or her ability to achieve viral suppression. Reliable transportation access for healthcare may be a key determinant of this place-suppression relationship. METHODS: ZIP code tabulation areas (ZCTAs) were the units of analysis. We used geospatial and ecologic analyses to examine spatial distributions of neighborhood-level variables (eg, transportation accessibility) and associations with: (1) community linkage to care, and (2) community viral suppression. Among Atlanta ZCTAs with data for newly diagnosed HIV cases (2006-2010), we used Moran I to evaluate spatial clustering and linear regression models to evaluate associations between neighborhood variables and outcomes. RESULTS: In 100 ZCTAs with 8413 newly diagnosed HIV-positive residents, a median of 60 HIV cases were diagnosed per ZCTA during the 5-year period. We found significant clustering of ZCTAs with low linkage to care and viral suppression (Moran I = 0.218, P < 0.05). In high-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 4% point increase in linkage to care (P = 0.02, R = 0.16). In low-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 30% point increase in ZCTA-level viral suppression (P = 0.01, R = 0.08). CONCLUSIONS: Correlations between transportation variables and community-level care linkage and viral suppression vary by area poverty level and provide opportunities for interventions beyond individual-level factors.

Mental health differences between rural and urban men living with HIV infection in various age groups.

Despite the disproportionate increase in rural, Southern residents and older persons during the third era of the HIV/AIDS epidemic, no known study has examined whether older, rural men living with HIV infection face a double jeopardy and have poorer psychosocial profiles than other subgroups of men. We investigated whether area of residence (rural, urban), age (young, middle-age, old), and the interaction of residence and age would be related to mental health factors by using two measurement methods to categorize rural and urban residence (US Census Bureau classification and The Office of Rural Health Policy's, Rural Urban Commuting Area Codes [RUCAs]). We conducted 2-3 hour-long, face-to-face interviews with all but 43 patients who met the study criteria and kept their clinic appointments at three different types of healthcare facilities (i.e., VA, university clinic, public health department) over a 20-month period. The sample consisted of 226 men living in the southeastern US. Rural and urban men of various age groups did not differ in socioeconomic factors, travel distance to clinics, use of medications, satisfaction with care, types of severe stressors, and confidentiality concerns. Using two methods to categorize area of residence, we found that rural men as compared to urban men had similar levels of total stress, AIDS-related stress, social support, active coping and avoidance coping, but higher rates of risk for depression. Rural men had higher levels of non-AIDS-related stress only when the US Census Bureau's categorization was used, which highlights the importance of carefully selecting and describing methods to categorize rural versus urban residence.