Social Determinants of Health among Adults with Diagnosed HIV Infection in the United States and Puerto Rico, 2020: Commentary

Overview

HIV continues to disproportionately affect many populations in the United States. Data in this report may be used to accelerate action to reach disproportionately affected populations and achieve national goals, including Healthy People 2030 [1], the National HIV/AIDS Strategy (NHAS) (2022‒2025) [2], and the Ending the HIV Epidemic in the U.S. (EHE) initiative [3]. HIV surveillance data have highlighted differences in HIV burden by assigned sex at birth, race/ethnicity, and transmission category in the United States. Factors other than these (i.e., social determinants of health) contribute to disparities, and a better understanding of the social determinants that affect the health of populations can be beneficial.

The term social determinants of health (SDOH) refers to the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life [4]. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems that are responsible for most health inequities [5], including the disproportionate effect of HIV on certain populations. Achieving equitable health will require focusing on factors associated with disparities and directing resources to disproportionately affected populations and geographical regions. This approach will improve the health of all persons.

Stratifying public health data by key SDOH, such as income and health insurance coverage, is useful for monitoring health inequities. Addressing SDOH makes it possible to measure and identify health differences between populations or geographic areas and can provide insight for identifying populations or areas that may benefit from HIV testing, prevention, and treatment initiatives.

For this report, the Centers for Disease Control and Prevention (CDC) uses geocoded HIV surveillance data reported by state and local HIV surveillance programs that have been linked with SDOH indicator variables on factors that may affect HIV transmission. HIV surveillance data are geocoded to the census tract level by address of residence at the time of diagnosis and then linked to census tract-level SDOH data from the U.S. Census Bureau’s American Community Survey (ACS). Using census tract-level surveillance data increases CDC’s ability to assess the geographic distribution of HIV, the social determinants associated with HIV, and the relationship of HIV to other diseases and health care resources in a defined area. Addressing SDOH that adversely affect health outcomes may advance efforts to reduce disparities in HIV diagnosis rates among populations and areas.

This surveillance supplemental report presents data on adults aged ≥18 years with HIV infection diagnosed in 2020 and reported to the National HIV Surveillance System (NHSS) through June 2022. Data were limited to adults aged ≥18 years to align with the population in the ACS from which SDOH indicator variables were collected. Numbers, percentages, and rates of diagnoses of HIV infection were based on data reported from the 50 states, the District of Columbia, and Puerto Rico after the jurisdictions geocoded cases to the census tract level, linked to ACS estimates, and transmitted SDOH information to CDC on cases (after personal identifiers were removed) diagnosed during 2020.

SDOH data presented in this report are the result of the linkage of geocoded HIV diagnosis data (at the census tract level) to SDOH indicator variables from the 2016–2020 ACS and are based on where the person was living at the time of diagnosis. The following are the measures for the 5 SDOH indicators presented in this report: federal poverty status, education level, median household income, health insurance coverage, and Gini index.

Impact of COVID-19 Pandemic

The overall number of HIV diagnoses in the United States in 2020 (30,403) was 17% lower than in 2019 (36,585) due to the impact of the COVID-19 pandemic on HIV testing [6–10]. The steep reduction in diagnoses in 2020 is likely due to disruptions in clinical care services, patient hesitancy in accessing clinical services, and shortages in HIV testing reagents/materials, which causes concern regarding underdiagnosis [6–9]. Although state/local health departments developed innovative strategies for HIV-related testing (self-tests) and care services (telehealth) during the COVID-19 pandemic, these strategies did not make up for declines in laboratory reporting because self-test results are not routinely reported to health departments or CDC [11, 12]. In addition, telehealth visits might not have included orders for laboratory testing during periods of strict social distancing or patients may have been reluctant to complete testing.

As the COVID-19 pandemic is still ongoing, more time and data are needed to accurately assess COVID-19’s impact on HIV in the United States. Data for the year 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state/local jurisdictions. To emphasize the need for caution, tables presenting data labels for the year 2020 include “COVID-19 pandemic.”

Report Changes

• The National SDOH Profile section includes figures for linkage to HIV medical care within 1 month of receiving a diagnosis and viral suppression within 6 months of HIV diagnosis.
• Tables 4‒8 include data by region.
• Tables were added (Tables B1‒B4) and display data for the 50 EHE Phase I jurisdictions.