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

National SDOH Profile

The statements in this section, unless otherwise indicated, are based on stable numbers (i.e., based on 12 or more diagnoses). All rates are per 100,000 population. SDOH data are estimates for the period 2016–2020, and HIV surveillance data are based on case information from 2020 diagnoses of HIV infection among adults aged ≥18 years in the 50 states, the District of Columbia, and Puerto Rico. Data on linkage to HIV medical care within 1 month and viral suppression within 6 months of HIV diagnosis are based on data from 46 jurisdictions with complete reporting of HIV-related laboratory results (including CD4+ T-lymphocyte [CD4] and viral load results) to CDC (see Technical Notes for list of jurisdictions).

Data presented in this report are a snapshot of the environment in which people lived at the time of HIV diagnosis, and some SDOH indicators and selected characteristics may be correlated. For example, lack of education is associated with both poverty and low income in the United States [13, 14]. However, correlations of indicators and characteristics were not assessed for this report.

Important notes:

• All data in this report are based on assigned sex at birth.
• Please use caution when interpreting data for American Indian/Alaska Native and Native Hawaiian/other Pacific Islander adults due to most rates and/or percentages being based on small numbers.
• The statements in the sections on linkage to care and viral suppression focus on SDOH extremes only (e.g., highest poverty, lowest uninsured) and not the overall values within the column unless otherwise indicated.
• For disparity measures, reference groups are based on the rate of the lowest group with more than 5% of cases.
• Please read all titles and footnotes carefully to ensure a complete understanding of the displayed data.
• See Technical Notes for information on definitions and data specifications.

Overview

In 2020 in the 50 states, the District of Columbia, and Puerto Rico, HIV infection was diagnosed for 29,346 adults (aged ≥18 years), of which 27,107 adults had residential address information that was sufficient for geocoding to the census tract (or tract) level (Table 1). These diagnoses represent approximately 92.4% of all diagnoses of HIV infection in 2020 among adults in these areas. The overall rate of diagnoses of HIV infection was 10.6. The rate was 17.9 for males and 3.6 for females based on assigned sex at birth (Table 1).

Linkage to HIV medical care was based on data for adults with infection diagnosed during 2020 in 46 jurisdictions that reported complete CD4 and viral load test results to CDC. Of the 25,055 adults whose infection was diagnosed during 2020 in the 46 jurisdictions, 82.6% (20,705 adults) were linked to HIV medical care within 1 month of diagnosis (Table 9).

Viral suppression within 6 months of HIV diagnosis was measured for adults whose infection was diagnosed during 2020 and who resided in the 46 jurisdictions at time of diagnosis. Of the 25,055 adults whose infection was diagnosed during 2020 in the 46 jurisdictions, 69.0% (17,280 adults) had a suppressed viral load within 6 months (Table 9).

Federal Poverty Status

Poverty is not a single factor but rather is characterized by multiple physical and psychosocial stressors [15]. Poverty places individuals from lower income households at increased risk for HIV due to economic disadvantages that may lead to increased risk behaviors [16]. Poverty and wealth can be viewed in relation to one another as follows: poverty is defined as lacking a usual or socially acceptable amount of money or material possessions; wealth is defined as having an abundance of valuable material possessions or resources [17, 18].

In 2020, adults who lived in census tracts with the highest level of poverty (i.e., lowest level of wealth; where 17% or more of the residents lived below the federal poverty level) accounted for

• the highest HIV diagnosis rates or percentages (diagnoses),
• the lowest percentages of adults linked to HIV medical care within 1 month of receiving a diagnosis (linkage), and
• the lowest percentages of adults with suppressed viral load within 6 months of receiving an HIV diagnosis (viral suppression) among groups by selected characteristics:

Assigned sex at birth:

• Diagnoses—rates: males, 30.6; females, 6.9 (Figure 1 and Table 1).
• Linkage—males, 81.6%; females, 81.4% (Figure 2 and Table 9).
• Viral suppression—males, 66.3%; females, 66.9% (Figure 2 and Table 9).

Age group:

• Diagnoses—all age groups for both sexes (Figures 3a/b and Table 1).
• Linkage—all age groups for both sexes (except males and females aged 18–24 years and females aged 45–54 and ≥55 years) (Table 9).
• Viral suppression—all age groups for both sexes (except females aged 18–24 and 45–54 years) (Table 9).

Race/ethnicity:

• Diagnoses—all racial/ethnic groups among both sexes (except American Indian/Alaska Native males and Asian and multiracial females) (Figures 4a/b and Table 2).
• Linkage—Black/African American males (79.3%) and females (80.9%), Hispanic/Latino females (82.3%), and White males (83.0%) and females (81.3%) (Table 10).
• Viral suppression—Black/African American males (63.7%) and females (66.6%), Hispanic/Latino males (69.1%), White females (63.0%), and multiracial males (60.2%) and females (61.5%) (Table 10).

Transmission category:

• Diagnoses—all transmission categories for both sexes (Figure 5 and Table 3).
• Linkage—all transmission categories for both sexes (except males and females with infection attributed to injection drug use [IDU] and males with infection attributed to male-to-male sexual contact [MMSC] and IDU) (Table 11).
• Viral suppression—all transmission categories for both sexes (Table 11).
• Among males with infection attributed to MMSC (Table 12):
  • Linkage—White (83.5%) and multiracial (83.5%), and
  • Viral suppression—American Indian/Alaska Native (58.7%), Black/African American (65.3%), Hispanic/Latino (70.7%), and multiracial (65.5%).

Area of residence and region: Diagnoses—rates (Table 4):

• Males—Area: District of Columbia (67.3), followed by Maryland (54.4); Region: South (36.2)
• Females—Area: District of Columbia (20.8), followed by Georgia (14.6); Region: South (9.0)
• Total—Area: District of Columbia (42.2), followed by Florida (32.9); Region: South (22.1)

Use caution when comparing the rates of diagnoses for the District of Columbia to the rates for states.

A look at disparities in diagnoses of HIV infection by poverty

In 2020, the disparities in HIV diagnosis by poverty for adults were as follows:

• Absolute disparities (rate difference)―If the rates of diagnoses of HIV infection among males or females in the highest poverty/lowest wealth tracts were similar to the rates among those in the lowest poverty/highest wealth tracts, then diagnoses could have been reduced by 22 cases and 5 cases per 100,000 population, respectively (Figure 1 and Table 1).
• Relative disparities (rate ratio)―Among males, the rate of diagnoses in the highest poverty/lowest wealth tracts was 3.4 times the rate in the lowest poverty/highest wealth tracts, and among females, the rate in the highest poverty/lowest wealth tracts was 4.3 times the rate in the lowest poverty/highest wealth tracts (Figure 1 and Table 1).

For absolute and relative disparities for assigned sex at birth stratified by age group and race/ethnicity, see Figures 3a/b and 4a/b. See Technical Notes for additional information on disparity measures.

Education Level

Education plays an important role in preventing HIV; increased education reduces the social and economic circumstances that may put someone at increased risk for HIV [19]. Persons with higher levels of education typically have better health outcomes due to higher levels of income and occupational status (i.e., social position) [20].

In 2020, adults who lived in census tracts with the lowest level of education (where 16% or more of the residents had less than a high school diploma) accounted for

• the highest HIV diagnosis rates or percentages (diagnoses),
• the lowest percentages of adults linked to HIV medical care within 1 month of receiving a diagnosis (linkage), and
• the lowest percentages of adults with suppressed viral load within 6 months of receiving an HIV diagnosis (viral suppression) among:

Assigned sex at birth:

• Diagnoses—rates: males, 27.0; females, 6.4 (Figure 6 and Table 1).
• Linkage—males, 81.8% (Figure 7 and Table 9).
• Viral suppression—males, 66.8%; females, 66.2% (Figure 7 and Table 9).

Age group:

• Diagnoses—all age groups for both sexes (Figures 8a/b and Table 1).
• Linkage—all age groups for males (except age groups 35–44 and 45–54 years) and females aged 45–54 years (Table 9).
• Viral suppression—all age groups for both sexes (except females aged 18–24 years) (Table 9).

Race/ethnicity:

• Diagnoses—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males, Hispanic/Latino males, Asian females, and multiracial males and females) (Figures 9a/b and Table 2).
• Linkage—American Indian/Alaska Native males (73.0%), Black/African American males (78.0%), Hispanic/Latino females (81.9%), and White males (82.9%) and females (81.1%) (Table 10).
• Viral suppression—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males and Asian males and females) (Table 10).

Transmission category:

• Diagnoses—all transmission categories for both sexes (Figure 10 and Table 3).
• Linkage—males with infection attributed to MMSC (82.3%) and heterosexual contact (80.0%) (Table 11).
• Viral suppression—all transmission categories for both sexes (except females with infection attributed to IDU) (Table 11).
• Among males with infection attributed to MMSC (Table 12):
  • Linkage—Black/African American (78.6%) and White (82.3%), and
  • Viral suppression—Black/African American (64.4%), Hispanic/Latino (72.0%), White (71.0%), and multiracial (58.8%).

Area of residence and region: Diagnoses—rates (Table 5):

• Males—Area: District of Columbia (74.5), followed by Florida (44.9); Region: Northeast (30.0)
• Females—Area: District of Columbia (26.9), followed by Florida (14.4); Region: South (8.1)
• Total—Area: District of Columbia (49.3), followed by Florida (29.6); Region: South (18.9)

Use caution when comparing the rates of diagnoses for the District of Columbia to the rates for states.

A look at disparities in diagnoses of HIV infection by education

In 2020, the disparities in HIV diagnosis by education for adults were as follows:

Absolute disparities (rate difference)—If the rates of diagnoses of HIV infection among males or females in the lowest education tracts were similar to the rates among those in the highest education tracts, then diagnoses could have been reduced by 16 cases and 5 cases per 100,000 population, respectively (Figure 6 and Table 1).

Relative disparities (rate ratio)—Among males, the rate of diagnoses in the lowest education tracts was 2.5 times the rate in the highest education tracts, and among females, the rate in the lowest education tracts was 3.9 times the rate in the highest education tracts (Figure 6 and Table 1).

For absolute and relative disparities for assigned sex at birth stratified by age group and race/ethnicity, see Figures 8a/b and 9a/b.

See Technical Notes for additional information on disparity measures.

Median Household Income

HIV has a direct and indirect cost on household income. Lower income households, when compared to higher income households, may require a greater proportion of expenditures for essential household items. HIV, like other chronic diseases, leads to economic hardship when resources (particularly, limited resources) are shifted from household necessities to costs incurred related to HIV morbidity and mortality [21]. Additionally, decreased median household income is related to a lower probability of survival after an HIV diagnosis [22].

In 2020, adults who lived in census tracts with the lowest median household income (where the median household income was less than $46,000 a year) accounted for

• the highest HIV diagnosis rates or percentages (diagnoses),
• the lowest percentages of adults linked to HIV medical care within 1 month of receiving a diagnosis (linkage), and
• the lowest percentages of adults with suppressed viral load within 6 months of receiving an HIV diagnosis (viral suppression) among:

Assigned sex at birth:

• Diagnoses—rates: males, 29.8; females, 6.9 (Figure 11 and Table 1).
• Linkage—males, 80.9%; females, 81.5% (Figure 12 and Table 9).
• Viral suppression—males, 66.2%; females, 66.6% (Figure 12 and Table 9).

Age group:

• Diagnoses—all age groups for both sexes (Figures 13a/b and Table 1).
• Linkage—all age groups for both sexes (except females aged 18–24, 35–44, and ≥55 years) (Table 9).
• Viral suppression—all age groups for both sexes (except females aged 18–24 and 35–44 years) (Table 9).

Race/ethnicity:

• Diagnoses—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males and Asian males) (Figures 14a/b and Table 2).
• Linkage—all racial/ethnic groups for both sexes (except Asian males and females, Hispanic/Latino females, and multiracial males and females) (Table 10).
• Viral suppression—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males, Asian males, Black/African American males, and Hispanic/Latino females) (Table 10).

Transmission category:

• Diagnoses—all transmission categories for both sexes (Figure 15 and Table 3).
• Linkage—all transmission categories for both sexes (except males with infection attributed to MMSC and IDU) (Table 11).
• Viral suppression—all transmission categories for both sexes (except males with infection attributed to MMSC and IDU) (Table 11).
• Among males with infection attributed to MMSC (Table 12):
  • Linkage—American Indian/Alaska Native (69.8%), Black/African American (79.5%), Hispanic/Latino (83.7%), and White (82.0%), and
  • Viral suppression—American Indian/Alaska Native (57.7%), Hispanic/Latino (70.5%), White (69.7%), and multiracial (68.0%).

Area of residence and region: Diagnoses—rates (Table 6):

• Males—Area: District of Columbia (106.2), followed by Delaware and New Jersey (both 54.7); Region: South (34.6)
• Females—Area: District of Columbia (30.3), followed by New Jersey (17.3); Region: Northeast (9.2)
• Total—Area: District of Columbia (61.9), followed by New Jersey (34.8); Region: South (21.0)

Use caution when comparing the rates of diagnoses for the District of Columbia to the rates for states.

A look at disparities in diagnoses of HIV infection by income

In 2020, the disparities in HIV diagnosis by income for adults were as follows:

Absolute disparities (rate difference)—If the rates of diagnoses of HIV infection among males or females in the lowest income tracts were similar to the rates among those in the highest income tracts, then diagnoses could have been reduced by 20 cases and 5 cases per 100,000 population, respectively (Figure 11 and Table 1).

Relative disparities (rate ratio)—Among males, the rate of diagnoses in the lowest income tracts was 3.1 times the rate in the highest income tracts, and among females, the rate in the lowest income tracts was 4.4 times the rate in the highest income tracts (Figure 11 and Table 1).

For absolute and relative disparities for assigned sex at birth stratified by age group and race/ethnicity, see Figures 13a/b and 14a/b.

See Technical Notes for additional information on disparity measures.

Health Insurance Coverage

Health insurance coverage is associated with the use of preventive services and better medical outcomes [23]. Additionally, insured persons with diagnosed HIV are more likely to receive HIV care and treatment, which prolongs life, increases the likelihood of viral suppression, and decreases mortality [24]. Limited access to health insurance and care can increase the risk for HIV and affect health and well-being.

In 2020, adults who lived in census tracts with the lowest health insurance or health coverage plan (hereafter referred to as health insurance coverage) (where 14% or more of the residents did not have health insurance coverage) accounted for

• the highest HIV diagnosis rates or percentages (diagnoses),
• the lowest percentages of adults linked to HIV medical care within 1 month of receiving a diagnosis (linkage), and
• the lowest percentages of adults with suppressed viral load within 6 months of receiving an HIV diagnosis (viral suppression) among:

Assigned sex at birth:

• Diagnoses—rates: males, 30.0; females, 6.6 (Figure 16 and Table 1).
• Linkage—males, 80.9%; females, 82.1% (Figure 17 and Table 9).
• Viral suppression—males, 66.4%; females, 65.0% (Figure 17 and Table 9).

Age group:

• Diagnoses—all age groups for both sexes (Figures 18a/b and Table 1).
• Linkage—all age groups for males, and females aged 35–44 years (Table 9).
• Viral suppression—all age groups for both sexes (except females aged 18–24 years) (Table 9).

Race/ethnicity:

• Diagnoses—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males) (Figures 19a/b and Table 2).
• Linkage—all racial/ethnic groups for both sexes (except Asian females, Hispanic/Latino males and females, White females, and multiracial females) (Table 10).
• Viral suppression—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males, Asian males and females, and multiracial males) (Table 10).

Transmission category:

• Diagnoses—all transmission categories for both sexes (Figure 20 and Table 3).
• Linkage—all transmission categories for both sexes (except males with infection attributed to IDU and females with infection attributed to heterosexual contact) (Table 11).
• Viral suppression—all transmission categories for both sexes (Table 11).
• Among males with infection attributed to MMSC (Table 12):
  • Linkage—Asian (87.2%), Black/African American (77.2%), White (82.8%), and
  • Viral suppression—Asian (77.4%), Black/African American (63.2%), Hispanic/Latino (71.9%), White (69.3%), and multiracial (69.5%).

Area of residence and region: Diagnoses—rates (Table 7):

• Males—Area: Nevada (45.1), followed by Louisiana (44.7); Region: South (33.3)
• Females—Area: Louisiana (13.9), followed by Maryland (13.5); Region: South (7.8)
• Total—Area: Louisiana (28.9), followed by Georgia and Hawaii (both 26.8); Region: South (20.2)

Use caution when comparing the rates of diagnoses for the District of Columbia to the rates for states.

A look at disparities in diagnoses of HIV infection by health insurance coverage

In 2020, the disparities in HIV diagnosis by health insurance coverage for adults were as follows:

• Absolute disparities (rate difference)—If the rates of diagnoses of HIV infection among males or females in the lowest insurance coverage tracts were similar to the rates among those in the highest insurance coverage tracts, then diagnoses could have been reduced by 22 cases and 5 cases per 100,000 population, respectively (Figure 16 and Table 1).
• Relative disparities (rate ratio)—Among males, the rate of diagnoses in the lowest income tracts was 3.7 times the rate in the highest income tracts, and among females, the rate in the lowest income tracts was 5.0 times the rate in the highest income tracts (Figure 16 and Table 1).

For absolute and relative disparities for assigned sex at birth stratified by age group and race/ethnicity, see Figures 18a/b and 19a/b.

See Technical Notes for additional information on disparity measures.

Income Inequality (Gini Index)

Poor health and income inequality are connected. Income inequality and socioeconomic deprivation are 2 key socioeconomic determinants of HIV diagnosis and care outcomes. High levels of income inequality may negatively affect the health of everyone, even the affluent, mainly because income inequality reduces social cohesion, which leads to more stress, fear, and insecurity [25]. Many factors—education and the historical legacy and impact of discrimination—are key components of income inequality [26]. Many of these same factors contribute to disparities in HIV diagnoses; however, assigned sex at birth and race/ethnicity components can also contribute to this disparity.

This report uses the Gini index, which summarizes income distribution, to measure income inequality. The Gini index ranges from 0 or 0%, indicating perfect equality (i.e., lowest income inequality—where all households have an equal share of income), to 1 or 100%, perfect inequality (i.e., highest income inequality—where only 1 household has all the income and the rest have none).

In 2020, adults who lived in census tracts with the highest income inequality (where income inequality was 46% or more) accounted for

• the highest HIV diagnosis rates or percentages (diagnoses),
• the lowest percentages of adults linked to HIV medical care within 1 month of receiving a diagnosis (linkage), and
• the lowest percentages of adults with suppressed viral load within 6 months of receiving an HIV diagnosis (viral suppression) among:

Assigned sex at birth:

• Diagnoses—rates: males, 23.0; females, 4.6 (Figure 21 and Table 1).
• Linkage—females, 81.2% (Figure 22 and Table 9).
• Viral suppression—males, 68.7%; females, 67.5% (Figure 22 and Table 9).

Age group:

• Diagnoses—all age groups for both sexes (except females aged 18–24 years) (Figures 23a/b and Table 1).
• Linkage—age groups 18–24 and ≥55 years for males and age groups 18–24 and 25–34 years for females (Table 9).
• Viral suppression—all age groups for both sexes (except males aged 25–34 and 45–54 years and females aged 35–44 and 45–54 years) (Table 9).

Race/ethnicity:

• Diagnoses—all racial/ethnic groups for both sexes (except American Indian/Alaska Native males and Asian females) (Figures 24a/b and Table 2).
• Linkage—American Indian/Alaska Native males (73.1%), Hispanic/Latino females (79.5%), and White females (77.4%) (Table 10).
• Viral suppression—Hispanic/Latino males (72.4%), multiracial males (65.1%), and White females (60.0%) (Table 10).

Transmission category:

• Diagnoses—all transmission categories for both sexes (Figure 25 and Table 3).
• Linkage—males and females with infection attributed to heterosexual contact (79.1% and 81.8%, respectively) (Table 11).
• Viral suppression—males with infection attributed to IDU (52.4%) and males and females with infection attributed to heterosexual contact (62.6% and 69.4%, respectively) (Table 11).
• Among males with infection attributed to MMSC (Table 12):
  • Linkage—the lowest percentage linked to care was not in highest income inequality group for any race/ethnicity, and
  • Viral suppression—Hispanic/Latino (73.8%) and multiracial (69.6%).

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Area of residence and region: Diagnoses—rates (Table 8):

• Males—Area: District of Columbia (58.3), followed by Georgia (42.1); Region: South (28.5)
• Females—Area: District of Columbia (16.7), followed by Georgia (9.5); Region: South (6.2)
• Total—Area: District of Columbia (35.8), followed by Georgia (25.0); Region: South (16.9)

Use caution when comparing the rates of diagnoses for the District of Columbia to the rates for states.

A look at disparities in diagnoses of HIV infection by income inequality

In 2020, the disparities in HIV diagnosis by income inequality for adults were as follows:

• Absolute disparities (rate difference) —If the rates of diagnoses of HIV infection among males or females in the highest income inequality tracts were similar to the rates among those in the lowest income inequality tracts, then diagnoses could have been reduced by 9 cases and 2 cases per 100,000 population, respectively (Figure 21 and Table 1).
• Relative disparities (rate ratio) —Among males, the rate of diagnoses in the highest income inequality tracts was 1.6 times the rate in the lowest income inequality tracts, and among females, the rate in the highest income inequality tracts was 1.6 times the rate in the lowest income inequality tracts (Figure 21 and Table 1).

For absolute and relative disparities for assigned sex at birth stratified by age group and race/ethnicity, see Figures 23a/b and 24a/b.

See Technical Notes for additional information on disparity measures.