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

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Report Contents

A. Geocoding of HIV Surveillance Data Overview

CDC funds state and local health departments to conduct HIV surveillance, and jurisdictions geocode to the census tract level the address of residence at the time of diagnosis. This report includes data for adults aged ≥18 years whose HIV infection was diagnosed during 2020 and reported to the NHSS through June 2022 from the 50 states, the District of Columbia, and Puerto Rico.

After a census tract was assigned to each person’s residence at the time of HIV diagnosis (2020), data were linked with the ACS estimates for 2016–2020 to assign a value for each of the SDOH indicator variables to each case. Cases or census tracts were excluded if the address was nonresidential (e.g., military base, corrections facility), a census tract could not be associated with the case, SDOH information was not available for the census tract, or the assigned census tract could not be matched to a census tract provided by the ACS. Although HIV diagnosis data associated with these exclusions were not included in all SDOH subpopulation totals, they were included in the overall subtotals stratified by sex at birth. Therefore, all tables display differing denominators for SDOH subpopulation categories.

All data presented in this report are considered provisional and subject to change as additional reports are submitted for HIV cases and as HIV surveillance data quality improves with further evaluation of the surveillance system and data repository.

B. Social Determinants of Health Indicator Variables

SDOH indicator variables [35] and definitions [36] were obtained from the U.S. Census Bureau’s ACS. This report uses data from the 2016–2020 ACS estimates. The 5-year estimates were used because census tract data are not available for 1-year estimates. The U.S. Census Bureau collected these data during the 5 years and created period estimates based on the information collected. Period estimates are estimates based on information collected over time (60 months for this report) [37]. Period estimates were not calculated as an average of 60 monthly values; the U.S. Census Bureau collected survey information continuously and then aggregated the results over a specific period (5 years) [36]. The data collection was spread evenly across the entire period so as not to over-represent any particular year within the period. All areas were sampled regardless of population size.

B1. SDOH Variables and Definitions

For this report, the SDOH indicator variables were categorized by using empirically derived quartiles, and each quartile cutpoint was rounded to the nearest integer. The quartile cutpoints were determined by using data from all census tracts in the 50 states, the District of Columbia, and Puerto Rico and not just from the data applicable to persons in this report (i.e., persons with an HIV diagnosis). This report presents 5 SDOH indicator variables: federal poverty status, education level, median household income, health insurance coverage, and Gini index.

  • Federal poverty status: proportion of residents in the census tract who were living below the U.S. poverty level (i.e., below a specified threshold) during the 12 months before the survey response (individuals aged ≥18 years)
  • Education level: proportion of residents in the census tract with less than a high school diploma (individuals aged ≥18 years)
  • Median household income: median income for a household within the census tract during the 12 months before the survey response
  • Health insurance coverage: proportion of residents in the census tract without health insurance or health coverage plan (individuals aged ≥18 years)
  • Gini index: proportion of household income distribution within the census tract during the 12 months before the survey response

B1.1 Poverty and Wealth

The percentage of the population aged ≥18 years who were living below the poverty level was determined by using the U.S. Census Bureau’s set of dollar-value thresholds (i.e., income cutoffs) that vary by family size and composition to determine who lives below the poverty level. A person’s poverty status is determined by comparing the person’s total family income during the 12 months before the survey response with the poverty threshold appropriate for that person’s family size and composition. If the total income of that person’s family is less than the threshold appropriate for that family, then the person, together with every member of his or her family, is considered “below the poverty level.” In the Census Bureau’s determination of poverty status, the following populations were excluded: (1) institutionalized persons, (2) persons residing in military group quarters, (3) persons in college dormitories, and (4) unrelated persons aged <15 years. The U.S. Census Bureau defines poverty areas as census tracts with poverty levels of 20% or more [38], whereas wealth is defined as a household net worth and is an important defining factor of economic well-being in the United States. In times of economic hardship, such as unemployment, illness, or divorce, a person’s or household’s financial assets (e.g., savings accounts) are an additional source of income to help pay expenses and bills.

B1.2 Education

The percentage of persons with less than a high school diploma was defined as the percentage of persons aged ≥18 years who were not enrolled in school and were not high school graduates. These people may be referred to as “high school dropouts.” No restriction is placed on when they “dropped out” of school; therefore, they may have dropped out before high school and never attended high school.

B1.3 Household Income

The median household income was determined by dividing the income distribution into 2 equal parts: one-half of the households in the census tract fall below the median income and one-half above the median. The median income was based on the income distribution of the total number of households, including those with no income.

B1.4 Health Insurance Coverage

The percentage of persons aged ≥18 years without health insurance coverage was determined based on the number of persons without plans or programs that provide comprehensive health coverage (both private health insurance and public coverage). Insured persons include: (1) insurance through a current or former employer (of this person or another family member) or union; (2) insurance purchased directly from an insurance company (by this person or another family member); (3) Medicare, for persons aged ≥65 years, or persons with certain disabilities; (4) Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low income or a disability; (5) TRICARE or other military health care; and (6) U.S. Department of Veterans Affairs (VA), including those who have ever used or enrolled for VA health care. Persons who had no reported health coverage, or those whose only health coverage was Indian Health Service, were considered uninsured. Also, plans that provide insurance for specific conditions or situations, such as cancer and long-term care policies, are not considered coverage. Likewise, other types of insurance, like dental, vision, life, and disability insurance, are not considered health insurance coverage. The population estimates for health insurance coverage excludes active-duty military personnel and the population living in correctional facilities and nursing homes.

B1.5 Gini Index

The Gini index of income inequality measures the dispersion of the household income distribution. The Gini index, or index of income concentration, is a statistical measure of income inequality ranging from 0 (or 0%) to 1 (or 100%). A measure of 1 indicates perfect inequality; i.e., one household having all the income and rest having none. A measure of 0 indicates perfect equality; i.e., all households having an equal share of income. The Gini index is based on the difference between the Lorenz curve (the observed cumulative income distribution) and the straight line denoting a perfectly equal income distribution. This measure is presented for household income.

C. Tabulation and Presentation of Data

C1. Definitions and Data Specifications

C1.1 Diagnoses

The term diagnosis of HIV infection is defined as a diagnosis of HIV infection regardless of the stage of disease (stage 0, 1, 2, 3 [AIDS], or unknown).

More information on counting diagnoses of HIV infection can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-33/index.html.

C1.2 Linkage to HIV Medical Care and Viral Suppression

The data on linkage to HIV medical care were based on persons whose infection was diagnosed during 2020 and who resided at the time of diagnosis in any of 46 jurisdictions that reported complete CD4 and viral load laboratory results to CDC. As of December 2021, 46 jurisdictions (45 states and the District of Columbia) met the criteria for the collection and reporting of CD4 and viral load test results: The 45 states are Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

Linkage to HIV medical care within 1 month of HIV diagnosis was measured by documentation of ≥ 1 CD4 (count or percentage) or viral load tests performed ≤ 1 month of HIV diagnosis, including tests performed on the same date as the date of diagnosis.

Viral suppression within 6 months of diagnosis was measured for persons whose infection was diagnosed during 2020 and who resided in any of the 46 jurisdictions at time of diagnosis. Viral suppression was defined as a viral load result of < 200 copies/mL at any viral load test within 6 months of an HIV diagnosis made during 2020.

More information on calculating linkage to HIV medical care and viral suppression can be found at https://www.cdc.gov/hiv/pdf/library/reports/surveillance/hiv-surveillance.html (Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2020).

C1.3 Measures of Disparities

This report includes absolute and relative measures of disparities. The literature recommends use of at least one absolute and one relative disparity measure to monitor the magnitude and direction of disparities [39]. The absolute rate difference and the relative disparities were chosen because these measures are used by federal initiatives—HHS core indicators, Healthy People 2030, NHAS, and EHE—to measure progress in the SDOH and HIV diagnosis indicators. In addition,

  • absolute disparity measures the simple difference between two rates. This report examines the disparity rate difference between SDOH variable categories (highest quartile versus lowest quartile) within and between selected characteristics by sex at birth (i.e., Ratehighest quartile − Ratelowest quartile). The absolute difference measures the magnitude of the difference, which provides some indication of how many lives could be improved if the difference between the two rates were eliminated or reduced [40].
  • relative disparity measures the relative magnitude of the disparity. This report examines the relative difference as the rate ratio between SDOH variable categories (highest quartile versus lowest quartile) within and between selected characteristics by sex at birth (i.e., Ratehighest quartile ÷ Ratelowest quartile).
  • for changes in disparities,
    • absolute disparity measures the difference between rates among a select race/ethnicity and rates among White persons (Rateselect race/ethnicity – RateWhite persons).
    • relative disparity measures the rates among a select race/ethnicity divided by rates among White persons (Rateselect race/ethnicity ÷ RateWhite persons).
  • for this report, White persons are the reference group and this is based on the lowest group rate with more than 5% of cases.

C2. Rates

Rates per 100,000 population were calculated for the numbers of diagnoses of HIV infection. The population denominators used to compute these rates for the 50 states, the District of Columbia, and Puerto Rico were based on the 5-year estimated total population for those areas [35]. The denominators used for calculating age-, sex-, and race/ethnicity-specific rates were computed by applying the 5-year estimates for age, sex at birth, and race/ethnicity for these areas [35]. Reported numbers less than 12, and rates and percentages based on these numbers, should be interpreted with caution.

Subpopulation stratifications of race data by [age group and] sex at birth from the 2016–2020 ACS estimates may include Hispanic/Latino persons for racial groups other than White persons. As a result, there may be overlap in populations for these racial groups and Hispanic/Latino persons and, therefore, diagnosis rates by race/ethnicity (Table 2) should be interpreted with caution. Of the denominator population from the ACS data in this report, for American Indian/Alaska Native persons, 22.9% were Hispanic/Latino (22.8% when Puerto Rico is excluded); for Asian persons, 1.3% were Hispanic/Latino (1.3% when Puerto Rico is excluded); for Black/African American persons, 3.8% were Hispanic/Latino (3.0% when Puerto Rico is excluded); and for Native Hawaiian/other Pacific Islander persons, 10.1% were Hispanic/Latino (10.0% when Puerto Rico is excluded). Finally, the denominator population from the ACS is based on the entire population aged ≥18 years; the numerator population is limited to persons whose HIV infection had been diagnosed and reported, with complete residential address, to the NHSS. Because the ACS uses predetermined age categories and varying criteria for SDOH variables, the denominators differ for some SDOH variables.

D. Demographic Information

D1. Age

All tables in this report reflect data for adults aged ≥18 years. This report was limited to adults aged ≥18 years with diagnosed HIV infection to align with the population from which data are collected for ACS SDOH indicator variables. For tables that provide data by age group, the specific age-group assignment (e.g., 18–24 years) was based on the person’s age at the time of HIV diagnosis.

D2. Assigned Sex at Birth

Sex designations in this report are based on a person’s assigned sex at birth. Data for gender are not provided in this report because of the absence of denominator data from the U.S. Census Bureau, the source of data used for calculating all rates in this report.

D3. Race and Ethnicity

In the Federal Register for October 30, 1997, the Office of Management and Budget (OMB) announced the Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Implementation by January 1, 2003, was mandated [41].

Hispanic and Latino persons can be of any race. Due to confidentiality concerns, the ACS [age- and] sex-specific population counts for racial groups other than White persons may include Hispanic/Latino persons. Therefore, race-specific diagnosis rates (except White persons) should be interpreted with caution. Also, the number of persons reported in each race category may include persons whose ethnicity was not reported.

More information on race and ethnicity can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-33/index.html.

D4. Transmission Categories

Transmission category is the term for the classification of cases that summarizes an adult’s or adolescent’s possible HIV risk factors; the summary classification results from selecting, from the presumed hierarchical order of probability, the 1 (single) risk factor most likely to have been responsible for transmission.

More information on transmission categories can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-33/index.html.

E. Geographic Designation

E1. Census Tract

Data presented in this report reflect the census tract of the person’s residential address at the time they received an HIV diagnosis. A census tract is a standard area used by the U.S. Census Bureau for the purpose of counting the population. Census tracts are small, relatively permanent statistical subdivisions of a county delineated by local participants as part of the U.S. Census Bureau’s Participant Statistical Areas Program. Census tracts must stay within a county and, therefore, a state. They do not necessarily coincide within any other geography. For example, although some census tracts follow place boundaries, there is no rule that says they must stay within a place. Census tracts are designed to be relatively homogeneous units with respect to population characteristics, economic status, and living conditions at the time of establishment. Each census tract generally contains 1,500 to 8,000 inhabitants (average, 4,000 inhabitants) [42].

Suggested Readings

CDC. Addressing social determinants of health: Accelerating the prevention and control of HIV/AIDS, viral hepatitis, STD and TB. External consultation, December 9–10, 2008. https://stacks.cdc.gov/view/cdc/5585. Published April 2009. Accessed December 8, 2022.

CDC. Social determinants of health among adults with diagnosed HIV infection, 2019. HIV Surveillance Supplemental Report 2022;27(No. 2). http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published March 2022. Accessed December 8, 2022.

Dailey AF, Gant Z, Hu X, Johnson Lyons S, Okello A, Satcher Johnson A. Association between social vulnerability and rates of HIV diagnoses among Black adults, by selected characteristics and region of residence—United States, 2018. MMWR 2022;71(5):167–170. doi:http://dx.doi.org/10.15585/mmwr.mm7105a2

Gant Z, Dailey A, Hu X, Lyons SJ, Okello A, Elenwa F, Johnson AS. A census tract–level examination of diagnosed HIV infection and social vulnerability among Black/African American, Hispanic/Latino, and White adults, 2018: United States. J Racial Ethn Health Disparities 2022:1–10. doi:10.1007/s40615-022-01456-7

Gant Z, Johnson Lyons S, Jin C, Dailey A, Nwangwu-Ike N, Satcher Johnson A. Geographic differences in social determinants of health among US-born and non-US–born Hispanic/Latino adults with diagnosed HIV infection, United States and Puerto Rico, 2017. Public Health Rep 2021;136(6):685–696. doi:10.1177/0033354920970539

Gillot M, Gant Z, Hu X, Satcher Johnson A. Linkage to HIV medical care and social determinants of health among adults with diagnosed HIV infection in 41 states and the District of Columbia, 2017. Pub Health Rep 2021;333549211029971. doi:10.1177/00333549211029971

Inequality.org. Income Inequality in the United States. https://inequality.org/facts/income-inequality/. Updated December 2021. Accessed December 8, 2022

Jin C, Nwangwu-Ike N, Gant Z, Johnson Lyons S, Satcher Johnson A. Geographic differences and social determinants of health among people with HIV attributed to injection drug use, United States, 2017. Pub Health Rep 2021;333549211007168. doi:10.1177/00333549211007168

Johnson Lyons S, Gant Z, Jin C, Dailey A, Nwangwu-Ike N, Satcher Johnson A. A census tract-level examination of differences in social determinants of health among people with HIV, by race/ethnicity and geography, United States and Puerto Rico, 2017. Pub Health Rep 2021;33354921990373. doi:10.1177/0033354921990373

Nwangwu-Ike N, Jin C, Gant Z, Johnson S, Balaji AB. An examination of geographic differences in social determinants of health among women with diagnosed HIV in the United States and Puerto Rico, 2017. Open AIDS J 2021;10:10–20. doi:10.2174/1874613602115010010

Watson L, Gant Z, Hu X, Johnson AS. Exploring social determinants of health as predictors of mortality during 2012–2016, among Black women with diagnosed HIV infection attributed to heterosexual contact, United States. J Racial Ethn Health Disparities 2019;6(5):892–899. doi:10.1007/s40615-019-00589-6

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