The Relationship Between Neighborhood Characteristics and HIV Treatment Outcomes

Abstract

BACKGROUND Adherence to antiretroviral therapy (ART) is crucial for achieving and maintaining viral suppression in people living with HIV (PLWH). While individual factors that affect the achievement of viral suppression have been extensively studied, less attention has been given to the role of community-level factors, specifically perceived neighborhood disorder. Recognizing the crucial role that community-level factors play in health behaviors, this dissertation research sought to address the gap in the understanding of how neighborhood dynamics affect treatment outcomes for individuals with HIV. OBJECTIVES This dissertation assessed the relationship between neighborhood characteristics and HIV treatment outcomes by investigating three specific aims: 1) Synthesize the literature on the scope, nature, and extent of available research on the association between neighborhood characteristics and HIV treatment outcomes. 2) Assess the relationship between perceived neighborhood disorder, ART adherence self-efficacy, and HIV viral suppression among people living with HIV. 3) Assess the influence of perceived neighborhood disorder on HIV-related care decisions among people living with HIV. METHODS Aim 1: This aim was investigated through a scoping review. For this review, PubMed, CINAHL (EBSCOhost), Embase (Elsevier), and PsychINFO (EBSCOhost) were searched from the start of each database to Nov 21, 2022. Screening was performed by three independent reviewers. Full-text publications of all study designs meeting inclusion criteria were included in the review. There were no language or geographical limitations. Conference proceedings, abstracts-only presentations, and opinion reports were excluded from the review. Aim 2: For aim 2, one hundred and eighty-eight (188) persons living with HIV who were aged 18 years and older from two HIV clinics in Arizona completed a questionnaire survey in a cross-sectional study. We assessed perceptions of neighborhood disorder, ART self-efficacy, social support, alcohol and drug use, depression, HIV stigma, provider-patient relationship, demographics, and length at the zip code. HIV viral loads were obtained from the clinical records. The analysis involved the use of Fisher's Exact test, Spearman's Rank test, Wilcoxon rank sum test, and firth logistic regression. All analyses were conducted using STATA 17. Aim 3: From a subset of participants from the cross-sectional study, a qualitative study with interpretive analysis was conducted. The interview guide and analysis were guided by the Broken Windows Theory and Social Cognitive Theory, enabling a comprehensive exploration of the intersection between environmental perceptions and healthcare behaviors. Data were collected through telephone in-depth interviews with 18 participants attending two HIV clinics in Southern Arizona from June 2022 to February 2023. Interviews were analyzed using the Dedoose Software 9.0.17 and narratives were enriched using participants quantitative data from a validated scale to measure perceived neighborhood disorder. RESULTS Aim 1: The search yielded 7,822 publications. Thirty-five (35) involving 277,856 PLWH met the inclusion criteria. Studies assessed the relationship between neighborhood-level disadvantage (n=25), composition and interaction (n=18), socioeconomic status (n=23), deprivation (n=17), disorder (n=11), and rural-urban status (n=7) and HIV treatment outcomes. There was no consistency across all the studies in demonstrating the association between neighborhood characteristics and HIV treatment outcomes. Seven 7 studies found that deprivation had a negative association with HIV treatment outcomes; 6 found that areas with high racial/ethnic minority population densities were associated with poor HIV treatment outcomes, and 6 showed that disorder was associated with poor HIV treatment outcomes. Three studies showed that rural residence was associated with improved HIV treatment outcomes. Aim 2: For specific aim 2, most participants were male (79%), white (62%), and identified as non-Hispanic (66%). Individuals with no perceived neighborhood disorder had median scores of 10 for integration and perseverance in ART self-efficacy, but those with high perceived disorder displayed decreased scores of 8.4 and 8.3 for integration and perseverance respectively. Both integration and perseverance showed statistically significant negative correlations with perceived neighborhood disorder, (Spearman's rho -0.2966; p<0.000 and -0.2387; p=0.0010 respectively). Individuals with virologic suppression (n=167) reported significantly lower perceived neighborhood disorder scores (median=0.9 [IQR: 0.2-2.0]) compared to those without virologic suppression (n=10, median=3.2 [IQR: 2.4-4], p=0.0012). Aim 3: Specific aim 3 found that perceived neighborhood disorder influences HIV care-related decisions through a diminished sense of control pathway. Also, healthcare settings emerge as a mitigator of the influence of perceived neighborhood disorder on HIV care-related decisions by offering a sense of control. Perception of lower degrees of neighborhood disorder correlates with a strong sense of control and a preference for specialized care. As the perception of neighborhood disorder increases, there's a shift toward care settings that balance specialized services with a supportive care environment. A higher perception of neighborhood disorder leads to prioritized care settings that provide a sense of community, support, and discretion, reflecting adaptations to a compromised sense of control resulting from the perception of their neighborhood environment. CONCLUSION Neighborhood characteristics are associated with HIV treatment outcomes albeit inconsistent in all studies that qualified for inclusion in the scoping review. The empirical research further illuminates these associations in looking at perceived neighborhood disorder specifically. The cross-sectional study revealed that perceptions of neighborhood disorder tend to negatively correlate with ART adherence self-efficacy and virologic suppression. Additionally, the qualitative study illustrated that perceived neighborhood disorder may diminish an individual’s sense of control thus impacting their preferences for certain HIV care characteristics that mitigate the reduced sense of control. This research bridges a gap in understanding the role of neighborhood characteristics in HIV treatment outcomes. It emphasizes the need for holistic approaches in HIV care that consider not only individual-level factors but also the broader environmental contexts in which PLWH live. These insights are crucial for developing targeted interventions and policies that address both the clinical and social determinants of health, thus, improving the effectiveness of HIV treatment and care.