Quantitative data from Chicago highlights disparities in viral suppression created by interlocking forms of discrimination and oppression. The study published in the July issue of AIDS highlights the importance of not considering a single identity category or form of oppression in isolation. The researchers say that their findings show that HIV programmes must be comprehensive – focusing on a single issue such as housing will not be enough to eliminate disparities among people living with HIV in the United States.
Consistent, or durable, viral suppression over time has several health benefits for people living with HIV. It also means that HIV will not be transmitted to sexual partners, as Undetectable = Untransmittable (U=U). Thus, viral suppression plays a crucial role in limiting the spread of HIV and ending epidemics. In the US, however, the number of people living with HIV on treatment who are virally suppressed remains far from optimal, at approximately 66%.
Disparities in viral suppression rates are largely due to social factors. Social determinants of health – such as poverty, a lack of adequate housing and limited access to healthcare services – intersect with systemic forms of discrimination. A person who holds multiple marginalised identities (such as being a Black trans woman living with HIV) is disadvantaged by interlocking systems of oppression and stigma impacting those identities: this is likely to result in lowered chances of maintained viral suppression.
However, many studies only account for individual social determinants of health, or for single axes of discrimination or stigma, such as racism or transphobia. Dr Adovich Rivera from Northwestern University and colleagues aimed to capture the effects of intersectionality upon viral suppression using different types of statistical analysis.
This study used electronic health records from a specialised LGBTQ health provider, Howard Brown Health in Chicago. Data came from nine locations in the city and included people living with HIV seen between 2012 and 2019 with more than three viral load tests.
The sample consisted of 5,967 electronic health records of adults living with HIV, with an average age of 43 at the time of the first viral load test. Most were assigned male at birth (82%), identified as men (89%) and gay (79%). A smaller number identified as straight (10%) and transgender (4%). The racially and ethnically diverse sample included the records of 39% White, 34% Black and 22% Hispanic participants. Nearly half the sample (46%) had been diagnosed with HIV before 2012.
Durable viral suppression was defined as one of two patterns: a consistently low viral load (such as three or more suppressed viral loads six months apart), or a viral load that started out high and rapidly decreased to less than 100 copies by the second year of follow-up. Those classified as not durably suppressed either took a longer time for viral load to drop or the viral load did not fall below the 100 copies threshold.
The researchers ran multiple analyses related to durable viral suppression. The purpose of using different types of analysis was to adequately account for intersectionality: considering interlocking forms of oppression and not merely looking at one identity category in isolation or considering only one form of systemic oppression. For instance, a simplistic approach could consider the impact racial discrimination has on maintaining viral suppression. However, an intersectional approach considers that a person is not only Black but may be a Black trans woman who is a substance user. More sophisticated analyses can reveal the impact these intersectional identities and their resultant forms of oppression have on an outcome such as sustained viral suppression.
Most of the participants achieved durable viral suppression (89%), with either consistently low viral load (63%) or had started high and rapidly achieved viral suppression (26%). Among the 11% who did not achieve durable viral suppression, 5% had a longer decline in viral trajectory or did not fall below the 100 copies threshold at all (6%).
Individual factors associated with durable viral suppression included poverty (64% less likely), not having private health insurance (62% less likely), substance use disorder (44% less likely) and being unhoused (61% less likely). Considering factors in combination, race and ethnicity significantly impacted viral load outcomes for those with the same type of health insurance. Thus, Black people with private insurance had a lower probability of durable viral suppression compared to White people with private insurance.
Further analysis revealed four distinct groups and associated viral suppression patterns. The group with highest viral suppression rate (95%) consisted of cisgender men of different races and ethnicities but with relatively lower rates of poverty and being unhoused. The next group had an 88% viral suppression rate, with mainly black cisgender men and women, including many in poverty and with government insurance. The third group had a viral suppression rate of 83% and consisted of cisgender men of different races and ethnicities with a high number of uninsured people. The fourth group had a viral suppression rate of 82%, were mainly Black, contained nearly all the trans women, and had a high number of unhoused people.
An additional analysis identified combinations of sufficient factors that were most likely to lead to durable viral suppression. While no single factor was identified as sufficient on its own among the whole sample, at least 85% of those with no mental health disorder, not experiencing poverty, with insurance and with no substance use disorder achieved durable viral suppression.
These combinations differed based on intersectional identities. For instance, White gay cisgender men who were housed and had insurance were able to attain durable viral suppression despite having mental health challenges. For this group, the role of factors such as substance use disorder was negligible. However, Black gay trans women needed four out five categories to be favourable to achieve durable viral suppression (housed, insured, not living in poverty and with no substance use disorder).
Interestingly, unlike the analysis focused on single factors, this final analysis showed that unfavourable conditions could still lead to durable viral suppression. Thus, although having a mental health or substance use disorder could impact adherence, diagnoses such as these could prompt referrals to wrapround services, which are associated with better outcomes for people living with HIV. They could also facilitate more focused and intense case management.
“This diversity of needs implies that HIV services need to be comprehensive and offer a minimum set of social interventions (e.g., social risk screening and referral, mental health services). Programs that focus on single issues (e.g., housing alone) may be inadequate for eliminating durable viral suppression disparities,” the authors conclude.
“Importantly, plans for eliminating the HIV epidemic should include interventions for social determinants of health such as homelessness and poverty. Fortunately, U.S. policy documents related to HIV elimination recognize these issues. However, these policies could still improve by putting more in the forefront that addressing social issues helps in improving HIV prevention and durable viral suppression outcomes.”
Rivera AS et al. Intersectionality-informed analysis of durable viral suppression disparities in people with HIV. AIDS 37: 1285-1296, 2023.