Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South^*

* Preliminary results for this manuscript were presented in part at the 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention [abstract A-729-0310-03361], July 19–22, 2015, Vancouver, Canada, and the AcademyHealth Annual Research Meeting [abstract 10924], June 26–28, 2016, Boston, USA.

ABSTRACT

Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.

KEYWORDS:

• HIV/AIDS
• geography
• travel time
• access to care
• structural barriers
• rural
• race/ethnicity
• disparities

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

* Preliminary results for this manuscript were presented in part at the 8th IAS Conference on HIV Pathogenesis, Treatment, and Prevention [abstract A-729-0310-03361], July 19–22, 2015, Vancouver, Canada, and the AcademyHealth Annual Research Meeting [abstract 10924], June 26–28, 2016, Boston, USA.

1. Fewer counties are in the top HIV prevalence quintile for racial/ethnic minorities, since more Hispanic and non-Hispanic Black than non-Hispanic White county estimates for HIV prevalence are suppressed due to low numbers of cases.

Additional information

Funding

This research was supported in part by the National Institutes of Health (CTSA award number KL2 TR000057 from the National Center for Advancing Translational Sciences and R01 MD011277 from the National Institute on Minority Health and Health Disparities) and the Virginia Commonwealth University. The funding sources played no role in the study, including study design; collection, analysis, and/or interpretation of data; the writing of the manuscript; and the decision to submit the manuscript for publication.