HIV care in the U.S. South


An estimated 1.2 million Americans are infected with human immunodeficiency virus, a manageable disease that can lead to death if untreated. Yet according to the Centers for Disease Control and Prevention, only 40 percent of people living with HIV are getting and staying on an effective treatment — a number in line with some of the poorest countries in the world. What’s more, only 30 percent are achieving viral suppression, or a very low level of HIV in their blood.

While clinical care for HIV has made tremendous advances since HIV and AIDS joined the common vernacular in the 1980s, most people living with HIV in the U.S. don’t receive the care that will allow them to live fuller lives and improve their health. Lack of effective HIV care is particularly problematic in the South, where poverty, lack of medical insurance and a constrained health workforce threaten effective care. “All of this equals new infections,” says April Kimmel, Ph.D., an assistant professor in the Department of Health Behavior and Policy, VCU School of Medicine. In fact, 50 percent of all newly diagnosed HIV cases are found in the South, where racial and ethnic minorities face disproportionate barriers to HIV care.

Kimmel is leading a multidisciplinary study titled “Delivering High-Quality HIV Care in the South: System-Level Policy Alternatives.” The research will examine how two modifiable system-level factors — geographic accessibility to care and physician payment policies — affect quality of HIV care and health outcomes, including new HIV infections, in 16 Southern states.

The four-year study is funded by a grant from the National Institutes of Health’s National Institute on Minority Health and Health Disparities. The research involves developing a database that combines multiple sources, including Medicaid administrative claims files (the main data source), HIV surveillance data from state health departments, and county and state characteristics from national datasets. Researchers will rely on state-of-the-art spatial network analysis and data visualization (mapping), econometric methods and systems science forecasting techniques in the research.

The study will answer a number of important questions: How do geographic accessibility (measured in travel time to receive care) and physician payment for services (reimbursements through Medicaid) affect quality of HIV care in the South? Are these effects different among racial and ethnic minorities? Do improvements in geographic accessibility or increased physician payments reduce new HIV infections and racial and ethnic disparities along the HIV care continuum?

These questions are not just applicable to the South or the U.S. “These same sorts of structural barriers are relevant in very high-HIV burden settings, such as sub-Saharan Africa,” Kimmel says. “This is a framework for beginning to think about the structural barriers that matter in HIV care and reducing new infections.”

Kimmel expects the study to reveal statistically significant factors that can be addressed through public policy. “By quantifying the role of system-level factors in quality of HIV care and population health along the HIV care continuum, as well as understanding disparities in these effects,” she says, “the research will provide valuable information to address systemic challenges to effective HIV care, efficiently allocate scarce resources and improve public health.”