An Exploratory Study of the Role of Community Strain on HIV Retention in Care Outcomes

Background:  Absolute adherence to HIV primary care appointments is vitally important to achieve successful clinical management of the disease.  Individual-level factors—biological, psychological, and social—can predict suboptimal HIV appointment adherence.  However, less is known about the relationship between community-level factors and adherence to care.  In light of the enactment of the Affordable Care Act and the National HIV/AIDS Strategy—both focusing on increasing access to and retention in medical care—the role of community correlates may provide important insight for future treatment engagement and policy strategies.  The purpose of this study is to investigate the role of community strain on HIV primary medical care retention.

Methods:  A sample of 226 HIV-infected adults who received primary medical care at an academic-based HIV clinic between 7/1/09-6/30/11 was included.  Principal outcomes included five measures of retention in care:  Missed visits, visit adherence, visit constancy, gaps in care, and the HRSA HIV/AIDS Bureau (HRSA-HAB) retention measure.  Secondary data available through a prospective cohort study provided individual-level information, and related descriptive statistics were completed.  Participant addresses at time of first clinic contact were matched to census tracts.  Census tracts were assigned a strain score for each of 12 domains investigated at the community-level; a composite community strain score was calculated by adding strain for each domain.  Community-level variables were modeled individually and also as aggregate domain variables with each principal outcome using bivariate logistic regression.  Ordinary Least Squares (OLS) regression was used for models including continuous composite community strain. 

Results:  Of 226 participants, 150 were non-white (mostly African-American), and 76 were white.  The sample was majority male (85%), uninsured or publicly insurance (60.6%), single (67.7%), and without children in the home (93.8%).  Mean age was 33.19 years (SD±11.13).  On average, 15.59% (SD±12.46%) of census tract families lived below 100% of the FPL over the past 12 months.  Communities were younger on average (Youth Dependency Ratio=35.10, SD±9.83).  Overall crime in these areas was low (Crime Rate=22.96, SD±25.57).  Strain domain variables statistically associated with retention in care measures included Family Structure, Age Structure, and Crime Rate.  The remaining domains failed to establish statistically significant relationships with any outcome.  Associations between composite community strain and principal outcomes were not achieved. 

Implications:  Findings from this study highlight community-level strain as an influence on retention in HIV primary medical care.  While more research is needed, these results have implications for social workers.  For HIV-infected persons residing in strained communities—especially communities with Family Structure, Age Structure,  and Crime strain—new interventions that alleviate the effects of strain may provide the added social support necessary to overcome such barriers at the earliest encounters.  In light of study limitations, findings set the stage for additional social work research that takes into account the role of neighborhood or community.  This study suggests a tremendous opportunity for social workers to actively participate in the contemporary public dialogue on the potential role of aggregate community conditions on health disparities among individuals with HIV.