People with HIV Who Drive a Long Distance to Receive HIV Care: How Does the Distance to Care Affect Their HIV Health?

Background

The geographic assignment of the Ryan White (RW) clinics was developed to ensure that all people with HIV (PWH) have geographically convenient access to a qualified HIV care provider; however, these service areas have remained static for more than 20 years, even with dynamic shifts in disease distribution. In particular, one urban clinic in the Deep South has experienced yearly increases in patients that reside outside its designated RW service area. Despite residing within proximity to other RW clinics, these patients have chosen to bypass more local clinics to receive medical care at the urban clinic. In addition to the increased personal burden for HIV care (time, money, and travel), the impact of increased clinic travel distance on HIV care outcomes is not well understood.

Methods

This retrospective cohort included PWH who initiated HIV care at an urban clinic between January 2010 and December 2022, resided in Alabama at the time of care initiation, and completed at least one follow-up visit or lab. Adult patients were categorized based on age (<50 or ≥50, years old) and one-way travel distance from their respective geocoded census tract corresponding to their addresses provided at care initiation (<50 or ≥50 miles). The primary outcome, time to viral suppression (VS), defined as the number of days from care initiation to VS, was assessed via the Cox-Gamma Frailty model. Retention-in-care outcomes, Institute of Medicine (IOM) definition of retention and rate of missed HIV care visits, were assessed by Modified Poisson Regression and Poisson Regression, respectively.

Results

Among the 5,867 eligible PWH for analysis, 1,138 (19.4%) resided ≥50 miles from the clinic, and 50% of patients were over the age of 50. A combined predictor of distance, age, and indicator of high socio-economic vulnerability (SeVI) was the primary exposure of interest for all multivariable models. Adjusted for gender, race, and year of care initiation, the joint effect of age, distance, and SeVI was found to be a statistically significant predictor of time to VS, retention in care, and incidence of missed HIV care visits. In particular, older PWH who traveled more than 50 miles from low SeVI areas achieved VS 39% faster than younger PWH living in high SeVI areas within 50 miles of the clinic.

Conclusion/Implications

This study provides insight into the complicated factors that affect outcomes for PWH’s HIV care and highlights the unintended challenges that clinics face when serving large percentages of patients outside of their designated RW service area. Particularly, younger PWH in high SeVI neighborhoods require particular attention from practitioners and researchers to help them achieve VS faster and keep their HIV care visits. In addition to representing a disproportionate share of provisions intended for the statewide RW network, clinics face challenges in the equitable distribution of resources that could be dedicated to local communities within the service area. More investigations are needed to guide policy modifications for HIV care provision throughout the Deep South’s RW networks to better serve the needs of PWH in and out of their own network.