Race, place and AIDS: the role of socioeconomic context on racial disparities in treatment and survival in San Francisco

Abstract

Prior evidence suggests that the health and longevity benefits of antiretroviral therapy (ART) for persons living with AIDS (PLWAs) have not been equally distributed across racial/ethnic groups in the United States. Notably, black PLWAs tend to fare worse than their counterparts. We examine the role of neighborhood socioeconomic context on racial/ethnic differences in AIDS treatment and survival in San Francisco. The study population encompassed 4211 San Francisco residents diagnosed with AIDS between 1996 and 2001. Vital status was reported through 2006. Census data were used to define neighborhood-level indicators of income, housing, demographics, employment and education. Cox proportional hazards models were employed in multivariate analyses of survival times. Compared to whites, blacks had a significant 1.4 greater mortality hazard ratio (HR), which decreased after accounting for ART initiation. PLWAs in the lowest socioeconomic neighborhoods had a significant HR of 1.4 relative to those in higher socioeconomic neighborhoods, independent of race/ethnicity. The neighborhood association decreased after accounting for ART initiation. Path analysis was used to explore causal pathways to ART initiation. Racial/ethnic differences in neighborhood residence accounted for 19-22% of the 1.6-1.8 black-white relative odds ratio (ROR) and 14-15% of the 1.3-1.4 Latino-white ROR for delayed or no treatment. Our findings illuminate the independent and synergistic contributions of race and place on treatment disparities and highlight the need for future studies and interventions to address treatment initiation as well as neighborhood effects on treatment differences.

Fig. 1

Schematic representation of the pathways linking race/ethnicity and neighborhood context to racial/ethnic disparities in AIDS mortality.

Fig. 2

Schematic representation of initial (saturated) treatment initiation path model tested. Each item in the trapezoid is hypothesized to be independently affected by race/ethnicity and to independently affect TPS and ART initiation.

Fig. 3

Comparison of 5-year survival curves for black, white and Latino persons diagnosed with AIDS between 1996 and 2001, San Francisco, CA.

Fig. 4

Estimated odds of delayed or no treatment among black PLWAs relative to whites from the final path analytic model on treatment initiation, San Francisco, CA, 1996 to 2006. Solid black lines indicate significant direct effects on ART initiation. Dashed lines indicate significant mediating pathways between black race and delayed or no treatment. For clarity, pathways with injection drug users (IDU) on homelessness, insurance, NSEC and treatment are not shown.

Fig. 5

Comparison of the predicted relative odds of delayed or no treatment for blacks and Latinos compared to white PLWAs when race/ethnicity effects are removed from homelessness and neighborhood socioeconomic context (NSEC) in the treatment initiation path model, San Francisco, CA, 1996-2006.