Associations of County-Level Social Determinants of Health with COVID-19 Related Hospitalization Among People with HIV: A Retrospective Analysis of the U.S. National COVID Cohort Collaborative (N3C)

Abstract

Individually, the COVID-19 and HIV pandemics have differentially impacted minoritized groups due to the role of social determinants of health (SDoH) in the U.S. Little is known how the collision of these two pandemics may have exacerbated adverse health outcomes. We evaluated county-level SDoH and associations with hospitalization after a COVID-19 diagnosis among people with (PWH) and without HIV (PWOH) by racial/ethnic groups. We used the U.S. National COVID Cohort Collaborative (January 2020-November 2023), a nationally-sampled electronic health record repository, to identify adults who were diagnosed with COVID-19 with HIV (n = 22,491) and without HIV (n = 2,220,660). We aggregated SDoH measures at the county-level and categorized racial/ethnic groups as Non-Hispanic (NH) White, NH-Black, Hispanic/Latinx, NH-Asian and Pacific Islander (AAPI), and NH-American Indian or Alaskan Native (AIAN). To estimate associations of county-level SDoH with hospitalization after a COVID-19 diagnosis, we used multilevel, multivariable logistic regressions, calculating adjusted relative risks (aRR) with 95% confidence intervals (95% CI). COVID-19 related hospitalization occurred among 11% of PWH and 7% of PWOH, with the highest proportion among NH-Black PWH (15%). In evaluating county-level SDoH among PWH, we found higher average household size was associated with lower risk of COVID-19 related hospitalization across racial/ethnic groups. Higher mean commute time (aRR: 1.76; 95% CI 1.10-2.62) and higher proportion of adults without health insurance (aRR: 1.40; 95% CI 1.04-1.84) was associated with a higher risk of COVID-19 hospitalization among NH-Black PWH, however, NH-Black PWOH did not demonstrate these associations. Differences by race and ethnicity exist in associations of adverse county-level SDoH with COVID-19 outcomes among people with and without HIV in the U.S.

Keywords: Access to care; Area-level; COVID-19 hospitalization; County-level; HIV; Pandemic; Race and ethnicity; SARS-CoV-2 infection; Social determinants of health.

Fig. 1

Flowchart summarizing the inclusion and exclusion criterion of our study population and final totals to evaluate county-level SDoH among people with and without HIV in the U.S. National COVID Cohort Collaborative (N3C) (Jan 1st, 2020–Nov 2nd, 2023)

Fig. 2

Prevalence of Hospitalization After a COVID-19 Diagnosis Among People with and without HIV in the U.S. National COVID Cohort Collaborative (N3C) (Jan 1st, 2020–Nov 2nd, 2023) (n = 2,243,151)

Fig. 3

Associations of county-level SDoH with COVID-19 hospitalization among people with HIV (A) and people without HIV (B) stratified by race/ethnicity (National COVID Cohort Collaborative, Jan 1st 2020–Nov 2nd, 2023)

Fig. 4

Individual examination of select county-level SDoH factors by quartiles with COVID-19 hospitalization among people with and without HIV stratified race/ethnicity (National COVID Cohort Collaborative, Jan 1st 2020–Nov 2nd, 2023)