Association of neighborhood- level socioeconomic status (SES) with time from HIV diagnosis to viral suppression among newly HIV diagnosed New Yorkers, 2006–2010 Ellen Wiewel, CUNY School of Public Health, New York, NY APHA abstract #300295, Session , “Healthography: Spatial Data and HIV,” Tuesday, November 18, 2014 sph.cuny.edu

Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Ellen Wiewel No relationships to disclose

About the CUNY SPH The CUNY School of Public Health (CUNY SPH) is committed to teaching, research and service that creates a healthier New York City and helps promote equitable, efficient and evidence-based solutions to pressing health problems facing cities around the world. The CUNY SPH is a CEPH-accredited school of public health which consists of four consortial campuses (Hunter College, Lehman College, Brooklyn College and the Graduate Center) and offers both master’s and doctoral degrees in public health.

About the Graduate Center The Graduate Center (GC) is the principal doctorate-granting institution of the City University of New York. Offering more than thirty doctoral degrees from Anthropology to Urban Education, and fostering research in a wide variety of centers and institutes, the GC combines rigorous academic training in the humanities, sciences, and social sciences with globally significant research. It is home to a core faculty of approximately 150 teachers and mentors, virtually all senior scholars, and many leaders in their disciplines. This faculty is enhanced by more than 1,800 faculty from across the CUNY colleges, as well as from cultural, academic, and scientific institutions throughout New York City and beyond. Through its extensive public programs including lectures, conferences, performances, exhibitions, and conversations, the Graduate Center also contributes to the intellectual and cultural life of New York City.

Background HIV viral suppression decreases the probability of onward transmission and is a goal of the National HIV/AIDS Strategy Population-based analyses of viral suppression have not examined the influence of neighborhood-level socioeconomic status (SES)

Poverty in New York City Figure 1b. Male HIV diagnosis rates

Text Explanation of Map NYC ZIP code map showing poverty rates Wide variation in poverty levels across NYC, from 0-10% in some ZIPs to ≥30% in others Clusters of high-poverty ZIPs in South Bronx, Upper Manhattan, and North and Central Brooklyn

Objective Determine whether neighborhood SES is associated with time from HIV diagnosis to viral suppression

Data Sources Data source NYC HIV surveillance registry American Community Survey US Census 2010 Population All NYC HIV cases Representative sample of US population Every US resident Measures Viral suppression, demographics, place of residence Poverty Unemployment Race/Ethnicity

Text Explanation of Data Sources Table Table of three data sources and the measures gleaned from each Data sources include NYC HIV surveillance registry, American Community Survey, and US Census

Geographic Information Geocoded patient address of residence to 2010 Census tract (CT; smaller than ZIP) CT-level data from ACS and Census linked to individual cases by their CT of residence

Population 17,825 total New York City residents ≥13 years old newly diagnosed with HIV in ,547 (70%) in final analysis – Criteria: Address geocodable to CT, diagnosis date accurate, patient domiciled and not institutionalized – Resided in 1,133 / 2,168 NYC CTs (52%)

Outcome Variable Time from HIV diagnosis to viral suppression – Viral suppression definition: First viral load test after diagnosis that indicated ≤400 copies of HIV RNA/mL – No viral load test = Not suppressed

Independent SES Variables Neighborhood poverty: Percent in a CT with incomes below the federal poverty threshold, categorized as 0- <10%, 10-<20%, 20-<30%, and ≥30% Neighborhood unemployment: Percent ≥16yo in a CT who were unemployed, divided by 10, modelled as continuous

Covariates Neighborhood-level covariate: Percent black Individual-level covariates: Year of HIV diagnosis, ART eligibility (initial CD4), demographics (age group, sex, race/ethnicity, region of birth), HIV risk

Analytic Methods % suppressed ≤12 mos after diagnosis Cox proportional hazards regression (time-to-event analysis), accounting for correlations of outcomes by CT, censoring at earlier of death or end of follow-up (12/31/2012)

Results 5,516 / 12,547 (44%) achieved viral suppression within 12 months of diagnosis Median time from diagnosis to suppression: 245 days (IQR: )

Proportional hazards regression of HIV viral suppression among persons newly diagnosed with HIV in New York City in and followed through 2012, by characteristics of the neighborhood (Census tract) persons were living in at diagnosis * Adjusting for both neighborhood-level SES variables, neighborhood-level percent black, and individual-level variables of year of diagnosis, ART eligibility, demographics (age group, sex, race/ethnicity, region of birth), and HIV risk. ** Hazard ratios presented for unemployment represent the risk per 10-percentage- point increase in unemployment.

Text Explanation of Table Table of hazard ratios of viral suppression among residents of higher- vs. lower-poverty or - unemployment neighborhoods All adjusted HRs cross 1; time to suppression does not differ by neighborhood SES factors

Summary of Findings Neighborhood-level SES characteristics did not influence time from HIV diagnosis to viral suppression

Limitations VL data only when persons sought care (median interval = every 3-4 months) Outmigration not ascertained No data on ART SES may influence intermediate outcomes between diagnosis and suppression – not measured here

Strengths Among the first US analyses investigating neighborhood influence on HIV outcomes using surveillance data Laboratory-confirmed measure of viral suppression Address geocoded to CT, the optimal geographic unit for detection of disparities

Conclusions Neighborhood SES not associated with time from HIV diagnosis to viral suppression in NYC NYC’s excellent HIV care and services, benefits for HIV-positive persons, and emphasis on linkage to care may mitigate effect of SES

Acknowledgments Academic advisor and coauthor Luisa N. Borrell (CUNY School of Public Health) Coauthors Lucia V. Torian (NYC Department of Health), Andrew R. Maroko and Heidi E. Jones (CUNY School of Public Health) Heidi Westermann Gortakowski and Hani Nasrallah (both formerly of NYC Department of Health) for geocoding cases CUNY SPH Dean Dr. Ayman El-Mohandes & NYC Department of Health for travel stipends

Contact Ellen Wiewel sph.cuny.edu