-When analyzing a disease, it is often obvious that behavior plays a vital part, and even the most vital component when dealing with a disease such as HIV/AIDS-While studies may find that behavior that is susceptible to contracting HIV/AIDS does not vary by groups (e.g. adolescent promiscuity produces a similar risk as middle-age promiscuity), these same studies ignore whether or not the risk of that behavior will vary dependent upon the area-Risky behavior in an area with high HIV/AIDS rate is, in fact, more risky than that same behavior in a low HIV/AIDS rate area.
-“Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV…Our study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. We emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach”
-A substantial number (1/3) of People Living with HIV/AIDS (PLWHA) across Texas are diagnosed late in the progression of HIV disease
-Blacks had the highest number and rate of new infections every year from 2001 to 2005. The 2005 rate of new cases in Blacks (78 per 100,000) was approximately five times higher than the rate in Whites and Hispanics
Clients often do not know where to go to get the services they need, or what services are needed. Assessment data consistently rate access to transportation as a primary barrier to care. “Publicly funded HIV health care services in Texas are concentrated in larger cities and individuals living outside these communities must travel long distances to access needed care and services.”
-The availability of safe affordable housing. Key informant interview data suggest that discrimination in housing, along with reimbursement rates below fair market rents for housing, places clients into housing in high crime/low income areas, a phenomenon that may lead to substance abuse issues, crime, and other factors that are known to affect access and maintenance in care-The lack of available health care choices in non-urban service areas affects access to care, especially for specialty services. The providers that are in operation are often dependent on one funding source and vulnerable to fluctuations in funds. Key informants from urban areas cite this as a potential problem if there are a small number of providers and clients are not comfortable accessing services from any of them
More details on the methods can be discussed after the presentation
Previous studies have shown lack of affordable housing to be associated with HIV risk behavior (Aidala, Cross, Stall, Harre, & Sumartojo, 2005; Shubert & Bernstein, 2007; Aidala & Sumartojo, 2007). 43% of geographic variation is attributable to the factors included here.
Highlighted areas = ZIP index > 20
Highlightedareas = ZIP index > 20
Red = Service provider; highlighted = top 20% HIV ZIP
Place vulnerability of hiv aids in texas
Neighborhood Characteristics of HIV/AIDS in Texas<br />Adam F. Harold<br />Dr. Joseph Oppong<br />Dr. ChetanTiwari<br />
Vulnerable People or Places?<br />Behavior influences disease<br />Risk/outcome of behavior depends on location<br />High Risk Area<br />Risky Behavior<br />Low Risk Area<br />Risky Behavior<br />
Previous Research on HIV/AIDS and Neighborhoods<br />Barriers to care <br />distance to service provider<br />owning vehicle<br />lack of health care professionals<br />financial resources<br />social capital<br /><ul><li>Social Disorganization
housing</li></li></ul><li>An interesting finding…<br />Individual risk factors do not alone explain geographic variation of HIV/AIDS<br />Neighborhoods and regions account for 14% and 6% of total variation in HIV/AIDS<br />Emphasizes need for both group-based AND place-based approach<br />Place matters: multilevel investigation of HIV distribution in TanzaniaWezi M. Msisha, Saidi H. Kapiga, Felton J. Earls and S.V. Subramanian AIDS 2008, 22:741–748<br />
Purpose<br />Place vulnerability of HIV/AIDS is under researched<br />Texas Department of State Health Services (DSHS) Statewide Coordinated Statement of Need 2008 – 2010 has identified and targeted:<br />Cross-cutting issues<br />Barriers to Care<br />Critical gaps<br />The purpose of this research is to operationalize these three areas<br />
Selected Cross Cutting Issues<br />Late Testing is a problem<br />
Selected Cross Cutting Issues<br />African Americans are disproportionately affected by HIV/AIDS<br />The Texas Department of State Health Services (DSHS) Statewide Coordinated Statement of Need 2008 – 2010<br />
Selected Barriers to Care<br />Access to services, especially in rural areas is a barrier<br />The Texas Department of State Health Services (DSHS) Statewide Coordinated Statement of Need 2008 – 2010<br />
Selected Barriers to Care<br />People recently released from incarceration have barriers in access to care and lower levels of treatment<br />
Selected Critical Gaps<br />Availability of safe affordable housing is limited<br />Lack of available health care choices in non-urban service areas affects access to care<br />The Texas Department of State Health Services (DSHS) Statewide Coordinated Statement of Need 2008 – 2010<br />
Data<br />Variables to measure Cross-Cutting Issues:<br />Late Testers (% of newly diagnosed HIV/AIDS who were late testers in ZIP)<br />Race (% of black population in ZIP)<br />Variables to measure Barriers to Care:<br />Poverty (% of 18+ population in poverty in ZIP) <br />Access to HIV/AIDS Service Providers (provider located in ZIP)<br />Own vehicle (% >16 own vehicle in ZIP)<br />Prison Presence (prison located in ZIP)<br />Variables to measure Critical Gaps<br />Rent (median rent in $ in ZIP)<br />Health Professional Shortage Area (is ZIP in HPSA)<br />
Methods<br />Standard OLS Regression with R-squared change<br />Poisson Regression Model due to positively skewed distribution<br />
Results<br />Cross-Cutting Issues <br />(explain 13% of geographic variation of HIV/AIDS counts in Texas ZIP Codes)<br /><ul><li>Zip codes with higher percent of population that is black had higher HIV/AIDS counts
The proportion of late testers is significantly higher in locations with higher HIV/AIDS counts.
Such locations have a greater risk of disease spread by those unaware of their infection</li></li></ul><li>Results<br />Barriers to Care <br />(explain 15% of geographic variation of HIV/AIDS counts in Texas ZIP Codes)<br /><ul><li>Zip codes with higher percent of population that is in poverty had higher HIV/AIDS counts
Zip codes with HIV/STD service providers have high HIV/AIDS counts compared to those without.
This may be because service providers prefer areas of higher risk</li></li></ul><li>Results<br />Barriers to Care (cont’d) <br />(explain 15% of geographic variation of HIV/AIDS counts in Texas ZIP Codes)<br /><ul><li>HIV/AIDS counts per ZIP decreased as the ZIP percent population aged who own a car increased.
This suggests that wealthier areas have lower HIV/AIDS counts.
ZIP codes where prisons are located have significantly higher HIV/AIDS counts than those without</li></li></ul><li>Results<br />Critical Gaps <br />(explain 15% of geographic variation of HIV/AIDS counts in Texas ZIP Codes)<br />HIV/AIDS count is higher in zip codes with high median rent <br />ZIP Codes located in a HPSA had higher HIV/AIDS counts<br />
Potential Future Use – Locating Unmet Need<br />Legend<br />Red = ZIP with Service Provider<br />Highlight = Top 20% HIV ZIP<br />
Future Research<br />Ground truthing and qualitative approach<br />Recognizing geographic differences<br />Incorporating structural level variables<br />Moving to specific measures of vulnerability, away from proxy measures<br />Incorporating time<br />Assessment of actual barriers for those areas that used the most recent SCSN survey tool in their last assessment. <br />Conduct targeted assessments using multiple data gathering techniques to identify specific barriers to care.<br />
Implications for HIV/STD Public Health<br />Conclusions based on previous models have informed HIV/AIDS public health prevention and treatment policies on how best to identify vulnerable individuals or groups and get them basic prevention tools and access to treatment<br />The model introduced here would improve on this by also identifying neighborhood characteristics that serve as a barrier to access for those areas needing prevention and treatment<br />In the end, a model such as this may be useful in identifying vulnerable places not only in terms of unmet need but also allow for prediction of future vulnerable places<br />
Acknowledgements<br />Dr. Joseph Oppong & Dr. ChetanTiwari<br />And the University of North Texas GIS & Public Health Research Group http://www.geog.unt.edu/gispublichealth<br />