Place Matters, Could Segregation Be a Factor for Higher HIV/AIDS Mortality Among African Americans?

In the late 1990s, Mary Jo Trepka, M.D., M.S.P.H., was the epidemiologist for Miami-Dade County in southern Florida. At the time, HIV/AIDS was more common there than anywhere else in the country. Looking at maps of the area, she noticed a pattern: The poorer neighborhoods had higher rates of HIV/AIDS, as well as other sexually transmitted diseases and tuberculosis, and African Americans were more likely to die from AIDS than their White counterparts were.

Dr. Trepka, now a professor of epidemiology at Florida International University in Miami, has spent the last 7 years trying to understand why HIV-positive African Americans and other non-Hispanic Blacks remain more likely than Whites to die from AIDS even though effective HIV medications are available. Inspired by her experience at the health department, Dr. Trepka has focused on determining what features of a neighborhood, such as segregation, poverty, and whether it is rural or urban, affect how likely a resident is to die from AIDS. Through careful study of Florida health records, she has started to identify exactly how things go wrong for people of color with HIV.

One question to address was whether non-Hispanic Blacks were not getting care for HIV because they were more likely to be poor or to live in rural areas. In a study published this year in the Annals of Epidemiology, Dr. Trepka showed that non-Hispanic Blacks were still more likely than Whites to die from HIV, even when she controlled for factors such as poverty and whether people lived in a rural or urban area.

However, Dr. Trepka's research suggests that segregation could play a role. After being controlled for poverty, the data show that non-Hispanic Blacks with HIV are more likely to die if they live in highly segregated areas.

African Americans living in highly segregated areas often have fewer opportunities, face significant discrimination, and experience neighborhood violence. People in segregated areas may have poorer nutrition or live farther from high-quality hospitals. The stress associated with these segregated neighborhoods can also affect how likely people are to be consistent about treatment: HIV medications have unpleasant side effects and must be taken several times a day, so people who do not have symptoms are sometimes less motivated to take their medications. "That's a barrier for everybody, but I think it's a greater barrier for people that have a lot of other stressors in their life," Dr. Trepka says.

Now Dr. Trepka is trying to find where in the healthcare system HIV-positive African Americans face problems. She has looked at how long it takes people to see a doctor after being diagnosed with HIV. Her study, yet to be published, found that non-Hispanic Black people were less likely than White people to see a doctor 3 or even 6 months after they were diagnosed. She speculates that stigma in the community might prevent some people from seeking medical care.

"Our work so far has led to a hundred more questions than what we had when we started," says Dr. Trepka. But her findings have started to point to specific barriers, such as stigma and segregation, that public health professionals can begin to address. It is especially important to target these barriers, considering that racial disparities in HIV/AIDS persist even though effective therapy has been available for almost 20 years, she says.

Not only are non-Hispanic Blacks more likely to die from AIDS than White people, but Dr. Trepka's research shows they are dying younger. "The racial disparities in terms of years of potential life lost are really quite large," she says. "It really highlighted how much is lost in the community by these people getting HIV infections and dying."

Dr. Trepka's research has been funded by NIMHD and its predecessor, the National Center on Minority Health and Health Disparities, since 2009. In 2011, Dr. Trepka was awarded a Presidential Early Career Award for Scientists and Engineers for her work on racial and ethnic disparities in HIV/AIDS.

References

1. Centers for Disease Control and Prevention. (2000). U.S. HIV and AIDS cases reported through December 2000. HIV/AIDS Surveillance Report, 12(2). Retrieved from https://www.cdc.gov/hiv/pdf/statistics_2000_HIV_Surveillance_Report_vol_12_no2.pdf (PDF, 2.7 MB)
2. Trepka, M. J., Fennie, K. P., Sheehan, D. M., Niyonsenga, T., Lieb, S., & Maddox, L. M. (2016). Racial-ethnic differences in all-cause and HIV mortality, Florida, 2000-2011. Annals of Epidemiology, 26(3), 176-182.e1. doi: 10.1016/j.annepidem.2016.02.002.
3. Fennie, K. P., Lufti, K., Maddox, L. M., Lieb, S., & Trepka, M. J. (2015). Influence of residential segregation on survival after AIDS diagnosis among non-Hispanic blacks. Annals of Epidemiology, 25(2), 113-119.e1. doi: 10.1016/j.annepidem.2014.11.023.
4. Trepka, M. J., Niyonsenga, T., Fennie, K. P., McKelvey, K., Lieb, S., & Maddox, L. M. (2016). Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000-2009. Public Health Reports, 130(5), 505-513.