title: 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.
authors.affiliation: Center for AIDS Prevention, University of California San Francisco, 50 Beale Street, Suite 1300, San Francisco, CA 94105, USA. m_arnold@hotmail.com
authors.forename: Michael
authors.initials: M
authors.lastname: Arnold
authors.forename: Ling
authors.initials: L
authors.lastname: Hsu
authors.forename: Sharon
authors.initials: S
authors.lastname: Pipkin
authors.forename: Willi
authors.initials: W
authors.lastname: McFarland
authors.forename: George W
authors.initials: GW
authors.lastname: Rutherford
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D019352:Censuses; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D044469:Racial Groups; D012495:San Francisco; D012923:Social Class; D016019:Survival Analysis; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents