title: Understanding Local Spatial Variation Along the Care Continuum: The Potential Impact of Transportation Vulnerability on HIV Linkage to Care and Viral Suppression in High-Poverty Areas, Atlanta, Georgia.
abstract: BACKGROUND
  Engagement in care is central to reducing mortality for HIV-infected persons and achieving the White House National AIDS Strategy of 80% viral suppression in the US by 2020. Where an HIV-infected person lives impacts his or her ability to achieve viral suppression. Reliable transportation access for healthcare may be a key determinant of this place-suppression relationship.
  
  
  METHODS
  ZIP code tabulation areas (ZCTAs) were the units of analysis. We used geospatial and ecologic analyses to examine spatial distributions of neighborhood-level variables (eg, transportation accessibility) and associations with: (1) community linkage to care, and (2) community viral suppression. Among Atlanta ZCTAs with data for newly diagnosed HIV cases (2006-2010), we used Moran I to evaluate spatial clustering and linear regression models to evaluate associations between neighborhood variables and outcomes.
  
  
  RESULTS
  In 100 ZCTAs with 8413 newly diagnosed HIV-positive residents, a median of 60 HIV cases were diagnosed per ZCTA during the 5-year period. We found significant clustering of ZCTAs with low linkage to care and viral suppression (Moran I = 0.218, P < 0.05). In high-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 4% point increase in linkage to care (P = 0.02, R = 0.16). In low-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 30% point increase in ZCTA-level viral suppression (P = 0.01, R = 0.08).
  
  
  CONCLUSIONS
  Correlations between transportation variables and community-level care linkage and viral suppression vary by area poverty level and provide opportunities for interventions beyond individual-level factors.
authors.affiliation: *Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA; †Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA; ‡Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA; §Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA; ‖Georgia Department of Public Health, Atlanta, GA; and ¶Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA.
authors.forename: Neela D
authors.initials: ND
authors.lastname: Goswami
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Schmitz
authors.forename: Travis
authors.initials: T
authors.lastname: Sanchez
authors.forename: Sharoda
authors.initials: S
authors.lastname: Dasgupta
authors.forename: Patrick
authors.initials: P
authors.lastname: Sullivan
authors.forename: Hannah
authors.initials: H
authors.lastname: Cooper
authors.forename: Deepali
authors.initials: D
authors.lastname: Rane
authors.forename: Jane
authors.initials: J
authors.lastname: Kelly
authors.forename: Carlos
authors.initials: C
authors.lastname: Del Rio
authors.forename: Lance A
authors.initials: LA
authors.lastname: Waller
mesh_terms: D003710:Demography; D005843:Geography; D005845:Georgia / Q000453:epidemiology; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality; D006297:Health Services Accessibility; D006801:Humans; D011204:Poverty Areas; D012111:Residence Characteristics; D014186:Transportation; D019562:Viral Load