Socioeconomic factors, such as housing, and personal identity, such as sexual orientation, jointly influence durable viral suppression in HIV.

“We know that viral suppression rates are increasing in the US,” Adovich Rivera, MD, PhD, says. “However, disparities exist. Many studies on HIV disparities use a reductionist approach (eg, identifying only racial disparities or trying to see the association of income). This is inconsistent with the real world, where people with HIV hold multiple axes of identities and experience social forces that do not act in isolation.”

For a study published in AIDS, researchers used “an intersectionality-informed approach to provide a more nuanced understanding, or at least a nuanced picture, of disparities in durable viral suppression and the factors that may be producing these disparities,” Dr. Rivera explains.

The study team, which included researchers from Northwestern and Howard Brown Health in Chicago, conducted a retrospective cohort analysis using EHR data for people with HIV treated at an LGBTQ federally qualified health center between 2012 and 2019. They identified people with HIV who attained durable viral suppression through latent trajectory analysis and then assessed disparities using three intersectional approaches: adding interactions, latent class analysis (LCA), and qualitative comparative analysis (QCA). Dr. Rivera and colleagues also compared the findings to main effects–only regression.

Culturally Competent Care & Durable Viral Suppression

The analysis included 5,967 people with HIV, 90% of whom had viral trajectories that aligned with durable viral suppression. Patients who reached durable viral suppression were older than those who did not (age at baseline, 43.43 vs 39.15) and more likely to identify as cisgender men (88.4% vs 85.6%). The sexual orientations of individuals did not vary significantly between the groups.

Dr. Rivera and colleagues demonstrated that substance use (OR, 0.56) and socioeconomic status, including factors like being unhoused (OR, 0.39) were associated with durable viral suppression, but not sexual orientation or gender identity. When they added interactions, results showed that race and ethnicity modified the association between insurance and durable viral suppression (P for interaction, <0.05).

In the LCA, the study team identified four social categories influenced by sexual orientation or gender identity with varying rates of durable viral suppression. “For example, the transgender women-majority class had worse [durable viral suppression] rates versus the class of mostly non-poor White cisgender gay men (82% vs 95%),” Dr. Rivera and colleagues wrote. “QCA showed that combinations, rather than single factors alone, were important for achieving [durable viral suppression]. Combinations vary with marginalized populations (eg, Black gay/lesbian transgender women) having distinct sufficient combinations compared to historically privileged groups (eg, White cisgender gay men).”

According to Dr. Rivera, the findings “show that the presence of negative conditions does not necessarily condemn a [person with HIV] to fail to achieve viral suppression.”

He continues, “In fact, even people with two or more adverse conditions (eg, being unhoused or having substance use disorder) were still able to achieve durable viral suppression.”

The key factor is the context in which patients obtain healthcare. “These individuals were receiving culturally competent care and case management and are being linked to wrap-around services that help them address different problems they face,” he says. “The findings about insurance, as well as race and ethnicity, show how single interventions will not necessarily have equal effects across all demographic categories. We are not saying that insurance does not matter; our results suggest that insurance might not be enough to ensure durable viral suppression is achieved in certain groups.”

Addressing the “Complexity of the Real World”

The findings indicate that “efforts that address single issues alone would likely fail to eliminate disparities in durable viral suppression,” according to Dr. Rivera.

“Our paper confirms findings of previous work that shows how substance use and housing are key issues that need to be co-managed alongside the HIV infection,” he says. “We see that across intersectional groups, people with substance use disorders or people who are unhoused were still likely to achieve durable viral suppression in the presence of other favorable conditions. As a result, we would argue that, while addressing social risks are important, in the context of people with HIV, interventions for these risks should be provided as a package. Efforts that address just single issues would likely fail to help eliminate disparities in durable viral suppression.”

Regarding future studies, Dr. Rivera would like to see more research that uses intersectionality at the stages of conception, analysis, and interpretation. “When it comes to disparities research, we should move toward using methods that better deal with the complexity of the real world,” he says. “As we showed in this paper, many details are hidden if we rely only on the usual regression modelling.” 

Key Takeaways

• Certain factors, such as substance use and being unhoused, were associated with durable viral suppression, but not sexual orientation or gender identity.
• However, individuals experiencing two or more adverse conditions (eg, being unhoused or having substance use disorder) were still able to achieve durable viral suppression.
• Substance use and housing are key issues that need to be co-managed alongside HIV infection.