Rural-urban differences in HIV viral loads and progression to AIDS among new HIV cases.

OBJECTIVE: The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in the United States has shifted to the South, where an increasing proportion is occurring in rural areas. We sought to gain a better understanding of the affected rural population in this region. METHODS: The statewide HIV/AIDS Electronic Reporting System database was used to examine the epidemiological characteristics of newly diagnosed HIV cases in South Carolina from 2005 to 2011. Rural-urban differences were examined in sociodemographic and clinical characteristics, including progression to AIDS and a decline in HIV viral load (VL) to undetectable levels within 1 year of diagnosis. RESULTS: Of the 5336 individuals newly diagnosed as having HIV, 1433 (26.9%) were from rural areas. Compared with urban residents, a higher proportion of rural residents were black, non-Hispanic (80.1% vs 68.5%; P ≤ 0.0001) and reported heterosexual risk (28.8% vs 22.9%; P = 0.0007). The proportion of female patients was higher in rural areas (29.7% vs 26.4%; P = 0.016). No significant rural-urban differences were found in initial CD4(+) T-cell and VL counts or proportion obtaining an undetectable VL at 1 year. Rural residents were significantly more likely than urban residents to have AIDS at diagnosis or within 1 year of the HIV diagnosis (adjusted odds ratio 1.15; 95% confidence interval 1.007-1.326). CONCLUSIONS: The reasons behind differences in proportions of rural and urban residents who were diagnosed as having AIDS or progressed to AIDS despite similar initial CD4(+) T-cell counts and VL suppression at 1 year are unclear and should be explored in future studies. Future prevention and treatment efforts may need to consider the unique characteristics of rural populations in the South.

Disparities in viral load and CD4 count trends among HIV-infected adults in South Carolina.

On a population level, trends in viral load (VL) and CD4 cell counts can provide a marker of infectivity and an indirect measure of retention in care. Thus, observing the trend of CD4/VL over time can provide useful information on disparities in populations across the HIV care continuum when stratified by demography. South Carolina (SC) maintains electronic records of all CD4 cell counts and HIV VL measurements reported to the state health department. We examined temporal trends in individual HIV VLs reported in SC between January 1, 2005 and December 31, 2012 by using mixed effects models adjusting for gender, race/ethnicity, age, baseline CD4 count, HIV risk category, and residence. Overall VL levels gradually decreased over the observation period. There were significant differences in the VL decline by gender, age groups, rural/urban residence, and HIV risk exposure group. There were significant differences in CD4 increases by race/ethnicity, age groups, and HIV risk exposure group. However, the population VL declines were slower among individuals aged 13-19 years compared to older age groups (p<0.0001), among men compared to women (p=0.002), and among people living with HIV/AIDS (PLWHA) with CD4 count ≤200 cell/mm(3) compared to those with higher CD4 counts (p<0.0001). Significant disparities were observed in VL decline by gender, age, and CD4 counts among PLWHA in SC. Population based data such as these can help streamline and better target local resources to facilitate retention in care and adherence to medications among PLWHA.

Defining the rural HIV epidemic: correlations of 3 definitions--South Carolina, 2005-2011.

PURPOSE: To gain a better understanding of the HIV epidemic in rural South Carolina (SC) by contrasting 3 definitions of rural and urban areas. METHODS: The sample included newly diagnosed HIV cases aged ≥18 years in SC between January 1, 2005, and December 31, 2011. Each individual was assigned a rural or urban status as defined by the Office of Management and Budget (OMB), Census Bureau (CB), and Rural Urban Commuting Area (RUCA) classifications. Descriptive statistics were conducted to compare sociodemographic characteristics, CD4 counts, viral loads, and time to AIDS diagnosis between rural and urban populations. Kappa statistics measured the agreement between the 3 definitions of rurality. FINDINGS: Depending on the definition used, the proportion of newly diagnosed HIV cases in rural areas varied from 23.3% to 32.0%. Based on the OMB and RUCA definitions, rural residents with HIV were more likely to be older, women, black, and non-Hispanic, report heterosexual contact, and have an AIDS diagnosis within 1 year of their HIV diagnosis. The OMB and RUCA definitions had a nearly perfect agreement (kappa = 0.8614; 95% CI = 0.8457, 0.8772), while poor agreements were noted between the OMB and CB or the RUCA and CB definitions. CONCLUSION: When examining the rural HIV epidemic, how "rural" is defined matters. Using 3 definitions of rurality, statistically significant differences were found in demographic characteristics, timing of HIV diagnosis and the proportion of rural residents diagnosed with HIV in SC. The findings suggest possible misclassification biases that may adversely influence services and resource distribution.