Addressing SDOH Improves the Maternal Health of Pregnant Women Living With HIV

Pregnant women living with HIV were less likely to have better virologic control if their neighborhoods had high rates of violent and prostitution crimes, in a study that also investigated the link between this outcome and extreme poverty, education, crime rates, and social capital (ie, positive interactions with neighbors and having a sense of belonging), reported JAMA Network Open.

“The association between adverse neighborhood exposures and HIV virologic control has not been well described for women with HIV during pregnancy,” the authors stated. “We hypothesized that adverse living conditions…contribute to an environment where chronic stress negatively affect the mother.”

Their population-based cohort study, which comprised 684 women who had 905 live deliveries in Philadelphia between January 1, 2005, and December 21, 2015, also determined there was better virologic control among pregnant women who lived in neighborhoods that had high education rates.

Using a viral load benchmark of ≥ 200 copies/mL at delivery and models that adjusted for confounders (Model 1) and confounders and mediators (Model 2), the investigators’ analyzed data through August 2020. Confounders were birth year, age, race/ethnicity, previous birth while living with HIV, and prenatal HIV diagnosis; potential mediators were prenatal care and substance use. Most viral loads were obtained a mean (SD) 8 (9.2) weeks before delivery.

Despite seeing positive results, in that the amount of women with an elevated viral load decreased 60.3% during the study period, from 58.2% in 2005-2009 to 23.1% in 2010-2015, using Model 1, the authors determined the women were more likely to have an elevated viral load under the following neighborhood conditions:

• More violent crime (adjusted odds ratio [aOR], 1.51; 95% CI, 1.10-2.07)
• More prostitution crime (aOR, 1.46; 95% CI, 1.06-2.00)
• Composite crime (aOR, 1.44; 95% CI, 1.05-2.96)

However, there was the positive link seen between better virologic control and higher neighborhood education, with an aOR of .070 (95% CI, 0.50-0.96).

Additional analyses with regression models found that the incidences of intermediate prenatal care (ie, any combination of presentation to prenatal care, number of prenatal visits, and delivery gestational age) and inadequate prenatal care (ie, having the first prenatal visit in the third trimester or fewer than 5 visits after 18 weeks’ gestation) remained consistent, for the most part. Intermediate prenatal care’s aOR ranged from 1.93 (95% CI, 1.28-2.91) to 1.97 (95% CI, 1.31-2.96), and that for inadequate prenatal care ranged from 3.01 (95% CI, 2.05-4.43) to 3.06 (95% CI, 2.08-4.49)

Among the women in the study, 373 (41.2%) had an elevated viral load at delivery. Overall, most (n = 463; 51.2%) were aged 25 to 34 years at this time, followed by 16 to 24 years (n = 257; 28.4%) and at least 35 years old (n = 185; 20.4%). A majority (n = 743; 82.1%) were also non-Hispanic Black. Close to two-thirds (n = 571; 63.1%) gave birth to their first child during the study period and received their HIV diagnosis (n = 699; 77.2%) before becoming pregnant.

More violent crime was considered to be more than 371 violent crimes per 10,000 individuals, while prostitution crime was measured at anything over 0 per 10,000.

“This cohort study found that the overlap between HIV (a chronic disease), adverse neighborhood exposures, and pregnancy continues to occur predominantly among racial/ethnic minorities, which may contribute to the persistence of racial disparities in maternal health,” the authors concluded. “Improving maternal health requires a paradigm shift in the way we approach women’s health and calls for addressing the negative effects of social determinants on maternal outcomes.”

Data for their analyses were provided by the Perinatal HIV Exposure Reporting program; the Enhanced HIV/AIDS Reporting System; 2000 and 2010 US Census Bureau TIGER files for Philadelphia County, Pennsylvania; the American Community Survey; the Philadelphia Police Department’s Mapping and Analysis Unit via OpenDataPhilly; and the Southeastern Pennsylvania Household Health Survey.

To improve overall outcomes among pregnant women living with HIV, the authors believe that a plausible solution should how consider social determinants of health affect maternal health.

Reference

Momplaisir FM, Nassau T, Moore K. Association of adverse neighborhood exposures with HIV viral load in pregnant women at delivery. JAMA Netw Open. doi:10.1001/jamanetworkopen.2020.24577