Past Redlining Continues to Affect Health Outcomes in Patients With HIV

Individuals diagnosed with HIV who live in historically redlined neighborhoods were found to have significantly worse health outcomes, including time to viral suppression, regardless of the present-day gentrification of the neighborhood, according to a new study published in JAMA Internal Medicine.¹ Systemic racism, including the act of redlining, is still having effects on health outcomes of today.

According to Encyclopedia Brittanica,² redlining is defined as a mortgage lender denying a loan or an insurance provider restricting services to certain neighborhoods based on the racial and socioeconomic makeup of the area in which the person lives. This practice began in the 1930s, during the Great Depression, when part of the New Deal programs included the Home Owners’ Loan Corporation (HOLC) assessing neighborhood lending risk for mortgages backed by the government. The HOLC provided a scale of A to D for the neighborhoods, with A being the best and D being the most hazaradous for providing loans. Neighborhoods graded as D, and therefore redlined, were often people of racial or ethnic minorities, which codified racial segregation.

Redlining can affect multiple health outcomes, including HIV viral suppression | Image credit: RAJCREATIONZS - stock.adobe.com

After a diagnosis of HIV, achieving viral suppression is the first step to giving patients a return to a more normal life. HIV care success is often measured by how quickly viral suppression is reached, with 3 months being the preferred time. Understanding which patients take longer to obtain viral suppression and where they live can help to treat HIV more effectively by targeting specific areas. This study aimed to evaluate how past and current housing practices affect HIV treatment.

This study focused primarily on patients living in New Orleans 13 years and older when they were diagnosed. All patients needed a full address in their medical record to be included in the study, as patients were only included if their residence corresponded to an HOLC-graded neighborhood. Individuals with HIV were excluded if they only had an address that corresponded to a post office or a correctional facility.

The authors used data from the Digital Scholarship Lab Mapping Inequality Project at the University of Richmond to obtain HOLC maps created from 1935 to 1940. The Enhanced HIV/AIDS Reporting System (eHARS) was used to collect data on lab results, demographics, HIV risk behaviors, and address at the time of diagnosis for all individuals with HIV or AIDS in Louisiana. Time to viral suppression was estimated by taking the time between the date of diagnosis and the first viral load recorded that was less than 200 copies/mL.

Census data from 2010 and 2019 were used for present-day neighborhood analysis. A neighborhood was defined as gentrified if it was populated by low-income households, had evidence of disinvestment, and poorer residents were displaced by wealthy residents followed by an increase in economic investment.

There were 1132 individuals included in the study, of whom 76.9% were men and 54.8% were aged 25 to 44 years. A total of 61.6% of the patients lived in redlined neighborhood and 25% had stage 3 HIV at the time of their diagnosis. Black patients made up 69.9% of the population living in redlined districts compared with 56.8% in the nonredlined neighborhoods. The redlined neighborhoods also had a higher percentage of people living in gentrifying census tracts (14.6%) compared with nonredlined neighborhoods (8.5%).

A total of 87.3% of the patients achieved viral suppression; 26.1% achieved viral suppression while living in redlined neighborhoods compared with 30.3% who lived in nonredlined neighborhoods. People with HIV who lived in redlined neighborhoods had an unadjusted median time to viral suppression of 193 days (95% CI, 167-223) compared with 164 days (95% CI, 143-185) in patients living in nonredlined neighborhoods. This amounted to 15% fewer days to viral suppression overall. After adjustment, the association between living in a redlined neighborhood and viral suppression was found to be statistically significant (HR, 0.86; 95% CI, 0.76-0.91; P = .03). Patients living with HIV who were living in gentrified HOLC grade D neighborhoods had a longer time to viral suppression compared with all other neighborhoods (HR, 0.54; 95% CI, 0.36-0.82; P = .049).

There were some limitations to this study. The data for individuals relied on the eHARS database, which means that any missing data could bias these results. Possible housing changes during the study also could not be accounted for, and variability within the census tract was possible, despite using the census tract uniformly. It is also possible that neighborhoods graded A, B, or C could still be subject to gentrification. Viral suppression could also be affected by numerous factors outside of redlining.

The authors concluded that redlining has an enduring effect on the health outcomes of patients living with HIV. Viral suppression could be heavily affected by the location of a patient’s residence, which could indicate areas of increased need when treating patients with HIV.

References

1. Bassler JR, Ostrenga L, Levitan EB, et al. Redlining and time to viral suppression among persons with HIV. JAMA Intern Med. Published online September 30, 2024. doi:10.1001/jamainternmed.2024.5003

2. Redlining. Britannica. Updated September 26, 2024. Accessed September 30, 2024. https://www.britannica.com/topic/redlining