HIV; Social Determinants; Late presentation


Background: In recent years, increased attention has shifted toward evaluating social determinants of health, and understanding how community, environment, and system factors affect health outcomes. HIV policies and guidelines emphasize the importance of earlier HIV diagnosis and presentation for care. This study evaluated the role of individual and community-level factors in late presentation to HIV care.

Methods: HIV-infected patients newly initiating outpatient HIV medical care at an academic medical center between 2005-2010 were included. Patients' self-reported addresses at their first clinic visit were geocoded using geographic information systems software to the appropriate United States census block group. Using data from the U.S. Census Bureau’s 2005-2009 American Community Survey, community-level data was recorded for each patient's census block group. Poisson regression was used to evaluate associations between individual- and community-level factors with late presentation for HIV care, defined as an initial CD4 count /mm3.

Results: Among 609 patients, 341 patients (56%) had an initial CD4 count /mm3. At a community level, late presentation was significantly associated with the proportion of African Americans in a census block group (RR=1.47; 95%CI=1.19-1.81); with proportion living in poverty, lack of fuel, and lack of vehicle demonstrating borderline statistical significance. At an individual level, older patients were more likely (1.12; 1.06-1.19), while white females were less likely (0.45; 0.24-0.84) to present with a CD4 count /mm3.

Conclusion: Both individual and community-level characteristics were associated with late presentation for HIV medical care. Research and interventions to promote earlier HIV diagnosis and care entry should include geographical information and social determinants of health to define priority populations.