Patient Race and Residential Segregation May Negatively Affect HIV Care Retention

Although inequities in HIV care retention were associated with residential racial segregation and patient race, these findings were attenuated after controlling for mental health and substance use data.

Residential segregation and historical disadvantage may negatively affect retention in HIV care among Black individuals in the United States. These study findings were published in Open Forum Infectious Diseases.

Data for this study were sourced from the Center for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS). Between 2010 and 2015, data on patient demographics, patient-reported outcomes, and health status were obtained from 7 centers participating in the CNICS. Predictors of HIV care retention were evaluated on the basis of race and residential factors.

The analysis comprised Black (n=7691) and non-Black (n=13,116) individuals with HIV infection. Of these patients, the median age was 43 (IQR, 34-51) and 43 (IQR, 35-50) years, 69% and 89% were men (P <.001), 54% and 46% had detectable viral loads (P <.001), and the median CD4+ T-cell count was 417 (IQR, 229-621) and 467 (IQR, 289-668) cells/mm3 (P <.001), respectively. In addition, 23% and 15% of Black and non-Black patients were uninsured, respectively (P <.001).

A total of 347,151 HIV care visits were evaluated, of which 82% were attended and 18% were missed. After adjustments for age, sex, gender, health insurance, viral load, and CD4+ T-cell count, the odds of missing an appointment were 51% greater among Black patients compared with non-Black patients (adjusted odds ratio [aOR], 1.51; 95% CI, 1.45-1.57; P <.001).

In the fully adjusted model, significant predictors for missing an HIV care visit were as follows:

  • Current substance use (aOR, 1.48; P <.001);
  • Black race (aOR, 1.34; P <.001);
  • Active smoking status (aOR, 1.33; P <.001);
  • Detectable viral load (aOR, 1.31; P <.001);
  • Symptoms of depression (aOR, 1.01; P <.001);
  • Age (aOR, 0.98; P <.001);
  • CD4+ T-cell count (aOR, 0.97; P =.001);
  • Proportion of Black residents within a neighborhood (aOR, 0.90; P <.001); and
  • Use of private insurance (aOR, 0.77; P <.001).

After adjustments for patient-reported outcomes such as mental health status and substance use among Black patients, the relationship between the proportion of Black residents within a neighborhood and missing an HIV care visit was attenuated (aOR, 0.94; 95% CI, 0.94-1.02; P =.0367).

This study may have been limited by selection bias. In addition, the proportion of Black residents residing in a neighborhood was determined via census tract data and used as a proxy for residential segregation.

Modifiable risks such as mental health and substance use must be addressed using multi-level approaches, such as trauma-informed care, to improve RIC.

“The social construct of Black race and neighborhood racial segregation may interact to diminish retention in HIV healthcare for Black PWH [patients with HIV],” the researchers noted. “Modifiable risks such as mental health and substance use must be addressed using multi-level approaches, such as trauma-informed care, to improve RIC [retention in care],” the researchers concluded.

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Crockett KB, Schember CO, Bian A, et al. Relationships between patient race and residential race context with missed HIV care visits in the United States, 2010-2015. Clin Infect Dis. Published online February 9, 2023. doi:10.1093/cid/ciad069