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AIDS Care. 2018 Nov;30(11):1459-1468. doi: 10.1080/09540121.2018.1476656. Epub 2018 May 30.

Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South.

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a Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , USA.
b Nelson A. Rockefeller Institute of Government , Albany , USA.
c Department of Public Administration and Policy , Rockefeller College of Public Affairs & Policy, University at Albany , Albany , USA.
d Department of Psychology , Virginia Commonwealth University , Richmond , USA.
e Department of Medicine, Division of Infectious Diseases , University of North Carolina at Chapel Hill , Chapel Hill , USA.
f Center for Health Analytics and Discovery , Eastern Virginia Medical School , Norfolk , USA.
g Department of Health Policy and Management , University of Pittsburgh , Pittsburgh , USA.


Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source-publicly-funded health centers serving low-income populations-could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.


HIV/AIDS; access to care; disparities; geography; race/ethnicity; rural; structural barriers; travel time

[Available on 2019-11-01]

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