| |
Pregnant Women/Poor outcomes & Neighborhood/Crime/violence/education - Association of Adverse Neighborhood Exposures With HIV Viral Load in Pregnant Women at Delivery
|
| |
| |
Download the PDF here
November 6, 2020 JAMA Network - Florence M. Momplaisir, MD, MSHP; Tanner Nassau, MPH; Kari Moore, MS; Clara Grayhack, BS; Wanjiku F. M. Njoroge, MD; Ana V. Diez Roux, MD; Kathleen A. Brady, MD
Conclusions
In summary, 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. Universal access to HIV care and treatment has helped mitigate the negative association of poverty with viral suppression. This mitigation is not the case for many other chronic diseases where poverty limits access to life-saving treatment during and after pregnancy. Living in high-crime environments likely has a deterrent effect on self-care. 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.
Key Points
Question Are adverse neighborhood exposures associated with poor virologic control of HIV in pregnant women at labor and delivery?
Findings In this cohort study of 905 births among 684 women with HIV, women residing in neighborhoods with high rates of violent and prostitution crimes were more likely to have poor virologic control, whereas women residing in neighborhoods with high rates of education were more likely to have better virologic control.
Meaning These findings suggest that social determinants need to be addressed to improve maternal health.
Abstract
Importance Racial disparities in maternal morbidity and mortality are in large part driven by poor control of chronic diseases. The association between adverse neighborhood exposures and HIV virologic control has not been well described for women with HIV during pregnancy.
Objective To evaluate the association between adverse neighborhood exposures and HIV viral load at delivery.
Design, Setting, and Participants This population-based cohort study assessed HIV surveillance data for pregnant women with HIV who had live deliveries in Philadelphia from January 1, 2005, through December 31, 2015. Data analyses were completed in August 2020.
Exposures Neighborhood exposures included extreme poverty, educational attainment, crime rates (using separate and composite measures), and social capital categorized above or below the median. Each neighborhood exposure was modeled separately to estimate its association with elevated HIV viral load.
Main Outcomes and Measures The main outcome was elevated HIV viral load of ≥200 copies/mL at delivery. We hypothesized that adverse neighborhood exposures would be associated with higher odds of having an elevated viral load at delivery. Confounders included birth year, age, race/ethnicity, previous birth while living with HIV, and prenatal HIV diagnosis. Prenatal care and substance use were considered potential mediators. We used logistic mixed effects models to estimate the association between neighborhood exposures and elevated viral load, adjusting for confounders in Model 1 and confounders and mediators in Model 2.
Results There were 905 births among 684 women with HIV, most of whom were aged 25 to 34 years (n = 463 [51.2%]) and were Black non-Hispanic (n = 743 [82.1%]). The proportion of women with elevated viral load decreased from 58.2% between 2005 and 2009 to 23.1% between 2010 and 2015. After adjusting for confounders in Model 1, higher neighborhood education was associated with lower odds of having an elevated viral load (adjusted odds ratio [AOR], 0.70; 95% CI, 0.50-0.96). More violent crime (AOR, 1.51; 95% CI, 1.10-2.07), prostitution crime (AOR, 1.46; 95% CI, 1.06-2.00), and a composite measure of crime (AOR, 1.44; 95% CI, 1.05-1.98) were positively associated with having a higher HIV viral load. These associations remained after adjusting for mediators in Model 2. In addition, the AOR for intermediate prenatal care varied between 1.93 (95% CI, 1.28-2.91) and 1.97 (95% CI, 1.31-2.96), whereas the AOR for inadequate prenatal care varied between 3.01 (95% CI, 2.05-4.43) and 3.06 (95% CI, 2.08-4.49) across regression models.
Conclusions and Relevance In this cohort study, adverse neighborhood exposures during pregnancy and poor engagement in prenatal care were associated with poor virologic control at delivery. These findings suggest that interventions targeted at improving maternal health need to take the social environment into consideration.
Factors at different levels are likely driving the association between HIV and maternal mortality. We know that HIV itself, even in the setting of viral suppression, creates a chronic inflammatory state, putting women at increased risk for adverse pregnancy outcomes.7-9 However, women with HIV encounter chronic stress in their environment (due to poverty, experiences of racism, and chronic exposure to adverse social determinants),10 and the impact of this stress on maternal health is less understood. We addressed this by studying the association between adverse neighborhood exposures during pregnancy and having poor virologic control at delivery. We hypothesized that pregnant women with HIV living in neighborhoods with high poverty, high crime, lower education, and lower social capital would be less likely to achieve virologic control at delivery.
Discussion
In this large observational cohort study, we found that lower neighborhood education and higher violent and prostitution crimes were each associated with an elevated HIV viral load at delivery. These associations were seen even as viral suppression improved over time and after adjusting for confounders and mediators, and taking into account clustering at the census tract and individual level (for women with multiple births). As improving maternal health becomes a public health priority, our study adds to the existing body of literature associating adverse neighborhood exposures with poor maternal outcomes31-33 and raises the need to address social determinants during care management in pregnancy.
One neighborhood exposure with no association with our study outcome was extreme poverty. This is in line with findings from the Chicago Women’s Interagency HIV Study, which found no association between neighborhood poverty and virologic control in a cohort of women with HIV.34 This finding could at least partly be explained by the presence of robust wraparound services provided to people with HIV, including access to ART at low or no cost owing to the Ryan White Comprehensive AIDS Resources Emergency Act.35 Under this act, quality metrics related to HIV care are routinely reported to local public health departments. This routine reporting is not the case for other chronic medical conditions driving maternal morbidity and mortality, such as hypertension and diabetes. For HIV-specific outcomes, the combination of free access to care during and after pregnancy and the development of potent and well-tolerated ART likely mitigate the negative effects of poverty on viral suppression.
Pregnant women with HIV residing in neighborhoods with higher education levels were significantly less likely to have an elevated viral load at delivery. One potential mechanism for the beneficial association of neighborhood education with viral suppression might be through community connections that influence health-related services utilization, attitudes, and norms.36 For example, women might use social networks within their community to receive recommendations about the use of specific clinics or practitioners. This is important during pregnancy, as both viral suppression12 and birth outcomes37 have been linked to receiving timely prenatal care. Our analysis demonstrates this importance, as poor prenatal care was associated with virologic failure. However, we did not find an association between social capital and virologic control. In the literature, there is substantial variation in the use of social capital measures, and the association with viral suppression showed mixed findings.38 As constructed here, social capital provides a global measure of social cohesion, which is not specific to HIV social support. It is possible that women living in neighborhoods with higher education levels particularly seek support for behaviors focused on improving HIV treatment.
We found an association between violent crime, prostitution crime, and the crime index and elevated viral load. One hypothesis is that neighborhoods with elevated rates of crime might create high-stress environments that negatively impact women’s ability to take their ART daily through a series of mechanisms, such as direct victimization, posttraumatic stress, or depression.39 In addition, women might not prioritize self-care in the setting of excessive exposure to stressful environments. The prolonged activation of the hypothalamic-pituitary-adrenal stress response system leads to increasing levels of cortisol affecting not only the mother but also the developing fetus. All of these factors together could reasonably contribute to the associations seen. Studies have shown a strong association between neighborhood violent crimes and higher community viral load,40 increased risk for HIV,41 and poor overall health.39,41
Limitations
Limitations include the fact that we can solely measure cross-sectional associations and cannot determine causation. Our analyses capture global associations of neighborhood exposures; future studies are needed to better understand the mechanisms driving these associations, particularly the link with chronic stress. In addition, we used census tract–level data, which may not fully capture the true extent of a person’s perception of their neighborhood, and we were unable to incorporate perceived or physiologic measures of chronic stress in our analysis. Finally, there may be additional person-level and census tract–level confounders that we are unable to adjust for owing to a lack of available data. Despite limitations of the geographic areas available and the absence of direct measures of potentially important neighborhood-level processes, the systematic way in which area data were collected for the entire population makes census-based measures a valuable resource.
Conclusions
In summary, 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. Universal access to HIV care and treatment has helped mitigate the negative association of poverty with viral suppression. This mitigation is not the case for many other chronic diseases where poverty limits access to life-saving treatment during and after pregnancy. Living in high-crime environments likely has a deterrent effect on self-care. 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.
|
|
| |
| |
|
|
|
