Community Resilience Estimates and HIV Health Outcomes: Insights from the CNICS Cohort

This study aims to better understand the association between community social vulnerabilities (e.g., income-to-poverty ratio, health insurance coverage) and the ability of people with HIV (PWH) to achieve viral suppression and optimal CD4 cell count levels. We conducted an observational study within the CFAR Network of Integrated Clinical Systems (CNICS) cohort of adult PWH in care at two CNICS sites between 1/2015 and 3/2023 with an identifiable residential address and HIV-related laboratory measures. Our exposure of interest, 2022 Community Resilience Estimates (CRE) from the US Census Bureau, is calculated at the census tract level and categorized as 0, 1-2, or 3-10 social vulnerabilities that impact community resilience. Outcomes included individual-level unsuppressed HIV viral load (≥ 50 copies/mL) and low CD4 count (< 350 cells/mm³). We estimated prevalence ratios and 95% confidence intervals (CI) using multivariable relative risk regression clustered by census tract, adjusting for individual-level demographic characteristics, site, and year of outcome measurement. Among 3,191 PWH, 342 (11%) were virally unsuppressed and 528 (17%) had low CD4 cell count. Compared to PWH in tracts with 0 vulnerabilities, those living in census tracts with 1-2 social vulnerabilities were 1.28 times more likely (95%CI: 1.00-1.63) to be virally unsuppressed. Those in census tracts with ≥ 3 social vulnerabilities were 1.95 times more likely (95%CI: 1.22-3.10) to be virally unsuppressed and were 1.51 times more likely (95%CI: 1.12-2.04) to have low CD4 cell counts. In the context of PWH, the CRE could be used to highlight areas for targeted interventions based on community-level influences to improve HIV-related outcomes.