Differences in the HIV Care Continuum By Rural and Urban Residence, Georgia, 2012

BACKGROUND: The HIV care continuum has become an important means of monitoring care and prevention in Georgia. Persons living in rural areas may have fewer available HIV resources and may face challenges in accessing HIV care. Analyzing the HIV care continuum by rural-urban residence will help identify disparities in services among affected subpopulations in Georgia.

METHODS: Case and laboratory surveillance data from the enhanced HIV/AIDS Reporting system (eHARS) from 2011-2012 were analyzed for Georgia residents aged 13 years and older diagnosed with HIV as of September 2011 and living as of 12/31/2012.  Persons were categorized as having an urban or rural residence based on zip code approximation from version 3.10 of the Rural-Urban Commuting Area (RUCA) codes developed by the United States Department of Health and Human Services and by the Department of Agriculture. Indicators of the HIV care continuum, including any care (>=1 CD4 or viral load), retention in care (>= 2 CD4 or VL), and viral suppression (most recent VL <200 copies/ml) were estimated by demographic and transmission categories and by rural and urban residence.  Measures of association and significance were calculated using SAS version 9.2 (alpha = 0.05)

RESULTS: Among rural residents(n=2,663), 41% received any care, 27% were retained in care, and 29% were virally suppressed, compared with 56% receiving any care, 40% retained in care, and 40% virally suppressed for urban residents(n=36,746).  The relative differences between rural and urban residents were 27%, 33%, and 25% for any care, retention in care and viral suppression, respectively. The rural-urban gap persisted by sex, race/ethnicity, transmission category, and age. The largest gap was observed among Hispanics, for whom the relative differences in rural compared to urban populations was 61%, 62% and 64% for any care, retention in care and viral suppression, respectively. The relative differences among whites (34%, 41%, 34% respectively), injection drug users (33%, 42%, 31% respectively), and persons 55 and older (33%, 43%, 46% respectively) were also elevated compared to all rural residents. All listed differences were statistically significant (p < 0.05).

CONCLUSIONS: HIV care continuum indicators for rural residents in Georgia were lower than for urban residents and warrant targeted efforts to re-engage out-of-care patients.  Additional investigation is needed to determine which factors contribute to the rural-urban gap, especially the large gaps seen among Hispanics.