Identifying HIV Risk Factors in a Single-Site Study

Abstract. Human immunodeficiency virus (HIV) is a chronic immunosuppressive disease that can progress in stages to acquired immunodeficiency syndrome (AIDS) if not treated effectively. Most HIV diagnoses in the United States are among men who have sex with men (MSM). In 2022, 67% of new HIV diagnoses in the United States were among this population, and 86% of all HIV diagnoses among men were from MSM, according to the CDC.¹ Still, there are many risk factors of HIV that extend beyond sexual activity as well as many barriers to treatment that should be acknowledged when counseling patients about HIV management. People with HIV (PWH) may experience disadvantages because of fewer financial resources, lack of housing, limited access to transportation, few caregivers, and inadequate education. These barriers can potentially lead to non-adherence to treatment, which increases the risk of progression from HIV to AIDS.

This paper examines the risk factors associated with higher viral load among PWH at a single-site HIV clinic. We found that heterosexual individuals were more likely to have HIV and progress to AIDS than MSM. We also found that transgender patients were more likely to be diagnosed with HIV and progress to AIDS than cis-gender patients. Lastly, we found that patients residing at a further distance from the HIV clinic were more likely to contract HIV and progress to AIDS. Further research on this topic can help clinicians better understand and identify the barriers associated with HIV management among PWH treated at a single-site HIV clinic.

Introduction. The prevalence of HIV in the United States is currently 1.2 million, peaking between the ages of 20 and 30 years of age, while AIDS peaks at close to 45 years of age. In the state of New Jersey, where our study was conducted, there are more than 38,000 PWH, at a prevalence of 448.5 per 100,000.^2-4

The risk factors for contracting HIV include family history of HIV, positive partner status, intravenous drug use (IVDU), migration, use of therapeutic injections, male gender, tattooing, geographical location, and a history of blood transfusions.^1,5,6 The risk factors for HIV progression to AIDS include male gender, older age, education status, and a decreased CD4 count.^7,8 While any individual can contract HIV, bisexual men and women, along with MSM, have a significantly greater risk of testing positive for HIV than heterosexual individuals. Among women, Black women who have sex with other women and bisexual women have the highest prevalence of HIV, whereas Latino MSM have the highest prevalence of HIV.^9,10

This study aims to go beyond gender or sexual activity when investigating data from a single-site HIV clinic. The goal is to also create new dialogue for counselors of those with one or more risk factors for HIV. Lastly, the discourse and research surrounding transgender patients is inadequate, in our view. We aim to explore the factors that may lead to more efficient physician-to-patient counseling for this patient population.

Methods. In this study, PWH have a poor rate of follow-up to the clinic, which could pose several risks and potentially death among this patient population. We wanted to further investigate the rates of follow-up in accordance with the clinic’s location, as well as determine the average number of PWH per zip code range. Along with zip code classification, we noted the patients’ sexual orientation that was provided.

This single-site study was conducted at a regional referral teaching hospital in Hudson County, NJ that was designated as a leader in LGBTQIA+ Health Care Equality by the health care quality index. The study included 256 patients who received treatment at the Ambulatory Care Center’s designated HIV Clinic within the previous 6 months, ending in March 2024. All patients included in the study were diagnosed with HIV. The diagnosis was confirmed with HIV antibody testing. The study participants were either referred to the Ambulatory Care Center’s designated HIV Clinic or remained as patients at the hospital. Each patient treated at the clinic was insured either by charity care, Medicaid, or other insurance carriers. We collected and recorded patient data via patient chart review in the hospital’s electronic medical record system, where each patient’s identifying data was removed to guarantee patient anonymity.  

Geographical location, specifically patient zip code, was also analyzed in relation to viral load of each patient. The single-site HIV clinic used in this study is in the zip code of 07035. Patients’ home zip codes were then mapped out to find their proximity to the clinic to determine whether transportation could be an impediment to these patients. Our statistical analysis of the data was performed using bivariate analysis.  

Results. In the current study, we reviewed the patient data of 256 patients who were treated in the single site’s HIV clinic within the previous 6 months from October 2023 to March 2024. Of these selected patients, 178 were men, 73 were women, and five identified as transgender women. 

A total of 113 patients were between 45 to 64 years of age, 94 patients were between 25 and 44 years of age, 41 patients were 65 years of age and older, and eight patients were between 13-24 years of age. Out of the 256 PWH, 57 were diagnosed with AIDS based on CDC guidelines. Out of these 57 patients with AIDS, 31 were between 45 and 64 years of age, 14 were 65 years of age or older, and 12 patients were between 25 and 44 years of age (Figure 1).

Figure 1. Proportion of patients with CDC-defined AIDS by age range.

Out of the 57 patients with AIDS, 40 were men, 15 were women, and two were transgender women.

We also examined other demographic risk factors, including mode of transmission, race, and zip code. Out of the 256 PWH in this cohort, 254 knew the mode of transmission, the most common of which was sexual transmission, comprising 227 of the total transmissions recorded. Out of the 227 PWH who knew the mode of transmission, 115 were heterosexual individuals, having only partners of the opposite gender assigned at birth, while 112 patients were MSM or bisexual individuals. The remaining modes of transmission among these patients were IVDU (n = 15), perinatal (n = 4), two patients preferred to remain unspecified, and one homosexual individual categorized himself as an IVD (Figure 2).

Figure 2. Mode of transmission among PWH.

Race is also a risk factor for contracting HIV and for earlier progression to AIDS.^1,2,7,11 This single-site clinic is in a multi-cultural, diverse population in northern New Jersey. The largest proportion of patients in this study identify as White (n = 127 patients). Black patients comprised the next largest proportion of patients listed (n =115 patients). There were six patients who identified as Asian, six patients who identified as multiracial, one patient who preferred to not specify, and one patient who listed their race as “other.” This patient population may not be representative of the larger surrounding community and suggests the remainder of the patients not included in this study could be considered lost to follow-up. 

Treatment adherence challenges within the universal HIV/AIDS population include lack of access to transportation and other financial barriers.¹² Reviewing the zip codes of those PWH could potentially identify the barriers preventing proper control of viral load. The most commonly occurring zip codes within this study include 07305, 07087, 07047, and 07310. It is crucial to note the HIV clinic is in the zip code of 07305. Among the patients included in the study, most had controlled viral loads, however, some did not. The patients with highest viral loads were in 07302, 07047, 07305, 07087, and 07002. All of the noted zip codes are considered far from the clinic (more than a 20-minute drive or areas with no access to public transportation) and possibly difficult to access. However, 07305 is within the same area as the clinic, which suggests other factors may influence the uncontrolled viral loads in these patients. 

Discussion. The findings of this study indicate and confirm many previously known risk factors for contracting HIV and progression to AIDS, such as age, race, and gender. However, our study also indicates that, at our site, the previously known risk factor of cis-gendered male is less significant when compared to risk of contraction and progression among transgender women. Our study also indicates that zip code has bearing on medication compliance and follow-up rate due to the proximity of where the patients are being counseled and treated by providers.

Older age is also a risk factor for progression of HIV to AIDS. One study⁸ adjusted for CD4 counts to follow the rate of progression to AIDS, found the relative risk of progression to AIDS any time after seroconversion was 1.45 for each 10-year increase in age (95% CI, 1.15 to 1.85; P = .002). In our study, most of the patients with AIDS fell within the 45 to 64 years of age range (54%), while the patients older than 65 years of age were the next largest group (24%), followed by those between 25 and 44 years of age (21%).

Regarding gender, women have a lower risk of AIDS, undergoing a slower progression of HIV disease and death compared with men.¹³ Women also have lower rates of contracting AIDS-defining illnesses compared with men. These differences in gender and treatment of HIV/AIDS have become more significant recently, particularly as access increases for highly active antiretroviral therapy.¹⁴ According to our study, male gender accounts for significantly more HIV-positive cases than female gender or transgender women. Moreover, male gender is also a known risk factor for progression to AIDS, with 70% of the patients with this diagnosis being cis-gendered male patients (40 out of 57). Female patients comprise 26% of the AIDS diagnoses in this study (15 out of 57). Lastly, transgender women comprise 3.5% of the AIDS diagnoses (2 out of 57). Of note, 40% (2 out of 5) transgender women in our study were diagnosed with AIDS.

Sexual activity is a noted risk factor for contraction of HIV and eventual progression to AIDS.⁶ Our study found that out of the 256 patients who were HIV-positive, 227 knew the mode of transmission to be sexual transmission. A total of 115 of these patients who contracted HIV were heterosexual individuals. The remaining 112 patients identified as MSM or bisexual men. In our study, 50 patients contracted HIV via sexual transmission out of the 57 patients who progressed to CDC-defined AIDS. Out of these 50 patients, 28 were heterosexual individuals and 22 MSM (Figure 3).

Figure 3. Sexual orientation of the patients who contracted HIV via sexual transmission who now are categorized as CDC-defined patients with AIDS. 

This study had several limitations. Patients may underreport their nonadherence to treatment and therefore skew the data making it appear less impactful. There is a possibility the population of this single-site HIV clinic may not represent national statistics on HIV transmission and progression to AIDS; however, it is also likely that the patients identifying as homosexual do not feel comfortable confiding in the practitioner. As our study shows, the largest percentage of PWH are male heterosexual patients, which conflicts with previous statistics and studies. This data could be skewed due to lack of reporting from these patients, or this data may clearly represent the patient population within Hudson County, but it is important to recognize both possibilities. There is a possibility the population of this single-site HIV clinic may not represent national statistics on HIV transmission and progression to AIDS; however, it is also likely that the patients identifying as homosexual do not feel comfortable confiding in the practitioner.

A notable risk factor for contraction of HIV and other sexually transmitted infections is race^.11 Although 49% of the patients in this study identified as White, only 43% of this population were diagnosed with AIDS. Comparatively, Black patients comprised 44% of the study population, but 50.8% of the CDC-defined AIDS group, which was the largest race percentage among the study demographics. Patients who identified as more than one race comprised 2% of the study, and 3.5% of the group with AIDS. Lastly, those who identified as Asian comprised 2.3% of the study, and 1.7% of the group with AIDS. This data is similar to the findings in previous research.^7,11,12           

The single-site HIV clinic is in the zip code of 07305 and the most commonly occurring zip codes of patients were as follows: 07305, 07087, 07047, and 07310. Aside from the zip code where the clinic is located, the other three most common zip codes are not within walking distance, which presented potential transportation barriers. Socioeconomic status varies significantly within each zip code (Figure 4).

Figure 4. Map of zip codes within Hudson County. 

Conclusions. The findings of this study indicate and confirm many previously known risk factors for contracting HIV and progression to AIDS such as age, race, and gender. However, our study also indicates that the previously known risk factor of cis-gendered male is less significant when compared to risk of contraction and progression among women who identify as transgender women. Our study does agree with prior work that shows cis-gendered men as a risk factor, but we found a significant risk among transgender patients, comparatively. The risk among transgender patients is not well-understood, with little evidence suggesting this group has a higher risk than cis-gender patients. In our experience, transgender patients are left out of most discussions about gender and risk factors, which creates barriers to education and screening. This disparity in research only widens the gap in prevention and treatment for these patients. If this is the case, interventions for transgender patients should also be implemented, as these patients are progressing to AIDS at higher rates than cis-gender patients.

Our study also indicates that zip code has bearing on medication compliance and follow-up rates due to the proximity of where the patients are being counseled and treated by providers. Location and transportation are known barriers to medical care.^12,14 Our study agrees with these findings, as zip codes at further distances from the primary HIV clinic had patients with the highest viral loads. 

This study indicates that multidisciplinary obligations to rectifying barriers among high-risk populations are warranted. We suggest providing further education and screening interventions for transgender patients. Physicians and future providers should also have continuing education on HIV within the transgender population. We also suggest more access to transportation modalities for patients who cannot reach their providers; whether due to physical or intellectual disability, barriers to transportation, or financial barriers. A potential solution for financial problems involving access to transportation or transportation expenses could be implementing programs such as Uber Health, which provides free transportation for clinic or hospital appointments affiliated with the company. Furthermore, future studies should actively include transgender PWH to ensure interventions are aimed properly at the needs of this patient population.