Racial Disparities Persist in Retention in Care for HIV

Efforts to end the HIV epidemic in the US face challenges in several parts of the country, notably in making sure that those with HIV adhere to their treatment to prevent further spread. A new study published in AIDS and Behavior¹ found that significant racial disparities still exist in retention in care (RIC) in people living with HIV (PWH) in South Carolina, emphasizing a need to support equitable access to care.

Disparities in retention in care persist in people living with HIV in South Carolina due to various factors | Image credit: Towfiqu Barbhuiya - stock.adobe.com

Reducing the incidence of HIV requires RIC to reduce the transmission of HIV as well as to reduce the risk of progression to AIDS. About 50% of those with HIV in the US are retained in care, and only 57% are virally suppressed,² indicating a significant disparity in care. Racial disparities are a primary reason for this low retention in care, with Black patients at increased risk of poor RIC compared with non-Hispanic White patients. This study aimed to use electronic health records to look at the social and structural factors that contribute to disparity in the state of South Carolina. They also looked to see the differences in the counties of South Carolina when it came to measurements of racial disparities in RIC.

This study used the SC Department of Public Health Enhanced HIV/AIDS Reporting System to collect data for this study. Any individual aged 18 years or older who was diagnosed with HIV between 2013 and 2020 across 46 counties in South Carolina was eligible to be included. RIC was calculated by using individual variables in the registry system to determine whether an individual had 2 or more CD4/viral load tests at least 3 months apart, based on the definition from the CDC. RIC for each county was calculated by measuring the percentage of PWH in the county who had been retained for 1 calendar year; Black-to-White ratio (BWR) was also calculated.

Publicly available datasets were used to collect 24 county-level characteristics that were separated into groups of racial residential segregation, social capital indices, health care resources and health behavior, social vulnerability indices, and other characteristics. The 46 counties were also separated into 4 public health regions.

There were 17,591 PWH who were included in the study, of which 72.2% were men and 75.9% were non-Hispanic Black. The primary mode of HIV transmission was through men who have sex with men (45.2%). There was a median (range) of 100 (14-2344) PWH per county.

The researchers found that the BWR varied from year to year, with the ratio exceeding 1 in some years and dropping below 1 in others. The southern and middle regions had higher racial disparities compared with the other 2 regions when using the index of disparity, whereas the northwest region of South Carolina had higher disparities when measured with the Gini index.

Less social interaction in Black individuals (isolation index: β, –1.92; 95% CI, –3.31 to –0.53), less collective efficacy (β, –1.27; 95% CI, –2.75 to –0.81), stronger family unity (β, 1.75; 95% CI, 0.40-3.13), fewer primary care providers (β, –1.78; 95% CI, –2.75 to –0.81), and fewer income inequalities (Gini index: β, –0.81; 95% CI, –1.5 to –0.08) were more likely to be found in counties with exacerbated racial disparities in RIC when using index of disparity as the outcome. Fewer primary care providers and less social capital were also found when the Gini coefficient was used as an outcome.

There were some limitations to this study. A lack of geographic identification information prevented a more granular spatial analysis from being conducted. Generalizing the findings to other geographic levels should be done with caution, as there is a threat of modifiable areal unit problems. Practices and characteristics of institutions in the areas were not collected. Other racial groups were not accounted for in this study due to the limited number of PWH of other ethnicities in this area.

The researchers concluded that racial disparities still persist for PWH living in South Carolina. They suggested that interventions to better support equitable access to health care could be beneficial to decreasing the disparities in RIC.

“These interventions could include strengthening health care infrastructure in underserved areas and promoting community-level support systems,” they wrote. “In addition, partnering with community leaders, advocacy groups, and PWH themselves will enhance the relevance and sustainability of these interventions, ultimately leading to better RIC…”

References

1. Shi F, Zhang C, Zhang J, et al. Longitudinal patterns and predictors of racial disparities of HIV retention in care: a statewide cohort analysis. AIDS Behav. Published online July 16, 2025. doi:10.1007/s10461-025-04813-9

2. HIV care continuum. HIV.gov. Updated February 26, 2025. Accessed July 16, 2025. https://www.hiv.gov/federal-response/other-topics/hiv-aids-care-continuum