AIDS and Behavior

, Volume 22, Issue 9, pp 3009–3023 | Cite as

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

  • A. S. Terzian
  • N. Younes
  • A. E. Greenberg
  • J. Opoku
  • J. Hubbard
  • L. P. Happ
  • P. Kumar
  • R. R. Jones
  • A. D. Castel
  • the DC Cohort Executive Committee
Original Paper


Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.


Distance Spatial patterns Retention Viral suppression Care continuum 



This work was supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health under Grant UO1 AI69503-03S2. Data in this manuscript were collected by the DC Cohort investigators and research staff located at: Cerner Corporation (Jeffrey Binkley, Cheryl Akridge, Thila Subramanian, Qingjiang Hou, Stacey Purinton, Nabil Rayeed, Rob Taylor and Kate Shelton); Children’s National Medical Center Adolescent (Lawrence D’Angelo) and Pediatric (Natella Rakhmanina) clinics; The Senior Deputy Director of the DC Department of Health HAHSTA (Michael Kharfen); Family and Medical Counseling Service (Michael Serlin); Georgetown University (Princy Kumar); George Washington Medical Faculty Associates (David Parenti); George Washington University Department of Epidemiology and Biostatistics (James Peterson, Lindsey Powers Happ, Maria Jaurretche, Brittany Wilbourn, and Kevin Trac); Howard University (Ronald Wilcox); La Clinica Del Pueblo (Ricardo Fernandez); MetroHealth (Annick Hebou); National Institutes of Health (Carl Dieffenbach and Henry Masur); Unity Health Care (Gebeyehu Teferi); Veterans Affairs Medical Center (Debra Benator); Washington Hospital Center (Maria Elena Ruiz); Whitman-Walker Health (David Hardy, Deborah Goldstein); Kaiser Permanente (Michael Horberg). We would also like to acknowledge the Research Assistants at all of the participating sites, the DC Cohort Community Advisory Board and the DC Cohort participants.


This work was funded by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (UO1 AI69503-03S2).

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Shacham E, Estlund AL, Tanner AE, et al. Challenges to HIV management among youth engaged in HIV care. AIDS Care. 2017;29(2):189–96.CrossRefPubMedGoogle Scholar
  2. 2.
    Dailey AF, Johnson AS, Wu B. HIV care outcomes among Blacks with diagnosed HIV - United States, 2014. MMWR Morb Mortal Wkly Rep. 2017;66(4):97–103. Scholar
  3. 3.
    Castel AD, Kalmin M, Hart R, et al. Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care - Washington. DC AIDS Care. 2016. Scholar
  4. 4.
    Wolitski RJ, Kidder DP, Pals SL, Housing and Health Study Team, et al. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav. 2010;14(3):493–503. Scholar
  5. 5.
    Ransome Y, Kawachi I, Braunstein S, et al. Structural inequalities drive late HIV diagnosis: the role of black racial concentration, income inequality, socioeconomic deprivation, and HIV testing. Health Place. 2016;42:148–58. Scholar
  6. 6.
    Eberhart MG, Voytek CD, Hillier A, et al. Travel distance to HIV medical care: a geographic analysis of weighted survey data from the Medical Monitoring Project in Philadelphia, PA. AIDS Behav. 2014;18(4):776–82. Scholar
  7. 7.
    Scribner RA, Simonsen NR, Leonardi C. The social determinants of health core: taking a place-based approach. Am J Prev Med. 2017;52(1S1):S13–9. Scholar
  8. 8.
    Hanna DB, Hessol NA, Golub ET, et al. Increase in single-tablet regimen use and associated improvements in adherence-related outcomes in HIV-infected women. J Acquir Immune Defic Syndr. 2014;65(5):587–96. Scholar
  9. 9.
    McFall AM, Dowdy DW, Zelaya CE, Women’s Interagency HIV Study, et al. Study. Understanding the disparity: predictors of virologic failure in women using highly active antiretroviral therapy vary by race and/or ethnicity. J Acquir Immune Defic Syndr. 2013;64(3):289–98. Scholar
  10. 10.
    An Q, Prejean J, McDavid Harrison K, et al. Association between community socioeconomic position and HIV diagnosis rate among adults and adolescents in the Unites States, 2005 to 2009. Am J Public Health. 2013;103(1):120–6. Scholar
  11. 11.
    Eberhart MG, Yehia BR, Hillier A, et al. Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression. J Acquir Immune Defic Syndr. 2015;69 Suppl 1:S37–43. Scholar
  12. 12.
    Eberhart MG, Yehia BR, Hillier A, et al. Behind the cascade: analyzing spatial patterns along the HIV care continuum. J Acquir Immune Defic Syndr. 2013;64 Suppl 1:S42–51. Scholar
  13. 13.
    Ransome Y, Kawachi I, Dean LT. Neighborhood social capital in relation to late HIV diagnosis, linkage to HIV care, and HIV care engagement. AIDS Behav. 2017;21(3):891–904. Scholar
  14. 14.
    Terzian AS, Irvine M, Laura M, et al. Effect of HIV housing services on engagement in care and treatment, New York City, 2011. AIDS Behav. 2015. Scholar
  15. 15.
    Castel AD, Befus M, Willis S, et al. Use of the community viral load as a population-based biomarker of HIV burden. AIDS. 2012;26(3):345–53. Scholar
  16. 16.
    Goswami ND, Schmitz MM, Sanchez T, et al. Understanding local spatial variation along the care continuum: The potential impact of transportation vulnerability on HIV linkage to care and viral suppression in high-poverty areas, Atlanta, GA. J Acquir Immune Defic Syndr. 2015. Scholar
  17. 17.
    Sheehan DM, Fennie KP, Mauck DE, et al. Retention in HIV care and viral suppression: individual- and neighborhood-level predictors of racial/ethnic differences, Florida, 2015. AIDS Patient Care STDS. 2017;31(4):167–75. Scholar
  18. 18.
    Ruiz MS, O’Rourke A, Allen ST. Impact evaluation of a policy intervention for HIV prevention in Washington, DC. AIDS Behav. 2016;20:22. Scholar
  19. 19.
    Division of HIV/AIDS Prevention. HIV/AIDS policy and law. Atlanta, Georgia: Centers for Disease Control and Prevention, 2016. Accessed 10 May 2017.
  20. 20.
    Blevins M, Wehbe FH, Rebeiro PF, et al. The Caribbean, Central, South America Network for HIV Epidemiology (CCASAnet). Interactive data visualization for HIV cohorts: leveraging data exchange standards to share and reuse research tools. PLoS ONE. 2016;11(3):e0151201. Scholar
  21. 21.
    Scribner RA, Johnson SA, Cohen DA, et al. Geospatial methods for identification of core groups for HIV/AIDS. Sub Use Misuse. 2008;43(2):203–21. Scholar
  22. 22.
    AIDSVu. Emory University, Rollins School of Public Health. Available at Accessed 24 Feb 2016.
  23. 23.
    Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol. 2001;30:668–77.CrossRefPubMedGoogle Scholar
  24. 24.
    Cook PA, Downing J, Wheater CP, et al. Influence of socio-demographic factors on distances travelled to access HIV services: enhanced surveillance of HIV patients in north west England. BMC Public Health. 2009;12(9):92. Scholar
  25. 25.
    Cope AB, Powers KA, Serre ML, et al. Distance to testing sites and its association with timing of HIV diagnosis. AIDS Care. 2016;28(11):1423–7. Scholar
  26. 26.
    Akullian AN, Mukose A, Levine GA, et al. People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda. J Int AIDS Soc. 2016;19(1):20171. Scholar
  27. 27.
    Magnus M, Herwehe J, Murtaza-Rossini M, et al. Linking and retaining HIV patients in care: the importance of provider attitudes and behaviors. AIDS Patient Care STDS. 2013;27(5):297–303. Scholar
  28. 28.
    Greenberg AE, Hader SL, Masur H, et al. Fighting HIV/AIDS in Washington, D.C. Health Aff. 2009;28(6):1677–87. Scholar
  29. 29.
    Brian McKenzie. 2015. “Transit Access and Population Change: The Demographic Profiles of Rail Accessible Neighborhoods in the Washington, DC Area.” SEHSD Working Paper No. 2015-023. U.S. Census Bureau. Washington, DC. Accessed 8 May 2017.
  30. 30.
    Kaiser Family Foundation (KFF). HIV/AIDS Policy Fact Sheet: The HIV/AIDS Epidemic in Washington, D.C. (2012). Available at Accessed May 10, 2017.
  31. 31.
    Greenberg AE, Hays H, Castel AD, et al. Development of a large urban longitudinal HIV clinical cohort using a web-based platform to merge electronically and manually abstracted data from disparate medical record systems: technical challenges and innovative solutions. J Am Med Inform Assoc. 2016;23(3):635–43. Scholar
  32. 32.
    Castel AD, Terzian AS, Opoku J, et al. Linking clinical cohort and surveillance data to define care patterns and outcomes among persons living with HIV in Washington, DC. Linkage of Clinical Cohort and Surveillance Data. JMIR Public Health Surveill. 2018;4(1):e23. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Valdiserri RO, Forsyth AD, Yakovchenko V, et al. Measuring what matters: the development of standard HIV core indicators across the US Department of Health and Human Services. Public Health Rep. 2013;128:354–9 PMID: 23997280.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    DC GIS Program. DC GIS Master Address Repository. Office of Chief Technology Officer (OCTO). Accessed 20 Apr 2017.
  35. 35.
    US Census Bureau. US Census Bureau 2010. ZCTA shapefiles (tl_2010_state_zcta510.shp). Accessed 1 Dec 2016.
  36. 36.
    ZIP Code FAQs. Accessed 21 Nov 2016.
  37. 37.
    ZIP Code Tabulation Areas. Accessed 28 Sept 2017.
  38. 38.
    Erickson SR, Lin YN. Geospatial analysis of statin adherence using pharmacy claims data in the state of Michigan. J Manag Care Spec Pharm. 2014;20(12):1208–15. Scholar
  39. 39.
    Cohen SM, Hu X, Sweeney P, et al. HIV viral suppression among persons with varying levels of engagement in HIV medical care, 19 US jurisdictions. J Acquir Immune Defic Syndr. 2014;67(5):519–27. Scholar
  40. 40.
    Althoff KN, Rebeiro P, Brooks JT, et al. Disparities in the quality of HIV care when using US Department of Health and Human Services Indicators. Clin Infect Dis. 2014;58(8):1185–9. Scholar
  41. 41.
    Rebeiro PF, Althoff KN, Lau B, et al. Laboratory measures as proxies for primary care encounters: implications for quantifying clinical retention among HIV-infected adults in North America. Am J Epidemiol. 2015;182(11):952–60. Epub 2015 Nov 17.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Rebeiro PF, Gange SJ, Horberg MA, et al. Geographic variations in retention in care among HIV-infected adults in the United States. PLoS ONE. 2016;11(1):e0146119. Scholar
  43. 43.
    Burchell AN, Gardner S, Ligh L, et al. Implementation and operational research: engagement in HIV care among persons enrolled in a clinical HIV cohort in Ontario, Canada, 2001–2011. J Acquir Immune Defic Syndr. 2015;70(1):e10–9. Scholar
  44. 44.
    Yehia BR, Stephens-Shields AJ, Fleishman JA, et al. The HIV care continuum: changes over time in retention in care and viral suppression. PLoS ONE. 2015;10(6):e0129376. Scholar
  45. 45.
    Hall HI, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med. 2013;173(14):1337–44. Scholar
  46. 46.
    Xia Q, Braunstein SL, Wiewel EW, et al. Persons living with HIV in the United States: fewer than we thought. J Acquir Immune Defic Syndr. 2016. Scholar
  47. 47.
    Greer GA, Tamhane A, Malhotra R, et al. Achieving core indicators for HIV clinical care among new patients at an urban HIV clinic. AIDS Patient Care STDS. 2015;29(9):474–80. Scholar
  48. 48.
    Korthuis PT, McGinnis KA, Kraemer KL, Gordon AJ, Skanderson M, Justice AC, et al. Veterans aging cohort study. Quality of HIV care and mortality rates in HIV-infected patients. Clin Infect Dis. 2016;62(2):233–9. Scholar
  49. 49.
    Engelhard E, Smit C, Nieuwkerk PT, Reiss P, Kroon FP, Brinkman K, Geerlings SE. Structure and quality of outpatient care for people living with an HIV infection. AIDS Care. 2016;28(8):1062–72. Scholar
  50. 50.
    Horberg MA. HIV quality measures and outcomes: the next phase. Clin Infect Dis. 2016;62(2):240–1.CrossRefPubMedGoogle Scholar
  51. 51.
    Jia Y, Sengupta D, Opoku J, Wu C, Griffin A, West T, et al. Site migration in seeking care services from multiple providers is associated with worse clinical outcomes among HIV-infected individuals in Washington, DC. AIDS Care. 2014;26(11):1346–51. Scholar
  52. 52.
    Amstislavski P, Matthews A, Sheffield S, et al. Impact of age on retention in care and viral suppression. J Acquir Immune Defic Syndr. 2015;68(4):413–9. Scholar
  53. 53.
    Ransome Y, Dean LT, Crawford ND, Metzger DS, Blank MB, Nunn AS. How do social capital and HIV/AIDS outcomes geographically cluster and which sociocontextual mechanisms predict differences across clusters? J AIDS. 2017;76(1):13–22.Google Scholar
  54. 54.
    District of Columbia Department of Health HIV/AIDS, Hepatitis, STD and TB Administration. 2017–2021 District of Columbia Eligible Metropolitan Area Integrated HIV/AIDS Prevention and Care Plan, 2017. Accessed 29 Jan 2018.
  55. 55.
    The District Department of Transportation, The District Mobility Project. 2017 (Washington, DC: 2017). Accessed 17 Oct 2017.
  56. 56.
    Rowlands, Daniel Walter. “See how long it takes to get from each metro station to the downtown core.” Greater Washington, 30 Jan. 2017, Accessed 17 Oct 2017.
  57. 57.
    Dunn, Peter. “Time Scale System Map.” Stonebrown Design. Accessed 17 Oct 2017.
  58. 58.
    Washington Metropolitan Area Transit Authority (WMATA). Available at Accessed 1 Dec 2016.
  59. 59.
    Zippel, Claire. “DC’s Black Residents Increasingly Live East of the Anacostia River.” DC Financial Policy Institute. September 28, 2016. Accessed 17 Oct 2017.
  60. 60.
    Itkowitz, Colby. “Poor, sick and still traveling long distances for health care in D.C. The Washington Post. 19 September 2017. Accessed 18 Oct 2017.
  61. 61.
    Bliss RL, Katz JN, Wright EA, et al. Estimating proximity to care: are straight line and zipcode centroid distances acceptable proxy measures? Med Care. 2012;50(1):99–106. Scholar
  62. 62.
    Shahid R, Bertazzon S, Knudtson ML, Ghali WA. Comparison of distance measures in spatial analytical modeling for health service planning. BMC Health Serv Res. 2009;9:200. Scholar
  63. 63.
    Krieger N, Chen JT, Waterman PD, Soobader MJ, Subramanian SV, Carson R. Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter?: the Public Health Disparities Geocoding Project. Am J Epidemiol. 2002;156(5):471–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Epidemiology and BiostatisticsMilken Institute School of Public Health, The George Washington UniversityWashingtonUSA
  2. 2.District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD, and TB AdministrationWashingtonUSA
  3. 3.School of MedicineGeorgetown UniversityWashingtonUSA
  4. 4.Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology & GeneticsNational Cancer Institute, National Institutes of HealthBethesdaUSA

Personalised recommendations