Despite the benefits of engagement in HIV care, a substantial number of black people living with HIV/AIDS (PLWHA) are poorly retained in care in the United States. An individual's race cannot fully explain these observed disparities in retention in HIV care. Social and behavioral determinants of health including an individual's actions, social/physical environment, and access to health services are also modifiable contributors. However, studies on the combined impact of individual-, community-, infrastructure/health system-, and structural-level social and behavioral determinants of health on retention in HIV care, with specific attention to race, are lacking.
The aims of this study are: 1) To develop and validate a predictive model which will include race as well as social and behavioral determinants of heath from multiple levels (individual-, community-, infrastructure/health system-, and structural-level) and; 2) To identify modifiable individual-level patient-reported outcomes (i.e. mental health, alcohol and substance use, quality of life, symptom burden) which partially or fully mediate the relationship between black race and missed visits, after accounting for less easily modifiable, community-and structural-level confounders. These results will inform the design of an intervention package aimed to reduce missed HIV healthcare provider visits for black patients, a population disproportionately affected by poor HIV health-related outcomes. Additionally, they will provide a predictive model that will allow point-of-care ascertainment of risk of missing visits in order to target this intervention package toward black patients most likely to benefit. This research team is uniquely positioned to complete the work proposed in this application. The principal investigator, Dr. Pettit has significant experience in conducting epidemiologic studies of HIV outcomes in large multi-cohort collaborations. Dr. Mugavero, a co-investigator on this proposal, brings content expertise in retention in HIV care and experience conducting studies of HIV outcomes within the CFAR Network of Integrated Clinical Systems (CNICS). Drs. Shepherd, Rebeiro, and Turan, also co-investigators on this proposal, bring complimentary skills in biostatistics and epidemiology as well as behavioral science and psychometrics required to carry out the analytic plan. Other resources available to the research team include Vanderbilt's Clinical and Translational Science Award, the Tennessee and University of Alabama Centers for AIDS Research, and the CFAR Network of Integrated Clinical Systems (CNICS) Core services. The proposed studies will provide important insights into the contribution of factors from multiple levels on missed HIV healthcare provider visits among black PLWHA in the United States. Moreover, these findings will inform the design and evaluation of a future intervention or support package aimed at modifiable social and behavioral determinants of health in order to improve health outcomes and reduce racial disparities for HIV- infected persons.

Public Health Relevance

/Public Health Relevance Social and behavioral determinants of health are known to contribute to poorer retention in HIV care and increased HIV-related mortality among black patients in the United States. Our understanding of these determinants from multiple levels (individual, community, infrastructure/health system, and structural levels) and their influence on racial disparities in missing HIV healthcare provider visits is incomplete. Further characterization of the association of social and behavioral determinants of health from multiple levels with retention in HIV care among blacks is critical for the development and evaluation of intervention support packages aimed to decrease the number of missed clinic visits and mortality in this population.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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AIDS Clinical Studies and Epidemiology Study Section (ACE)
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Greenwood, Gregory
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Vanderbilt University Medical Center
United States
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