Intersectionality-informed analysis of durable viral suppression disparities in people with HIV.

OBJECTIVE: Examine drivers of durable viral suppression (DVS) disparities among people with HIV (PWH) using quantitative intersectional approaches.

DESIGN: Retrospective cohort analysis from electronic health records informed by intersectionality to better capture the concept of interlocking and interacting systems of oppression.

METHODS: We analyzed data of PWH seen at a LGBTQ federally qualified health center in Chicago (2012-2019) with ≥3 viral loads. We identified PWH who achieved DVS using latent trajectory analysis and examined disparities using three intersectional approaches: Adding interactions, latent class analysis (LCA), and qualitative comparative analysis (QCA). Findings were compared to main effects only regression.

RESULTS: Among 5,967 PWH, 90% showed viral trajectories consistent with DVS. Main effects regression showed that substance use (OR: 0.56, 0.46-0.68) and socio-economic status like being unhoused (OR: 0.39, 0.29-0.53), but not sexual orientation or gender identity (SOGI) were associated with DVS.Adding interactions, we found that race and ethnicity modified the association between insurance and DVS (p for interaction <0.05). With LCA, we uncovered four social position categories influenced by SOGI with varying rates of DVS. For example, the transgender women-majority class had worse DVS rates versus the class of mostly non-poor white cisgender gay men (82% vs 95%). QCA showed that combinations, rather than single factors alone, were important for achieving DVS. Combinations vary with marginalized populations (e.g., Black gay/lesbian transgender women) having distinct sufficient combinations compared to historically privileged groups (e.g., white cisgender gay men).

CONCLUSION: Social factors likely interact to produce DVS disparities. Intersectionality-informed analysis uncover nuance that can inform solutions.