Investigating structural inequities in area-level socioeconomic and health care access measures among people with HIV and cancer (2004–2020)

Abstract

Background

People with HIV (PWH) are less likely to receive cancer treatment compared to those without HIV. The objective of this study was to evaluate the role of area-level social determinants of health (SDoH) in cancer treatment receipt among PWH and cancer in the United States.

Methods

The authors used the National Cancer Database (NCDB; 2004–2020) and included adult patients (18–89 years) with HIV, identified via International Classification of Diseases (ICD)-9 and ICD-10 codes. We focused on the 14 most common cancers common among PWH. The primary outcome was receipt of first-line curative cancer treatment as documented by NCDB. Key SDoH exposures were area-level educational attainment (percent of adults without a high school degree) and income (median income quartiles) by zip code. Hierarchical multivariable logistic regression models, clustered by cancer treatment facility, were used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

Results

The authors included 31,549 people with HIV and cancer, 16.5% of whom did not receive first-line curative cancer treatment. Overall, 43% were ≥60 years old, 38% were non-Hispanic Black, 68% were male, and 39% resided in the Southern United States. The most common cancers were lung (21%), diffuse large B-cell lymphoma or DLBCL (12%), colorectal (9%), and prostate (9%). PWH living in areas of lowest educational attainment (quartile [Q]4 vs. Q1: aOR, 0.73; 95% CI, 0.66–0.82) and lowest-income (Q4 vs. Q1: aOR, 0.73; 95% CI, 0.65–0.81) areas were less likely to receive cancer treatment, after adjusting for age, sex, stage, year, and cancer type.

Conclusion

Area-level SDoH are associated with cancer treatment receipt among PWH, suggesting structural factors may impact this long-standing observed inequity.