Of the 37.6 million people living with HIV (PLWH) globally in 2020, 84% knew their status; 73% were accessing treatment, and 66% were virally suppressed1. These numbers were far below the UNAIDS 90-90-90 target, where the goal was to have 90% of PLWH becoming aware of their status, of those 90% on treatment, of those on treatment 90% achieving viral suppression by 2020. AIDS-related deaths have decreased since the introduction of antiretroviral therapies (ART), in fact deaths have reduced by 61% since the peak in 20041. ART stops HIV from multiplying and reduces the amount of HIV (viral load) in the blood to such low levels that tests often cannot detect them in a milliliter of blood, which is described as viral suppression. Having an undetectable HIV viral load translates to person being unable to transmit the virus to others (U = U means undetectable equals un-transmittable), and this follows 20 years of evidence2–7. However, without a considerable proportion of the population living with HIV initiating ART, taking ART consistently as prescribed and achieving viral suppression, the impact of ART will not reach its potential in treating and preventing HIV8.
Neighborhood Characteristics and Conceptual Model
HIV prevention and treatment research have mostly focused on individual risk behaviors such as sexual behaviors, substance use, and healthcare seeking behaviors9–11. Intervening on these factors has only been effective to a certain extent due to limited inclusion of community level factors that influence the sustainability of individual behaviors9–11. Community level factors influence an individual’s risk behavior by modifying norms, attitudes, values, and context of risk behaviors within a defined community11. The socioecological model (SEM) postulates that an individual’s health is influenced by interactions with their physical and sociocultural environments12. The central concept of an ecological model is that behavior has multiple levels of influences: intrapersonal (biological, psychological), interpersonal (social, cultural), institutional or organizational factors, community, and policy12. The environmental component (institutional or organizational factors, community, and policy) of the ecological model is what distinguishes this model from other behavioral models12. In this review, we will focus on community level influences on health that consider factors such as formal or informal social norms that exist among individuals, groups, or organizations, that can limit or enhance healthy behaviors13. The conceptual model for this review (Fig. 1) is based on the interconnected five-level socioecological model described above that assesses how an individual’s access and utilization of HIV treatment and care is influenced by interactions with their physical and sociocultural environments14–16. The intrapersonal level focuses on the demographic, biological, knowledge, attitudes, and practices. The interpersonal level focuses on the influence of family and social networks on access and utilization of HIV treatment and care. The organizational or institutional level focuses on the organization’s (e.g., healthcare facilities) culture, policies, capacity, resources, physical and social environmental influences on access and utilization of HIV treatment and care. At the policy level, the focus is on the content and implementation of policies that promote access and utilization of HIV treatment and care. In Fig. 1, we illustrate the conceptual model for this review, where we highlight our focus on the culture; resources; capacity; and the social and physical environment of a community that influence access and utilization of HIV treatment and care. All the levels in the conceptual model are important in having sustained access and support for HIV treatment and care13–15.
The community level explores settings, such as neighborhoods, schools, and workplaces, in which social relationships occur, and seeks to identify the characteristics of these settings that are associated with health17. We will particularly concentrate on neighborhood characteristics. A neighborhood is described as an area where individuals live and interact with each other, where residents typically have similar incomes and social characteristics such as education level, housing preference, sense of public order etc.18 A neighborhood’s physical and social characteristics have been known to impact health19. Physical characteristics refer to the quality of physical structures such as buildings and streets in a neighborhood. Social characteristics refer to the quality of social structures such as employment, education, income, social order etc. Collectively, these physical and social characteristics are typically a way in which a neighborhood’s socioeconomic status (SES) is defined. Neighborhood SES provides an overall marker of neighborhood conditions that may shape access to care independent of individual characteristics20. People living with HIV with low SES are more likely to have poorer treatment outcomes21. Related to SES, neighborhood disadvantage is also a term used to describe a neighborhood where the percentage of households below the poverty-line are greater than a critical prevalence22. Likewise, neighborhood disadvantage reduces the likelihood of having a standard source of care and of acquiring services, while it increases the likelihood of having unmet medical needs as reduced resources encourage trade-offs between basic needs and health care23. Neighborhood deprivation is also another term used to describe a neighborhood that refers to the relatively low physical (e.g. abandoned home, graffiti, etc.), social (e.g. loitering, unemployment, etc.) and economical position (ex. education, income etc.) of a neighborhood24, which has been linked to risky health behavior25 and poorer well-being26. Higher prevalence of educated residents within neighborhoods may be demonstrating higher levels of human capital that, collectively encourage health-promoting attitudes and behaviors within the neighborhood27. In looking at specific health literacy, community level HIV/AIDS knowledge is positively associated with ART adherence as it can decrease misconceptions and increase support for PLWH28,29. Another similar term is neighborhood disorder, which refers to observed or perceived physical (e.g. trash, vandalism etc.) and social (e.g. over policing, homelessness, etc.) features of neighborhoods that may signal the breakdown of order and social control that can undermine the quality of life30. Individuals living in situations of constant disorder, the physical signs serve as visible reminders of a dissatisfying living environment31. Constant disorder also further heightens feelings of entrapment and fear among those in economic or social situations that may not allow residential mobility32. Through these pathways, neighborhood disorder can contribute to psychological distress33–35. Physiological distress on the other hand has been associated with late ART initiation and ART non-adherence36–38, therefore the physiological distress brought on by living in a disordered neighborhood may lead to poorer HIV treatment outcomes. Generally neighborhood characteristics such as depravation, disadvantage and disorder have been theorized to lead to negative health outcomes influenced by chronic stress and associated maladaptive physiological responses that encourage risky health behavior, and disintegrating social interactions among residents19,39,40.
Why it is important to conduct the review
Understanding and intervening at the community level of influence in HIV research not only has a broad reach of impact, but is also cost effective11. Evidence suggests that community level socio-economic status (SES), physical and social structures have an impact on HIV prevention and treatment outcomes31,41,42. These community level factors then influence individual behavior by enhancing or limiting access and utilization of HIV care31,41,42 essential for ART initiation, ART adherence and achieving HIV viral suppression. A review that specifically looked at community level impacts on HIV treatment among pregnant women found that social stigma was a major barrier to seeking and accessing care41. Health system use, access to services, and health worker attitudes functioned as barriers or enablers to HIV care depending on various situations41. Majority of the current reviews have combined their findings on the community level impacts on HIV treatment with HIV risk behaviors31,42−44 and reproductive health45, making it difficult to disaggregate its impact on HIV treatment outcomes alone. Additionally, current reviews focused more on community structural characteristics than social characteristics (social cohesion, social capital, social disorder, collective efficacy etc.)45, others focused on specific groups (adolescents45, men who have sex with men46, pregnant women43), and describing methodological approaches to assessing community level factors31. Furthermore, community level factors were defined and measured31 in various ways using geographical boundaries (zip codes, census tracts or blocks)42,44,45, or defined by demographic characteristics of the community. In this review we expand the scope of community level factors to not only assess geographical boundaries, but social and physical neighborhood characteristics. The objective the scoping review is: (i) to examine the extent, range, and nature of research activity on the associations between neighborhood characteristics and HIV treatment outcomes among adults; (ii) to provide a synthesis of findings inclusive of assessment methods used; and (iii) identify research gaps.