Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Diana M. Sheehan

First Advisor's Committee Title

Committee Chair

Second Advisor's Name

Mary Jo Trepka

Second Advisor's Committee Title

Committee member

Third Advisor's Name

Tan Li

Third Advisor's Committee Title

Committee member

Fourth Advisor's Name

Stephen F. Pires

Fourth Advisor's Committee Title

Commitee member


sustained viral suppression, HIV/AIDS, neighborhood factors, racial/ethnic disparities, geographic disparities, hotspots/cold spots, travel distance

Date of Defense



Sustained viral suppression (all viral load tests/mL in a year) decreases the risk of HIV transmission and disease progression to AIDS for people with HIV. Racial/ethnic minorities living with HIV are particularly challenged by barriers, including neighborhood factors, to maintain viral suppression. This dissertation examined the contribution of neighborhood and geographic factors on racial/ethnic disparities in achieving sustained viral suppression. A cross-sectional analysis of secondary data collected in 2017 for 6491 clients enrolled in the Miami-Dade County Ryan White Program (RWP) was conducted.

The first study examined the moderating role of neighborhood level factors on the association between race/ethnicity and sustained viral suppression for 6491 RWP clients. Using multilevel logistic regression models, we observed that non-Hispanic Blacks (NHB) had lower odds of sustained viral suppression compared to non-Hispanic Whites (NHW) in low socioeconomic disadvantage (adjusted odds ratio [aOR]: 0.39; 95% confidence interval [CI]: 0.20-0.74), moderate residential instability (aOR: 0.31; CI: 0.15-0.65), and low (aOR: 0.38; CI: 0.16-0.88) and high (aOR: 0.38; CI: 0.19-0.75) racial/language homogeneity neighborhoods. Moreover, Haitians also had poor sustained viral suppression in moderate residential instability (aOR: 0.42; CI: 0.18-0.97) and high racial/language homogeneity (aOR: 0.49; CI: 0.26-0.93) neighborhoods, when compared to NHW.

The second study examined individual and neighborhood level factors that are associated with residing in geographic hotspots of poor sustained viral suppression. Using spatial autocorrelation tools, we identified 10 hotspots of poor sustained viral suppression. Using multivariate logistic regression models, we identified race/ethnicity, age, poverty, and neighborhood-level characteristics were significantly associated with residing in hotspots of poor sustained viral suppression.

The third study examined the moderating effect of travel distance and transportation needs to Medical Case Management (MCM) sites and AIDS Drug Assistance Program (ADAP) pharmacies on the association between race/ethnicity and sustained viral suppression. We observed that racial/ethnic minorities had poor sustained viral suppression compared to NHW among clients without access to transportation and other travel distance related variables (travel distance to the nearest facility of care, median travel distances to clients MCM site of choice, and median travel distance to nearest ADAP pharmacy).

In conclusion, racial/ethnic difference in achieving sustained viral suppression were observed within different neighborhood characteristics and geographic locations across Miami-Dade County. Sustained viral suppression supports the “(U=U) Undetectable=Untransmittable” concept that emphasizes the importance of consistent viral suppression to help end the HIV epidemic. Targeted place-based interventions within specific geographic locations and among racial/ethnic minorities should be implemented within Miami-Dade County to minimize the observed disparities.





Included in

Epidemiology Commons



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