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As 2020 draws to a close, we asked David Alain Wohl, M.D., a professor of medicine in the Division of Infectious Diseases at the University of North Carolina and a highly respected HIV clinician-researcher, to take stock of the year's most momentous research developments and other critical events. In this exclusive series of articles, Wohl calls attention to 10 such developments that have tremendous short-term implications for our day-to-day efforts to improve HIV prevention, treatment, patient care, and policy in the U.S., and analyzes each development with his trademark wit and clinical savvy.

Black women in the U.S. are three times more likely to die during pregnancy than white women, and maternal mortality for HIV-positive women is approximately five times greater than it is for HIV-negative women. While HIV infection itself may contribute to adverse pregnancy outcomes, a team of academic and public health investigators in Philadelphia sought to identify structural and contextual factors that could also influence the well-being of pregnant women living with HIV infection in that city.

With the Social Ecological Model as a roadmap, the team used various publicly available data sources to look at individual (age, substance use, prenatal HIV diagnosis), interpersonal (support, disclosure, intimate partner violence), neighborhood (education level, crime, poverty, social capital), and societal (socioeconomic advancement, sexual and reproductive health) factors that they hypothesized could impact HIV viral suppression among pregnant women.

From 2005 to 2015, there were 905 recorded births among 684 HIV-positive women (82% of whom were Black). At the time of delivery, 41% had a detectable plasma HIV RNA level, but this fell from 58% in the first half of the study period to 23% in the second half. Among the host of factors that were explored as potentially being associated with a detectable viral load at delivery, neighborhood education attainment and crime levels were the most significant.

Specifically, education attainment (as measured by whether at least 10% of adults age 25 or older had a bachelor’s degree) was associated with lower odds of having an elevated viral load (adjusted odds ratio [AOR] was 0.70; 95% confidence interval [CI] was 0.50-0.96). Similarly, the presence of more neighborhood violent crime (AOR 1.51; 95% CI, 1.10-2.07), prostitution crime (AOR 1.46; 95% CI, 1.06-2.00), and a composite measure of crime (AOR 1.44; 95% CI, 1.05-1.98) were all positively associated with having a higher HIV viral load. Poverty was not associated with lack of viral suppression, but inadequate prenatal care was.

The Bottom Line on Hyperlocal Variables Affecting HIV Viral Load in Pregnancy

A reasonably understandable initial response to this important study could be “WTF”—a reaction that appropriately mixes the sadness, anger, and sense of injustice that these findings evoke. But the forces that conspire to harm people of color and people living in poverty are persistent and intransigent. The investigators carefully isolated and identified such forces, depicting how they impact the well-being of women and their children.

The finding that poverty itself was not independently associated with viremia at delivery is notable. It very much suggests that the services provided to people living with HIV—especially programs funded through the Ryan White CARE Act—are effective at mitigating the adverse effects of extreme poverty on HIV health. In other diseases without such federal intervention, the link between poverty and adverse outcomes is strong.

In contrast, there are other challenges not being addressed that are harder to reckon with or abide. The exact mechanism by which low education attainment and high levels of crime influence viral load during late pregnancy are not clear. However, one can imagine that in places where few people have the benefits of educational opportunities or freedom from the threat of crime, self-care is difficult to prioritize.

It is challenging not to read this paper through the lens of COVID-19. During these past months, we have seen colossal investments made in response to this international health crisis. In the U.S., that response has been swift and largely uncontested—but although billions are being spent, much of it going toward speculative bets on multiple vaccines and therapeutics.

Can we imagine what the potential benefits would have been if we had made similar investments to create and foster healthy environments?

There are no shortages of good ideas about how to help people in our cities, suburbs, and rural regions receive health care, quality education, and employment that is sustainable. What we were short on, we have been told, was money. But with COVID-19, we see that money—a lot of money—can be printed and spent when there is a sense of urgency and will.

In Philadelphia—the same city where an effort was made to disenfranchise thousands, most of whom were people of color, from voting for their elected officials—we see that this lack of investment is clearly a form of racism that costs us not only the many dividends of health, but even the best chance to keep a baby from becoming infected with HIV.

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