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Abstract
Socioeconomic status has a robust positive relationship with several health outcomes at the individual and population levels, but in the case of HIV prevalence, income inequality may be a better predictor than absolute level of income. Most studies showing a relationship between income inequality and HIV have used entire countries as the unit of analysis. In this study, we examine the association between income inequality at the community level and HIV prevalence in a sample of persons who inject drugs (PWID) in a concentrated epidemic setting. We recruited PWID and non-PWID community participants in Thai Nguyen, Vietnam, and administered a cross-sectional questionnaire; PWID were tested for HIV. We used ecologic regression to model HIV burden in our PWID study population on GINI indices of inequality calculated from total reported incomes of non-PWID community members in each commune. We also modeled HIV burden on interaction terms between GINI index and median commune income, and finally used a multi-level model to control for community level inequality and individual level income. HIV burden among PWID was significantly correlated with the commune GINI coefficient (r = 0.53, p = 0.002). HIV burden was also associated with GINI coefficient (β = 0.082, p = 0.008) and with median commune income (β = −0.018, p = 0.023) in ecological regression. In the multi-level model, higher GINI coefficient at the community level was associated with higher odds of individual HIV infection in PWID (OR = 1.46 per 0.01, p = 0.003) while higher personal income was associated with reduced odds of infection (OR = 0.98 per $10, p = 0.022). This study demonstrates a context where income inequality is associated with HIV prevalence at the community level in a concentrated epidemic. It further suggests that community level socioeconomic factors, both contextual and compositional, could be indirect determinants of HIV infection in PWID.
Highlights
The ecologic relationship between health and wealth has been well characterized in the global development field [1]
We present one of the few analyses demonstrating the association between income inequality and HIV prevalence at a community level of aggregation, where the social determinants of health are primarily believed to operate [30]
The positive relationship between HIV prevalence and income inequality has been shown in a number of other studies in which the country was the unit of aggregation [13,14,16,18,19,31]
Summary
The ecologic relationship between health and wealth has been well characterized in the global development field [1]. Societies with higher wealth may have better living, working and housing conditions, have less stress, and are able to purchase better health care. The potential relationship between health and absolute wealth has been shown for various outcomes and populations [4,5,6]. In the US, at the state level, income inequality has been shown to be associated with poorer self assessed health and higher mortality [7,8], as well as Chlamydia and AIDS case rates [9]. Wilkinson [10,11,12] has argued that relative wealth is more important for mortality and premature mortality than absolute wealth, especially in developed OECD countries
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