Poverty and AIDS

Public health experts have long known that black Americans infected with HIV die sooner on average than non-Hispanic white Americans. Many experts suspected this was because black HIV patients are more likely to be poor.

But incredibly, no one knows for sure.

“It seems kind of obvious, but the research hasn’t been done yet,” says FIU associate professor Mary Jo Trepka.

So now Trepka, on the faculty in the Department of Epidemiology in the Robert Stempel College of Public Health & Social Work, is conducting a five-year, $1.35 million study funded by the National Institutes of Health to prove whether the hypothesis is true. She is studying all 66,000 Floridians diagnosed with AIDS between 1993 and 2004. ZIP code by ZIP code, she is correlating each patient with measures of socioeconomic status for their area. (Personally identifying information was removed to preserve patient confidentiality.)

Some researchers have worked with data at the county level, but that is less reliable because factors like income and education can vary widely within a county but tend to be more uniform within a ZIP code.

“It’s a unique methodology that she developed,” says collaborator Spencer Lieb, HIV/AIDS research coordinator for The AIDS Institute and the Florida Consortium for HIV/AIDS Research. “I think it’s important research, and it’s going to have an impact. The important thing is we’re documenting what’s anecdotally thought to be known.”

If Trepka’s statistical analysis proves the poverty link, her conclusions could have important public policy implications for how to effectively address a major public health problem, both in Florida and the nation. 

“Florida has the highest HIV mortality rate and one of the 10 highest HIV case fatality rates in the country,” Trepka notes.

Meanwhile, other states that also have high rates of infection seem to have found ways to lower the death toll. For instance, “New York is way up there with HIV cases, but their case fatality rate is low.”

One possible reason is that New York has extensive programs to ensure HIV treatment for people living with AIDS, including the poor, while Florida has more than 3,000 patients on a waiting list to receive subsidized HIV medication. And recent research shows that HIV treatment has benefits beyond prolonging the life of the infected person.

“There’s a very important public benefit of getting people into care,” explains Trepka, who is both a physician and an epidemiologist. “When people are taking the medications, those people cannot pass the virus to other people. And new research also shows that when you get people diagnosed, they change their behaviors. By getting people treated and into care, you’re protecting the general community.”

While serving as director of the Office of Epidemiology and Disease Control for the Miami-Dade County Health Department from 1998 to 2003, Trepka observed the strong geographical tie between poverty and the spread of infectious diseases like sexually transmitted diseases and tuberculosis.

“I was very aware that if you superimpose the maps of cases of those diseases with a map of poverty, they all overlap. The places with the highest rates for STDs are also the poorest areas. The highest birth rates to teen moms are also in the poorest areas.”

If her study indeed concludes that poverty worsens survival rates for HIV, she would like to see further research showing what interventions are the most effective. 

“There may be two mechanisms where poverty may be leading to lower survival,” she theorizes. “One is people don’t have access to care and medication. Or they may have difficulty taking the medication even if they have it: If I don’t know where my next meal is coming from or I can’t pay my rent, I won’t take my medication as reliably as those who don’t have those worries.” 

Trepka saw joining the faculty at FIU as an ideal way to conduct groundbreaking research on topics that intrigued her. She joined the full-time faculty in 2003 after teaching as an adjunct for several years.

“I came to FIU because a new school of public health was being developed,” Trepka says. “There are not very many schools of public health in the United States, and I really wanted to be part of forming this new entity.”

In fall 2011, Trepka received the Presidential Early Career Award for Scientists and Engineers from U.S. President Barack Obama. The award is “intended to recognize and nurture some of the finest scientists and engineers who, while early in their research careers, show exceptional potential for leadership at the frontiers of scientific knowledge during the twenty-first century.”