Where You Live Matters: Health Insurance, Place, and Racial/Ethnic Disparities In HIV Diagnosis In the United States

Background:

Ending the HIV epidemic in the United States requires addressing not only individual risk behaviors but also the structural conditions that shape access to prevention, diagnosis, and treatment. Where people live fundamentally determines their health outcomes, as place reflects the distribution of resources, healthcare infrastructure, and policy-environments. Health insurance is a central mechanism linking place to HIV outcomes, influencing testing, linkage-to-care, and sustained viral suppression. Despite the federal Ending the HIV Epidemic (EHE) initiative targeting high-burden jurisdictions, persistent racial/ethnic disparities raise critical questions about whether improvements in healthcare access, particularly insurance coverage, translates into equitable outcomes. The objective of the study was to explore how racial/ethnic disparities in HIV diagnosis rates compare in EHE and non-EHE counties, by health insurance coverage.

Methods:

We analyzed 2023 National HIV Surveillance System data on all adult HIV diagnoses, geocoded to county of residence, and linked these data to 2019–2023 American Community Survey estimates of health insurance coverage. Counties were categorized into quartiles based on the percentage of uninsured residents as: Q1: ≤ 5.6% uninsured; Q4: >11.5% uninsured. We assessed racial/ethnic disparities in HIV diagnosis rates (per 100,000) for Black and Hispanic/Latino populations relative to White populations using rate ratios (relative disparities) and rate differences (absolute disparities). Overall inequality was measured using the Gini-coefficient, derived from Lorenz curves. Analyses were stratified by EHE counties, and percentage changes in disparity measures were examined across insurance quartiles.

Results:

Across all levels of insurance coverage, relative disparities were consistently lower in EHE counties than in non‑EHE counties. In the most uninsured counties (Q4), Black‑to‑White rate ratio was 5.76 in EHE counties, compared to 8.39 in non‑EHE counties; Hispanic‑to‑White rate ratio was 3.39 versus 4.39, respectively. Similar patterns persisted in highly insured counties (Q1). Overall inequality, measured by Gini coefficient, was also lower in EHE counties. However, absolute disparities were larger in EHE counties, reflecting higher overall HIV burden in these areas. Improvements in insurance coverage (Q4 to Q1) were associated with reductions in absolute disparities but paradoxically increases in relative and overall inequality, particularly in non‑EHE counties. Hispanic‑to‑White rate ratios increased by 73.2% in non-EHE counties compared to19.6% in EHE counties. Black‑to‑White rate ratios increased in non‑EHE counties but remained stable in EHE counties. Racial/ethnic inequality increased more substantially in EHE counties, with a 21.7% increase in Gini coefficient, compared with a 4.6% increase in non‑EHE counties. In contrast, absolute disparities decreased with higher insurance advantage, as Black‑to‑White rate differences declined by 30.2% in EHE counties and by 39.9% in non‑EHE counties, while Hispanic‑to‑White rate differences changed little.

Conclusions:

These findings underscore that ending the HIV epidemic is not solely a biomedical challenge but a structural one. While expanding health insurance coverage is essential and reduces the overall burden of disease, it is insufficient to eliminate inequities. Improvements in coverage may disproportionately benefit populations already positioned to access care, thereby widening relative disparities even as absolute gaps narrow. Place-based strategies, such as the EHE initiative, demonstrate promise in reducing relative inequality, yet persistent absolute disparities.