Lens: HIV Prevalence and Mpox Vulnerabilities – A Data Mapping Tool

The Lens: HIV Prevalence and COVID-19 Vulnerabilities data-mapping tool (Lens) was created by the UCLA Center for Neighborhood Knowledge in partnership with the Southern California HIV/AIDS Policy Research Center. The authors thank the California Department of Health, Office of AIDS for their input. The authors also thank UCLA Center for Neighborhood Knowledge staff, Megan Potter and Chhandara Pech, for their support. Funding for this project was provided by the California HIV/AIDS Research Program (award #H21PC3466).

We acknowledge the Gabrielino/Tongva peoples as the traditional land caretakers of Tovaangar (Los Angeles basin, So. Channel Islands) and pay our respects to the Honuukvetam (ancestors), ‘Ahiihirom (elders), and ‘Eyoohiinkem (relatives/ relations) past, present, and emerging.

The views expressed herein are those of the authors and not necessarily those of the University of California, Los Angeles or the California HIV/AIDS Research Program. The authors alone are responsible for the content of this report.

The previous generation of Lens sought to respond to the need to understand if elevated risk of COVID-19 disease and mortality among persons living with HIV (PLWH) results from related risk behaviors, a higher burden of comorbidities, and/or social determinants of health. This updated Lens tool remains motivated by a concern for social and structural factors underpinning health disparities, including those related to HIV. This tool can help decision-makers, community-based organizations, and other stakeholders to access critical neighborhood-level information about the intersection of socio-economic and health vulnerabilities and HIV. The Lens portal also contains information on mpox (monkeypox) case rates where such information is available. We hope this information helps guide overstretched public health and health systems to recast, prioritize, and improve HIV prevention and treatment services in an era of emerging health threats.

This brief is organized into two major parts. The first provides background information on HIV and mpox: state epidemiological data, ethnoracial and gender disparities, social determinants of health, mpox, and HIV services. The second part of the brief provides information to help users navigate and utilize the Lens tool.

HIV in California

In California, recent state surveillance data indicate that from 2015 through 2019, the annual number and rate of new HIV diagnoses declined. Over the same period, however, the number of persons living with HIV (PLWH) increased, representing a 4% increase in HIV prevalence across the State. Approximately three fourths of Californians diagnosed with HIV were receiving HIV care and nearly two-thirds (65.3%) achieved viral suppression. In addition, in 2019, the annual number of deaths of PLWH in California increased, representing a 2.1% increase in the crude death rate of persons with diagnosed HIV infection since 2015. Causes of death among those diagnosed with HIV may or may not be related to HIV infection.

HIV and Social Determinants of Health

HIV affects communities with overlapping vulnerabilities and those disadvantaged by structural barriers to health care. Recent research using U.S. census-tract level data identified associations between HIV diagnoses and key social determinants of health (e.g., poverty, education, income, employment, health insurance, housing vacancy). HIV rates among adults increased 1.4 to 4.0 times among men and 1.5 to 5.5 times among women as census-tract poverty levels increased, education levels decreased, income decreased, unemployment increased, lack of health insurance increased, and vacant housing increased. The authors also found differences by race/ethnicity and geography across the U.S. A factor of increasing significance to HIV diagnoses is the experience of homelessness with HIV rates increasing among those experiencing homelessness. In California from 2015 to 2017, cross-sectional data of PLWH from the Medical Monitoring Project (MMP) documented that 28% lived at or below the federal poverty threshold, 40% were unemployed, 22% had gone without food owing to lack of money, and 12% had experienced homelessness. Additionally, among low-income recipients of federally funded Ryan White HIV/AIDS Program services in 2017, unhoused persons were found to experience the greatest disparities in achieving viral suppression.

Disparities in HIV and Mpox

The California Department of Public Health has issued numerous reports highlighting specific HIV-related disparities. Based on surveillance data reported through December 31, 2020, Black/African Americans are the most disproportionately affected by HIV with new diagnoses rates 3.8 times higher than Whites for men and 6.9 times higher for women. The rate of new HIV diagnoses among Black/African American men who have sex with men (MSM) was 3.9 times higher than White MSM; the rate for Latino MSM was 2.2 times higher than White MSM. Among women, the rate among newly diagnosed Black/African Americans was 6.9 times that of Whites; the rate for Latinas was 1.3 times that of Whites. Rates for transgender people remain unavailable, as there are no data on population denominators. However, evidence suggests that transgender people are disproportionately affected by HIV.

As of August 23, 2023, the 30,767 US mpox cases accounted for roughly 34% of the nearly 90,000 cases globally, and there have been 50 deaths from mpox nationally. California has the highest case count of any state, and Los Angeles County (LAC) has the highest reported number of cases in the state. Most county cases have occurred among men who have sex with men (MSM), and people living with HIV have accounted for 40% of diagnosed mpox cases, a disproportionate share. Of the total US cases cited above, 30.5% identify as Black/African American, 29.2% as Hispanic/Latino, and 27.7% as White, according to the CDC. Race and ethnicity information is missing for about 6% of cases reported to the CDC.

Though US mpox cases peaked in August 2022 and the public health emergency was declared to have ended on January 31, 2023, continuing vaccination among people most susceptible to mpox exposure, including newly sexually active men who have sex with men, is necessary to prevent subsequent outbreaks. Research on vaccine coverage among persons at risk for mpox found that from May 2022 to the end of January 2023, one- and two-dose (full dose) vaccination coverage among persons at risk in the US were 37% and 23% respectively. In California as of August 22, 2023, according to the CDC, at least one-dose coverage was 66% and two-dose coverage was 41%. Based on state data as of September 15, 2023, excluding cases with unknown race or ethnicity information, in California, 45.3% of mpox cases area were among persons identifying as Hispanic or Latino, 31.4% as White, and 13.2% as Black or African American. Of people vaccinated with one or more doses and for whom data are reported in the state immunization registry, 26.9% identify as Hispanic or Latino, 44.3% as White, and 7.3% as Black or African American.

Vulnerabilities at the Intersection of HIV and Mpox

A 2022 CDC report in eight US jurisdictions noted that persons with HIV (38%) or were diagnosed with STIs in the preceding year (41%) disproportionately accounted for persons with mpox. People living with HIV, particularly those with low CD4 counts or not virally suppressed, were more likely to be hospitalized with mpox than persons without HIV. In September 2022, the LAC Department of Public Health warned county health care professionals of severe mpox among PLWH with weakened immune systems or who were untreated. Vulnerability to severe disease calls for targeted mpox vaccination efforts and improved access to antiretroviral treatment among PLWH and Black and Latinx MSM. Policy suggestions highlighting the intersection of HIV and mpox vulnerability include the following:

• making harm reduction and vaccine promotion materials available in Spanish and culturally tailoring them to resonate with, educate, and empower Black and Latinx MSM communities
• leveraging existing public health infrastructure to boost mpox vaccination among PLWH
• co-locating mpox vaccination with HIV testing to ensure people newly diagnosed with HIV have immediate access to mpox prevention
• offering specialized vaccine promotion, including pop-up clinics, in Black and Latinx communities to address vaccine fatigue and hesitancy
• advocating financial assistance programs for people diagnosed with mpox to support home isolation.

Mapping Tool Overview

The Lens data-mapping tool was developed to better understand geographic health and social disparities impacting PLWH. The tool includes these determinants of vulnerability across California:

1. HIV cases per population
2. Percent of population over 50
3. Percent of people age 50+ living with HIV by ZCTA
4. Percent of people age 26-49 living with HIV by ZCTA
5. Percent of people age 50+ living with HIV by county
6. Percent of people age 26-49 living with HIV by county
7. Mpox case rate by county
8. Mpox vaccination rate by county
9. Mpox case rate for public health region
10. Mpox vaccination rate for public health region
11. Distribution of same-sex households
12. Highly vulnerable areas as designated by the Healthy Places Index
13. Highly vulnerable areas as designated by the Social Vulnerability Index
14. Medicaid (Medi-Cal) coverage
15. No health insurance
16. Median household income
17. Largest ethnoracial group
18. Pharmacies
19. HRSA-funded providers
20. Ryan White HIV/AIDS program providers

The U.S. Census Bureau’s ZIP Code Tabulation Areas (ZCTA) serve as the geographic unit of analysis for the Lens tool.[1] The visual distribution of data for each layer varies in order to produce accurate visual representations of trends across California. In general, darker-shaded areas represent greater vulnerabilities across the various layers.

Data Description

• HIV cases per population: This layer displays HIV prevalence as a rate per 100 people across California ZCTAs. HIV cases per population are calculated by taking the number of people living with HIV divided by the total population within a ZCTA, then converting that value to a percent. Data reflect people living with diagnosed HIV in California as of December 31, 2019. ZCTAs with case counts below 10 are suppressed prior to calculating the rate in the interest of the safety and privacy of inhabitants. Data were acquired from the California Department of Public Health (CDPH).
• Percent of population over 50: This layer shows how age is distributed by ZCTA throughout California. These data do not include any statistics on PLWH and merely show where the highest concentrations of young and old populations exist in California. Population age data came from the 2019 American Community Survey 5-year estimate.
• Percent of people age 50+ living with HIV by ZCTA: This layer shows the percent of people age 50+ living with HIV out of the population age 50 and over of each ZCTA. Data at the ZCTA level may be sparse and have been suppressed where necessary to protect privacy. Data of PLWH came from the California Department of Health, Office of AIDS for 2019.
• Percent of people age 26-49 living with HIV by ZCTA: This layer shows the percent of people age 26-49 living with HIV out of the 26-49-year-old population of each ZCTA. Data at the ZCTA level may be sparse and have been suppressed where necessary to protect privacy. Data of PLWH came from the California Department of Health, Office of AIDS for 2019.
• Percent of people age 50+ living with HIV by County: This layer shows the percent of people age 50+ living with HIV out of the population age 50 and over of each county. Data of PLWH came from the California Department of Health, Office of AIDS for 2019.
• Percent of people age 26-49 living with HIV by County: This layer shows the percent of people age 26-49 living with HIV out of the 26-49-year-old population of each county. Data of PLWH came from the California Department of Health, Office of AIDS for 2019.
• Mpox case cate by county: This layer displays mpox case rates per 100,000 people by county. Data as of June 21, 2023 were acquired from the California Department of Public Health.
• Mpox vaccination rate by county: This layer displays mpox vaccination rates per 100,000 people by county. Data as of June 21, 2023 were acquired from the California Department of Public Health.
• Mpox case cate for public health region: This layer displays mpox case rates per 100,000 people for each of the six public health regions. Estimates by regions only include counties where there are data on actual counts of cases. Data as of June 21, 2023 were acquired from the California Department of Public Health.
• Mpox Vaccination Rate for Public Health Region: This layer displays mpox case rates per 100,000 people for each of the six public health regions. Data as of June 21, 2023 were acquired from the California Department of Public Health.
• Same-Sex households (SSH): This layer displays the distribution and prevalence of same-sex households (SSH) across California by ZCTA as a percentage. Data include both married and coupled partners counts that are divided by the population within each ZCTA to obtain the percent of same-sex households by neighborhood. Data were acquired from the U.S. Census Bureau’s 2015-2019 American Community Survey (ACS) data portal.
• Highly vulnerable areas as designated by the Healthy Places Index (HPI): This layer shows areas designated as least healthy by the Healthy Places Index (HPI), developed by the Public Health Alliance of Southern California. The HPI combines 25 community characteristics to generate a single indexed score at the census tract level, and those values are proportionately allocated into ZCTAs. Only the most vulnerable areas are displayed by this layer. Data were acquired as of October 2020.
• Highly vulnerable areas as designated by the Social Vulnerability Index (SVI): This layer shows areas designated as most vulnerable by the Social Vulnerability Index (SVI) by ZCTA. This layer displays only the most vulnerable ZCTAs by analyzing fifteen different census variables to scale different neighborhoods from least to most vulnerable. The SVI was created by the Centers for Disease Control and Prevention (CDC), explaining that “social vulnerability refers to the potential negative effects on communities caused by external stresses on human health. Such stresses include natural or human-caused disasters or disease outbreaks.” Data were acquired as of October 2020.
• Medicaid (Medi-Cal) coverage: This layer shows the distribution of the population covered by Medicaid insurance by ZCTA. Medicaid is a government program “administered at the state level, which provides medical assistance to the needy. Families with dependent children, the aged, blind, and disabled who are in financial need may be eligible for Medicaid.” In California, the Medicaid program is known as Medi-Cal. Values are calculated by dividing the total number of individuals with Medicaid health insurance coverage in a ZCTA by the total population (civilian non-institutionalized population) in that area. The indicator on Medicaid insurance coverage is visualized in quintiles, dividing the data into five roughly equal segments, meaning roughly 20% of California’s ZCTAs fall within each quintile. Neighborhoods are ranked from lowest to highest quintiles and each neighborhood ranking is relative to all ZCTAs in California. The data are based on the 2014-2018 American Community Survey, which asked respondents about their health insurance coverage status.
• No Health Insurance: This layer shows the distribution of the percentage of people with no health insurance by ZCTA. Health insurance is defined as “plans and programs that provide comprehensive health coverage” as opposed to coverage for specific conditions or other kinds of coverage like dental, life, or disability insurance. If respondents marked “no” for all health insurance options on the ACS, they are considered as having no health insurance. Data on no health insurance coverage are visualized in quintiles, dividing the data into five roughly equal segments, meaning roughly 20% of California’s ZCTAs fall within each quintile. Neighborhoods are ranked from lowest to highest quintiles and each neighborhood ranking is relative to all ZCTAs in California. The data are based on the 2014-2018 American Community Survey (ACS), which asked respondents about their health insurance coverage status.
• Median Household Income: This layer shows the distribution of median household income by ZCTA. According to the U.S. Census Bureau, “median income is the amount which divides the income distribution into two equal groups, half having income above that amount, and half having income below that amount.” In calculating median household income, the Census Bureau looks at the incomes of only those people who are 15 or older in the household. Data are visualized in quintiles, dividing the data into five roughly equal segments, meaning roughly 20% of California’s ZCTAs fall within each quintile. Neighborhoods are ranked from lowest to highest quintiles and each neighborhood ranking is relative to all ZCTAs in California. Data on median household income come from the 2014-2018 American Community Survey.
• Largest Ethnoracial Group: This layer shows the distribution of the largest ethnoracial groups in ZCTA. The largest ethnoracial group is defined as the group that makes up the majority of the population in a ZCTA (>50%) or the group that is the plurality (<50% but still the most numerous group). The following ethnoracial groups were considered: Non-Hispanic White, Asian, Black, Hispanic & Latino, and American Indian & Alaska Native. Data were acquired from the U.S. Census Bureau’s 2014-2018 American Community Survey (ACS) data portal.
• Pharmacies: This layer shows the locations of pharmacies that provide HIV and addiction-related services. These services include naloxone to treat narcotic overdose as well as pre-exposure prophylaxis and post-exposure prophylaxis. Data on pharmacies were made available by the California State Board of Pharmacy.
• HRSA-funded providers: This layer shows service centers funded by the U.S. Health Resources & Services Administration that are especially equipped to manage HIV-related issues.
• Ryan White HIV/AIDS Program Providers: This layer shows centers that serve low-income people living with HIV and provide essential health services, medication, and HIV primary care.
  

[1]  With the exception of COVID-19 case rates in Los Angeles County, as Los Angeles County reports COVID-19 case data by community rather than ZCTA.

Using the Lens Tool

Main Navigation: Use the tools in the top corners to navigate the mapping tool. On the top right, there are widgets that allow you to read and explore the data more thoroughly.

To search for a specific location, type a county, city, zip code, address, or place into the search bar and the map will automatically zoom to that location. Once you have typed your desired search location, you can either select it from the options that appear below the search bar or click on the magnifying glass icon to zoom to that location.

To zoom, use the boxes with the + and – symbols on the left-hand side of the map to zoom in and out. Clicking the “+” will zoom in to wherever your page is centered around and clicking the “–” will zoom out. You can also place your mouse over a desired location and swipe with two fingers on your trackpad to zoom in and out. Alternatively, you can click and hold your mouse anywhere on the map while dragging to pan around the screen.

To return to the original map extent, click the “Home Button” with the home icon at any time.

To zoom to your current location on the map, click the “My Location” button to zoom to your current location on the map. Note that location settings must be enabled on your browser in order to use this feature.

To read more about the layers, click on the “About” widget, which includes descriptions for all layers in the mapping tool. This is the default widget to open when launching the mapping tool.

To view a complete list of layers included in the mapping tool, click on the “Layer List” widget. Layers can be turned off and on by clicking the white box next to each layer. A layer that is turned on will be indicated by a turquoise check mark. The legend for any layer, whether it is on or off, can be viewed by pressing the small gray arrow of that layer to reveal a drop-down legend. To compare various layers to one another, we recommend zooming to a location of interest and turning both layers on. Then, repeatedly click off and on the overlying layer to compare trends for that location. Alternatively, users can open the mapping tool in two side-by-side browser windows and compare trends visually.

To display the legends for all layers that are turned on, click on the “Legend” widget.

To change the basemap, click on the highlighted icon composed of four white squares titled “Basemap Gallery”. The light gray canvas basemap serves as the default background. Other background options include a terrain map or a street map. You can change the basemap at any time without affecting your other selections/zoom.

To share the data-mapping tool, click on the “Share” widget. A link to the data-mapping tool will be available, and optional specifications can be found under “Link options.” The code to embed the data-mapping tool to a website can be found in the text box below “Embed this app in a website.”

To view data about a specific ZCTA, click on any tract within the map and a tiny window will pop up: the zip code appears on the window and, if the “County” layer is turned on, clicking on the plain white arrow to the second window page will display the county. Click on the encircled right arrow to view the following data:

1. The unique ZCTA code.
2. If the ZCTA falls under an area designated as highly vulnerable by the Social Vulnerability Index (SVI), where “1” indicates vulnerability, “0” indicates no vulnerability.
3. If the ZCTA falls under an area designated as highly vulnerable by the Healthy Places Index (HPI), where “1” indicates vulnerability, “0” indicates no vulnerability
4. The percentage of same-sex households within that ZCTA
5. COVID-19 case rate per 100 thousand people, not available for all ZCTAs
6. The percentage of the population with Medicaid
7. The percentage of the population with no health insurance coverage
8. The median household income of that ZCTA
9. The largest ethnoracial group of that ZCTA

The three dots at the bottom left corner of the data display also gives two more options:
1. “Pan to” re-centers the selected tract to the middle of your screen.
2. “Add a marker” places a marker on the tract so that it may be located easily if zoomed out to a
greater extent.