Hispanic/Latino persons are disproportionately affected by HIV in the United States. Although accounting for only 19% of the U.S. population in 2021 [1], infections among this ethnic group accounted for 29% (9,300 of 32,100) of estimated new HIV infections [2]. About 15 of every 100 Hispanic/Latino persons living with HIV infection were unaware of their infection in 2021[2]. Of those who received a diagnosis during 2021, 84.5% of Hispanic/Latino persons were linked to HIV medical care within 1 month of diagnosis and 73.2% had viral suppression within 6 months, making Hispanic/Latino persons the second highest racial/ethnic group for linkage to care and viral suppression within 6 months, despite disparities in diagnoses and lower levels of knowledge of HIV status [3]. Yet, observations for receipt of any HIV medical care and viral suppression at the most recent viral load test during 2021 among all persons living with diagnosed HIV show that Hispanic/Latino persons are among the lowest percentages, compared to other racial/ethnic groups [3]. Improving all indicators of HIV care outcomes among the Hispanic/Latino population is necessary to lessen disparities and achieve the National HIV/AIDS Strategy (NHAS) goals [4].

Health disparities among racial/ethnic groups in the United States, including Hispanic/Latino persons, result from a culmination of systemic, social, economic, and environmental disadvantages, such as poverty, poor housing conditions, and lack of quality health care [5–6]. Social vulnerability is a term that refers to the external stressors that affect a community’s resilience and may lead to negative health effects [7]. Due to social and economic segregation, Hispanic/Latino persons and some other traditionally marginalized groups tend to live in socially vulnerable census tracts [7]. Studies have found that those in more socially vulnerable areas have negative health outcomes across an assortment of conditions [8–13]. A study by the Centers for Disease Control and Prevention (CDC) also noted that a disproportionate number of Hispanic/Latino adults lived in the most socially vulnerable tracts at the time of HIV diagnosis, 51.5% compared to 24.4% for their White counterparts [14].

In addition to the impact that community-level factors have on health outcomes among Hispanic/Latino persons, this group also experiences unique individual-level factors. Approximately one-third (32%) of Hispanic/Latino persons residing in the United States were born outside of the country [15]. Nativity and birthplace represent just two social determinants of health for which Hispanic/Latino persons face distinct differences within the ethnic group. For HIV, CDC reports that mode of HIV transmission varies by birthplace among Hispanic/Latino persons [16]. For example, Hispanic/Latino males with diagnosed HIV infection who were born in Puerto Rico and the Caribbean have less infection attributed to male-to-male sexual contact (77.7% and 72.9%, respectively) and more infection attributed to heterosexual contact (14.5% and 21.7%), compared to other birthplaces including the United States (85.4% and 5.5%, respectively) [16]. Differences in HIV care outcomes by transmission category have been reported, both overall and among Hispanic/Latino persons [3] and may be attributed to different sociostructural factors depending on the population (e.g., stigma, criminalization, access to low barrier services, comorbidities) [3,17]; it is not known how birthplace may contribute, but cultural differences may impact HIV knowledge, healthcare seeking behaviors, and perceived stigma and vary by transmission category [18]. Additionally, differences by birthplace have been noted for other care outcome measures: increased odds of short HIV-to-AIDS intervals among Mexico- or Central America-born versus U.S.-born Hispanic/Latino persons, increased risk of opportunistic infections among U.S.-born versus Central America-born Hispanic/Latino females, lower survival for those with Stage 3 (AIDS) classifications among Puerto Rico-born versus U.S.- or South America-born Hispanic/Latino persons, and differences in HIV-related mortality (inconsistent results by birthplace across studies) [19].

As health equity takes on a central role in HIV prevention and treatment, it is crucial to recognize the diversity within the Hispanic/Latino population in the United States and avoid analyzing data for them as a homogenous ethnic group [20–22]. In research of HIV and other diseases, disaggregation by demographic characteristics such as nativity and birthplace has revealed health disparities within the Hispanic/Latino ethnicity [19,23–26]. The importance of disaggregation is emphasized by the continually evolving demographics of Hispanic/Latino persons in the United States. Greater proportions are U.S.-born compared to immigrants; populations with origins in South America, Central America, and the Caribbean are faster growing than populations of Mexican origin; and rates of U.S. citizenship, college attendance, and English-language proficiency continue to increase [15]. With these demographic shifts come shifts in the challenges to equitable health outcomes for this group.

Few studies have determined the effects of social vulnerability or birthplace on HIV care outcomes among Hispanic/Latino persons [19,23–24,27–28]. This study is one of the first to analyze national, census tract-level HIV data by birthplace and social vulnerability to evaluate linkage to care and viral suppression (core indicators of the Ending the HIV Epidemic in the U.S. [EHE] initiative [3]). Comparing characteristics of Hispanic/Latino persons with diagnosed HIV by birthplace can inform the different challenges subgroups face within this ethnic population. This paper will assess prevalence ratios of non-linkage to care and non-viral suppression by individual- and community-level characteristics, which will quantify barriers to HIV care services and identify additional opportunities for focused HIV prevention and control efforts.

Data were obtained from CDC’s National HIV Surveillance System (NHSS) and the CDC/Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI).

In this analysis, 86.1% and 76.6% of Hispanic/Latino adults with HIV diagnosed in 2021 were linked to care within one month and had viral suppression within six months of diagnosis, respectively. Overall, the results showed that, among Hispanic/Latino adults, non-linkage was lowest in males, those aged 35–44 years, and those born in Mexico and South America. Non-viral suppression was highest in those aged 55 years and older and lowest in those born in Mexico, South America, and the Caribbean. Additionally, the greatest proportion of Hispanic/Latino adults with diagnosed HIV resided in the most socially vulnerable census tracts (Q4), but no significant difference was found in non-linkage or non-viral suppression by SVI quartile.

This analysis found that higher linkage to care was observed among Hispanic/Latino persons living in the United States who were born in Mexico and South America, and viral suppression was higher among those born in Mexico, South America, and the Caribbean. Previous research showed contrary results to our analysis. Two studies of Hispanic/Latino persons with HIV living in Florida observed an increased odds of positive care outcomes for Cuba- and Puerto Rico-born Hispanic/Latino persons and decreased odds of positive outcomes for Mexico-born and Central America-born Hispanic/Latino persons [23–24]; these differences may be attributable to differences among the population at the state level compared to national level. In addition, studies on other HIV indicators (e.g., time of diagnosis, stage of disease, and survival) by birthplace have been inconsistent in their findings with no clear pattern among Mexico-, South America-, or Caribbean-born persons observed [23,28,31]. One potential explanation for our findings is a phenomenon observed in public health research called the “Hispanic Health Paradox” [32–33]. The paradox notes the relatively good health and health outcomes (particularly less mortality) of Hispanic/Latino persons compared to non-Hispanic/Latino persons in the United States, despite lower wealth, less educational attainment, and other factors classically linked to poor health outcomes [34–38]. This observation strongly depends on there being better health among non-U.S. born Hispanic/Latino persons. Proposals for the reasoning behind the health paradox have ranged from the “healthy immigrant effect” (i.e., the idea that the strongest persons migrate and bring with them the advantage of good health) to “salmon bias” (i.e., that unhealthy migrants return to their home countries and thus their health conditions and deaths are unreported in the United States) to unreliable data (e.g., early studies were based on unstandardized demographic collection) [35–40]. The paradox is broad and views Hispanic/Latino persons as a homogenous group. Our study shows that the paradox may be less overarching and relevant based on birthplace.

The protective effect for Mexico-, South America-, and Caribbean-born Hispanic/Latino persons seen in this study may be linked to aspects of immigration and culture (e.g., acculturation, English language proficiency, co-ethnic density) that we are not able to analyze with the given data. Mexico- and South America-born Hispanic/Latino persons have contrasting demographic, such as with respect to education (i.e., South America-born Hispanic/Latino immigrants have higher levels of educational attainment than Mexico-born counterparts [41–42]), citizenship status (i.e., higher percentage of citizenship among South American immigrants than Mexican immigrants [1]), and English-language proficiency (i.e., recent Hispanic/Latino immigrants from South American countries are more likely to be proficient in English compared to Mexican immigrants [41]). An interesting commonality between the two groups, however, is that Hispanic/Latino adults with diagnosed HIV born in Mexico and South America (as well as those born in Central America) were less likely to have reported experiencing any health care discrimination [43]. It is likely that differing intersections of demographics and experiences for each group rather than a singular common characteristic contribute to the positive care outcomes observed for these specific groups. Additional information on non-U.S.-born persons (e.g., timing of entry into the United States and history of immigration status) and U.S.-born persons (e.g., generation status and country of heritage) could provide insight into how these protective effects may be confounded by immigration and acculturation.

Our analysis found no significant difference in the prevalence of non-linkage and non-viral suppression by SVI quartile in univariate or multivariate analyses. Previous research has only observed differences in HIV diagnoses rates by SVI quartile among Hispanic/Latino persons and has not evaluated care outcomes [14, 44]. One study observed fewer within-group disparities of HIV diagnoses among Hispanic/Latino adults than among Black/African American or White adults, when comparing the most socially vulnerable census tracts to the least socially vulnerable census tracts [14]. When breaking down SVI by minority status and English proficiency theme (note that theme groups have changed slightly for the SVI version used in our study), the diagnoses rates among Hispanic/Latino adults who lived in the most socially vulnerable census tracts were 1.5 times those who live in the least socially vulnerable census tracts; notably, more than two-thirds (68.1%) of Hispanic/Latino adults lived in the most vulnerable tracts for this theme [44]. Although the association between social vulnerability and diagnoses was lower for Hispanic/Latino adults than other races, it was still significant in these studies. We anticipated that a similar degree of association would be seen with care outcomes in our study, especially given the consideration of birthplace. However, the lack of significant difference by SVI quartile may be explained by research showing that, despite Hispanic/Latino persons having low knowledge of HIV status [2] and later stage diagnosis [3], care outcomes are good [45].

Our analysis is subject to several limitations. First, diagnoses of HIV infection do not represent new infections (incidence). The time from infection to diagnosis varies by individual, and residence at the time of HIV diagnosis may not be the residence at the time infection was acquired. This is relevant to immigrant populations, as data on the country where HIV infection was acquired and/or related self-reported date on initial HIV diagnosis (outside of the US) may be limited. Relatedly, NHSS only captures diagnoses reported by the confidential name-based HIV registries of state and local health departments and does not include anonymous HIV testing or self-testing. Due to concerns of cost, deportation, and other barriers to healthcare access, Hispanic/Latino immigrants may be underreported in HIV registries. Second, HIV care outcome data are limited to jurisdictions with laws requiring reporting of CD4 and VL tests and with complete reporting of results to NHSS. For 2021, this resulted in the exclusion of data from New Jersey, Puerto Rico, Pennsylvania, and Idaho; the former three have significant populations of Hispanic/Latino persons, collectively 10.3% of all diagnoses among Hispanic/Latino persons. The exclusion of data from some states with large Hispanic/Latino populations and potentially different nativity/birthplace characteristics may result in the underrepresentation of cases among Hispanic/Latino persons and certain subgroups. Third, about one-third (34.6%) of Hispanic/Latino persons with HIV diagnosed in 2021 had missing or invalid data for birthplace. The distribution of these excluded cases may affect certain subgroups disproportionately, and thus the study population may not be representative of the birthplaces of the whole population of Hispanic/Latino persons with diagnosed HIV. The higher overall linkage and viral suppression among Hispanic/Latino adults observed in our study population may result from the exclusion of cases with limited data on birthplace and address of residence. Individuals missing these types of information could be less likely to seek or to have access to HIV medical care beyond testing, thus their exclusion could inflate the percentage of those linked to care and with viral suppression in our study. Fourth, we used census tract–level data as a surrogate to represent the environment in which people with diagnosed HIV infection lived at the time of diagnosis. Conclusions and findings should be interpreted with caution and not inferred at the individual level.

As the U.S. Hispanic/Latino population continues to grow and its demographics change, public health research must evolve to evaluate health disparities within the group as well as in comparison with other racial/ethnic groups. Hispanic/Latino persons in the United States vary by nativity, language, immigration status, healthcare access and insurance coverage, and experiences with discrimination, yet they are often viewed as a single, homogenous group. This study aimed to challenge the narrow perspective on HIV care outcomes by examining the impact of birthplace and social vulnerability. Future analyses should consider the role of culture, immigration, and community-level factors on barriers to HIV prevention and care services among Hispanic/Latino persons in the United States to better inform the development of effective and novel strategies and programs to address ethnic disparities.