Health Informatics to Model the Scott County HIV Outbreak

ABSTRACTCOVID-19 cases and deaths are surging in rural areas of the United States. In the last two weeks of April2020, the average number of COVID-19 cases per 100,000 persons rose 125% in rural U.S. counties but only68% in urban counties. During this same time period, COVID-19 related deaths rose 169% in rural areascompared to 113% in urban areas. As of May 4 2020, Georgia had 28,945 confirmed cases of COVID-19 and1,186 COVID-19-related deaths. Georgia is a predominantly rural state. Rural people living with HIV (PLHIV)are at-risk for COVID-19 due, in part, to compromised immune systems and high rates of comorbid healthconditions. Rural PLHIV with comorbid substance use disorders (SUDs) are at particularly high risk for COVID-19 infection. Many rural PLHIV + SUDs lack access to medical and psychological care, must travel vastdistances to receive HIV and SUD treatments, experience high rates of mood disorders, and experiencediscrimination, prejudice, and stigma related to their HIV-status, sexual-identity, and SUD. Georgia is anopportune state in which to study risk for COVID-19 in rural PLHIV + SUDs. In 2017, Georgia had the highestHIV prevalence rate per 100,000 residents of any state. Currently, Georgia ranks 12th in number of COVID-19cases, 5th in hospitalizations due to COVID-19, but has the nation's 7th slowest COVID-19 testing rate. Thisstudy's scientific premise is that, to date, most COVID-19 research has been conducted in urban centers; littleis known about (i) rates of COVID-19 in rural PLHIV + SUDs, (ii) factors predictive of COVID-19 infection in thisgroup, and (iii) types of preventive behaviors in which rural PLHIV + SUDs engage to avoid infection. Thisstudy will assemble a prospective longitudinal cohort of 100 rural PLHIV in northeast Georgia, 50% of whomhave an active SUD (most likely opioid use disorders). The study will be conducted in Georgia's Health District10, in which all ten counties are classified as "rural," 9 are mental health professional shortage areas, and 8are primary care professional shortage areas. To maximize participant safety, all data will be collected usinginnovative remote assessment methodologies. Guided by Wilson and Cleary's model of life quality, participantswill complete assessments at baseline and 3-, 6- and 9-month follow-up that collect: (1) biologic data: CD4count, HIV viral load, viral hepatitis status; (2) behavioral/psychosocial data: tobacco and marijuana use, vapingpractices, depressive symptoms, ways of coping with COVID-19-related stress, and coping self-efficacy; and(3) environmental data: housing status and correctional systems involvement. Surveys will also assessCOVID-19 prevention behavior data (e.g., washing hands with soap and water; social distancing). Analyseswill compare rural PLHIV + SUDs to rural PLHIV without SUDs on rates of engaging in COVID-19 preventivebehaviors. Logistic regression analyses will identify factors predictive of COVID-19 infection in this group.Study findings can inform the development of COVID-19 prevention interventions for rural PLHIV and possiblycontextualize interventions for the unique needs of rural PLHIV + SUDs.