Persons with HIV (PWH) represent a socially and medically vulnerable population who often depend on public resources. We examined voter registration among PWH in North Carolina. Sixty-four percent were registered to vote. Registration was lower among PWH who were young, Hispanic, publicly insured or uninsured, and who had poor HIV health status

Belenky, N

Moss, H.A

Napravnik, S

Rosen, D.L

Schranz, A.J

Carolina Digital Repository

B R I E F  R E P O R TOpen Forum Infectious DiseasesBRIEF REPORT • ofid • 1 Received 16 December 2020; editorial decision 14 January 2021; accepted 18 January 2021.Correspondence: Asher J.  Schranz, MD, MPH, 130 Mason Farm Rd. (Bioinformatics), CB #7030, Chapel Hill, NC 27599-7030 (aschranz@med.unc.edu).Open Forum Infectious Diseases®2021© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.comDOI: 10.1093/ofid/ofab037Voter Registration Among People With HIV in North CarolinaAsher J. Schranz,1,  Nadya Belenky,2 Haley A. Moss,3 Sonia Napravnik,4 and David L. Rosen51Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA, 2RTI International, Research Triangle Park, North Carolina, USA, 3Duke Cancer Institute, Durham, North Carolina, USA, 4Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA, and 5Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USAPersons with HIV (PWH) represent a socially and medically vulnerable population who often depend on public resources. We examined voter registration among PWH in North Carolina. Sixty-four percent were registered to vote. Registration was lower among PWH who were young, Hispanic, publicly insured or uninsured, and who had poor HIV health status.Keywords.  HIV; politics; voting; voter registration.Voter participation is linked with health. Persons with disabil-ities, certain chronic conditions, and worse health are less likely to vote [1], although these populations are especially impacted by health care policies determined by elections. Persons with HIV (PWH) exemplify a medically and socially vulnerable pop-ulation, with high rates of noninsurance [2], incarceration [3], and suboptimal clinical outcomes despite availability of effective treatment [4]. HIV exists at the nexus of individual and public health, with the highest incidence rates among young Black and Hispanic men in the Southeastern United States [5]. To assess civic engagement among PWH, we examined voter registration in a large cohort of PWH in North Carolina and evaluated dem-ographic and clinical factors associated with voter registration.METHODSData on PWH were drawn from the University of North Carolina (UNC) Center for AIDS Research Clinical Cohort (UCHCC), which contains demographic and clinical informa-tion about consenting persons receiving HIV care at UNC. UCHCC participants aged ≥18 years who had at least 1 HIV care visit during 2019 were included and linked to publicly available voter registration records from the NC State Board of Elections, downloaded in July 2020. Of the total 8 007 192 voter records available in July 2020, voter records for persons aged <18 years or >115 years were excluded (n = 29 359). UCHCC participants residing outside North Carolina were excluded (n = 30). Linkage was performed using first name, last name, zip code of residence, and birth year, using Link Plus 2.0 (Centers for Disease Control and Prevention). The linkage strategy is de-scribed in the Supplementary Data. Four UCHCC participants matched to 2 separate voter records each. Their match status was determined by individual review of available identifiers.UCHCC patient records that could not be linked to a reg-istration record or were linked but had a registration status coded as “denied” or “removed” were considered unregistered. UCHCC patient records that were linked and had a registration status coded as “active,” “inactive,” or “temporary” were con-sidered registered, as these statuses denote the ability to vote with the current registration. Demographic information was drawn from UCHCC data. CD4 cell count and HIV RNA were based on the last available value from 2019. Rural residence was defined by county [6]. Persons with Medicare, Medicaid, or Tricare were labeled as having public insurance. Viral suppres-sion was defined as HIV RNA ≤50 copies/mL.Proportions of registered voters were calculated among UCHCC participants and examined based on demographic and clinical factors. The association between voter registra-tion and clinical and demographic factors was estimated with multivariable logistic regression, including gender, age, race/ethnicity, rural residence, insurance status, and viral suppres-sion. CD4 cell count was not included in the multivariable model due to substantial misssingness (245 persons, 15%). Analyses were performed with SAS, version 9.4.Patient Consent StatementParticipants provided written informed consent to be included in the UCHCC. The study was approved by the UNC institu-tional review board.RESULTSOf 1555 PWH residing in North Carolina with at least 1 care visit in 2019, 992 (64%) were registered to vote. Among PWH who were registered, 916 had an active registration status and 76 had an inactive status. None had registration removed or denied. Overall, the cohort was primarily male (72%), aged 50–64  years (43%), and Black/non-Hispanic (58%) (Table 1). A substantial minority had rural residence (27%), and the most common insurance types were public (47%) and commercial applyparastyle “fig//caption/p[1]” parastyle “FigCapt”2 • ofid • BRIEF REPORT(42%). Most patients had a CD4 >350 (83%) and viral suppres-sion (92%). Among registered voters, Democrat was the most common party affiliation (71%).In bivariable analyses, PWH who were young (18–34 and 35–49), Hispanic, uninsured, had low CD4, and were not vi-rally suppressed were significantly less likely to be registered to vote. In the results from a multivariable model, public in-surance status was also significantly associated with not being registered.DISCUSSIONIn this cohort of PWH in North Carolina, less than two-thirds were registered to vote. The health of underserved and disad-vantaged populations, including PWH, is impacted by social determinants, government resources, and government policies. PWH frequently rely on safety net public assistance programs for medical care, prescription drugs, and community services, and such programs are influenced by political will, budgets, and leadership. Because many PWH are not registered to vote, their interests may be politically underrepresented.We found that those insured by public insurance or unin-sured were less likely to be registered to vote. These persons may be most impacted by health policy decisions. For example, Medicaid expansion remains unadopted in North Carolina; nonexpansion states include much of the Southeast, where in-cident HIV infections are highest [5, 7]. Similarly, uninsured PWH rely on the AIDS Drug Assistance Program for medica-tion access, a state-operated program, co-funded by federal and state funds and vulnerable to state budget cuts, which can re-sult in waitlists and barriers to care for PWH [8]. Further, PWH with poorer HIV health status (lower CD4 cell count and viral Table 1. Demographic and Clinical Factors of Persons With HIV in North Carolina, by Voter Registration StatusTotal Registered Unregistered Bivariable Multivariable No. No. Row % No. Row % Estimate 95% CI Estimate 95% CIGender          Male 1112 717 64 395 36 1  1  Female 443 275 62 168 38 0.90 (0.72–1.13) 0.78 (0.60–1.01)Age          18–34 y 250 122 49 128 51 0.38 (0.28–0.51) 0.37 (0.27–0.52)35–49 y 429 235 55 194 45 0.48 (0.37–0.61) 0.56 (0.43–0.74)50–64 y 673 483 72 190 28 1  1  ≥65 y 203 152 75 51 25 1.17 (0.82–1.68) 1.23 (0.83–1.81)Race/ethnicity          White/non-Hispanic 477 333 70 144 30 1  1  Black/non-Hispanic 904 601 66 303 34 0.86 (0.68–1.09) 1.07 (0.83–1.39)Hispanic 127 26 20 101 80 0.11 (0.07–0.18) 0.15 (0.09–0.25)Other/unknown 47 32 68 15 32 0.92 (0.49–1.76) 1.06 (0.54–2.01)Rural          No 1133 719 63 414 37 1  1  Yes 422 273 65 149 35 1.06 (0.84–1.33) 1.15 (0.89–1.49)Insurancea          Commercial 649 447 69 202 31 1  1  Public 722 475 66 247 34 0.87 (0.69–1.09) 0.68 (0.52–0.88)None 176 66 38 110 63 0.27 (0.19–0.38) 0.43 (0.29–0.63)CD4b          >350 cells/mm3 1093 709 65 384 35 1    201–350 cells/mm3 149 81 54 68 46 0.61 (0.44–0.86)   ≤200 cells/mm3 68 28 41 40 59 0.36 (0.22–0.59)   Viral loadc          Suppressed (≤50 copies/mL) 1403 918 65 485 35 1  1  Not suppressed 120 55 46 65 54 0.45 (0.31–0.65) 0.57 (0.38–0.85)Party affiliationd          Democratic  708        Republican  61        Unaffiliated  217        Bolded values correspond to P < .05.aFewer than 10 participants had other insurance status and are not reported due to small cell size. bMissing for 245 participants (71 unregistered and 174 registered). cMissing for 31 participants (12 unregistered and 19 registered). dFewer than 10 participants had another party affiliation and are not reported here. BRIEF REPORT • ofid • 3nonsuppression) were registered in lower proportions than those with better HIV metrics. While this finding may indicate poor health status impeding civic engagement, it also may be a marker for other psychosocial and structural barriers impacting both health and voting.People choose not to register to vote for myriad reasons, in-cluding perceiving that their vote does not impact real-world decisions, busy schedules, or a lack of interest in government [9]. While qualitative research around civic engagement among PWH is needed, PWH likely face unique issues and barriers, in-cluding experienced and internalized stigma, ineligibility due to incarceration or citizenship, or lack of opportunity. In 2019, the most common source of voter registration in North Carolina was the Department of Motor Vehicles (DMV) [10]. Yet PWH, especially those most medically impacted by HIV, may be less likely to visit the DMV. Research from another setting in the Southeast has found that lower community viral suppression was associated with residence in areas with lower automobile ownership [11]. We found no records of voter registration ap-plications denied due to felony status. However, persons who are aware of ineligibility may not apply and thus may not appear in the voter registration database.To our knowledge, this is the first report directly exam-ining voter registration among PWH in the United States. Identifying a benchmark voter registration rate for compar-ison is difficult because different methodologies result in a wide range of registration rates. In North Carolina, there were 7 000 558 registered voters as of July 2020, representing 86% of the 8 187 369 residents over 18 years during 2019 [12]. However, state voter registration records may contain du-plicate records and registrations for persons who have died or moved out of state. In contrast, a survey performed by the United States Census Bureau found that 65% of eligible voters in North Carolina were registered for the 2018 election. Patterns of registration identified in the survey were generally similar to patterns we identified in our population of PWH [13]. For example, both our study and the survey found that the proportion of those registered increased with age and that patterns of registration by racial and ethnic category were sim-ilar. However, the Census Bureau findings were drawn from self-report, so they may not be a reasonable comparison to our study findings considering the different methodologies. Further study among PWH and other socio-medically vulner-able populations is needed to fully understand voter registra-tion and participation as well as the most effective means to improve them.This study is limited by the possibility of invalid or missed linkage of UCCHC and voter records. Given that the linkage strategy incorporated residence information, persons who re-cently moved or with unstable housing may have been missed and thus labeled as unregistered. As we did not have data on citizenship or felony convictions, we were unable to restrict the analysis based on eligibility. Lastly, the generalizability of our findings to all PWH or states is unknown. However, the lim-ited data available suggest that our study population reflects the demographic and clinical profile of PWH in care in North Carolina [14].In summary, we found that more than one-third of PWH were not registered to vote, and those who are most medi-cally vulnerable were less likely to be registered. Providers and health systems addressing social determinants of population health should consider their role in encouraging patients’ civic engagement. These findings support implementation of clinic-based nonpartisan interventions to enhance voter registration and enfranchise PWH and other underrepresented patients in the electoral process.Supplementary DataSupplementary materials are available at Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.AcknowledgmentsFinancial support. This work was supported by the National Institute on Drug Abuse (K23DA049946 to A.J.S.); the National Institutes of Health (K12HD043446-18 to H.A.M.); the National Institute of Allergy and Infectious Diseases (R01AI129731 to D.L.R.); the National Institute of Minority Health and Health Disparities (R01MD012469 to D.L.R.); and the University of North Carolina at Chapel Hill Center for AIDS Research (CFAR), a National Institutes of Health–funded program (P30AI050410).Potential conflicts of interest. All authors: no reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.References1. Brown CL, Raza D, Pinto AD. Voting, health and interventions in healthcare set-tings: a scoping review. Public Health Rev 2020; 41:16.2. Yehia BR, Fleishman JA, Agwu AL, et al. Health insurance coverage for persons in HIV care, 2006–2012. J Acquir Immune Defic Syndr 2014; 67:102–106.3. Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, Hammett TM. HIV/AIDS among inmates of and releasees from US correctional facilities, 2006: declining share of epidemic but persistent public health opportunity. PLoS One 2009; 4:e7558. 4. Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital signs: HIV transmission along the continuum of care—United States, 2016. MMWR Morb Mortal Wkly Rep 2019; 68:267–272.5. Centers for Disease Control and Prevention. HIV surveillance report 2018. 2020. Available at: http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed 8 September 2020.6. North Carolina Department of Health and Human Services. County designations of core based statistical areas. Available at: https://files.nc.gov/ncdhhs/Metro%20Micropolitan%20Counties%20%2812DEC16%29.pdf. Accessed 8 September 2020.7. Kaiser Family Foundation. Status of state action on the Medicaid expansion deci-sion. 2020. Available at: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed 8 September 2020.8. Walensky  RP, David  Paltiel  A, Freedberg  KA. AIDS drug assistance programs: highlighting inequities in human immunodeficiency virus–infection health care in the United States. Clin Infect Dis 2002; 35:606–610.9. The Pew Charitable Trusts. Why are millions of citizens not registered to vote? 2017. Available at: https://www.pewtrusts.org/-/media/assets/2017/06/ei_why_are_millions_of_citizens_not_registered_to_vote.pdf. Accessed 6 October 2020.10. North Carolina State Board of Elections. NVRA transactions by year and source. Available at: https://public.tableau.com/views/NVRA_Transactions_by_Year_and_Source/Cha4 • ofid • BRIEF REPORTrtYearlyTransactionsbySource?%3Aembed=y&%3AshowVizHome=no&%3Adisplay_count=y&%3Adisplay_static_image=y&%3AbootstrapWhenNotified=true&%3Alanguage=en&:embed=y&:showVizHome=n&:apiID=host0#navType=0&navSrc=Parse. Accessed 9 October 2020.11. Goswami ND, Schmitz MM, Sanchez T, et al. Understanding local spatial vari-ation along the care continuum: the potential impact of transportation vulnera-bility on HIV linkage to care and viral suppression in high-poverty areas, Atlanta, Georgia. J Acquir Immune Defic Syndr 2016; 72:65–72.12. Centers for Disease Control and Prevention. Bridged-race population estimates. Available at: https://wonder.cdc.gov/bridged-race-population.html. Accessed 18 August 2020.13. US Census Bureau. Voting and registration tables. Available at: https://www.census.gov/topics/public-sector/voting/data/tables.html. Accessed 5 January 2020.14. 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Voter Registration among People with HIV in North Carolina

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Voter Registration among People with HIV in North Carolina

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