Category: Healthcare Reform

Current Climate of HIV Disparity in NC: Part 2

Impact of Disparity

Research has shown that the prevalence of HIV diagnoses and the rates of new HIV infections are highest in the southern US, including North Carolina.7 In the state of North Carolina:

  • Male-to-male sexual contact represents the mode of transmission for almost 70% of men living with HIV8
  • Almost 6% of transmissions for men living with HIV were the result of dual exposure through injection drug use and male-to-male sexual contact8
  • Almost three-fourths of total HIV transmission in the state are the result of male-to male sexual contact8
  • Among new diagnoses, these numbers only seem to be increasing, closer to 84%8
  • Black men in the state of North Carolina are also 6 times more likely to be living with HIV than white males8
  • The Durham-Chapel Hill, Winston-Salem, Greensboro-High Points metropolitan areas were also identified within the top 25 metropolitan areas for prevalence of HIV diagnoses and rates of new infections7

Causes of Disparity

Pre-exposure prophylaxis offers many opportunities to prevent the spread of HIV; however, stigma surrounded the drug itself may be preventing many gay and bisexual men from seeking out the drug and many medical providers from prescribing the drug to their gay and bisexual patients. This could partially be a result of general stigma about asking patients sexual health questions or questions about sexuality. Simply prescribing PrEP to all gay and bisexual men would result in overuse. Hence, discussions about sexual risk behaviors is important for assessing an individual’s need for the drug. However, medical provider stigma might represent a larger barrier to accessing PrEP, especially for black men who have sex with men. Further, the population of medical providers has been less of a focus for current public health interventions to increase the use of PrEP.

 

References

  1. Duran, D. Truvada Whores? Huffinton Post. 2012. https://www.huffingtonpost.com/david-duran/truvada-whores_b_2113588.html
  2. Addison, V. Larry Kramer, Truvada Whores and the Angry Divide Between Two Generations. HIVEqual. n.d. http://www.hivequal.org/homepage/larry-kramer-truvada-whores-and-the-angry-divide-between-two-generations
  3. Logo. Revisiting “Truvada Whore” Three Years Later. NewNowNext. 2016. http://www.newnownext.com/revisiting-truvada-whore-three-years-later/02/2016/
  4. Emory University Rollins School of Public Health. North Carolina. AIDSVu. n.d. https://aidsvu.org/state/north-carolina/
  5. Calabrese SK, Underhill K. How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. American journal of public health. 2015;105(10):1960-1964.
  6. Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS and behavior. 2014;18(2):226-240.
  7. Rosenberg ES, Grey JA, Sanchez TH, Sullivan PS. Rates of Prevalent HIV Infection, Prevalent Diagnoses, and New Diagnoses Among Men Who Have Sex With Men in US States, Metropolitan Statistical Areas, and Counties, 2012-2013. JMIR Public Health Surveill. 2016;2(1):e22.
  8. Britz JJ. To Know or not to Know: A Moral Reflection on Information Poverty. Journal of Information Science. 2004;30(3):192-204.

Current Climate of HIV Disparity in NC: Part 1

For many people, the term AIDS is no longer representative of the state of HIV; with current treatment options, no individual’s manifestation of HIV should reach the level of AIDS. However, more work needs to be done to prevent the spread of HIV, specifically with a goal of protecting men in the gay community. In the US, men who have sex with men continue to carry the burden of prevalence of individuals living with HIV and rates of new diagnoses. This issue is exacerbated in the South and among black men who have sex with men. Pre-exposure prophylaxis for HIV (PrEP) represents an opportunity to drastically reduce the number of new HIV diagnoses; however, individuals must be able to gain access to this preventative treatment.

Evidence of Disparity

On November 12, 2012, more than five years ago, David Duran wrote an article for the Huffington Post, titled “Truvada Whores?” Duran argued that pre-exposure prophylaxis for HIV (PrEP) allows gay men (and other men who have sex with men) to engage in unsafe sex while taking a pill, rather than encouraging them to partake in safer-sex practices, by which I assume he means the use of a barrier method like a condom.1 In the past five years, little has changed in the way that people think about stigma and PrEP. Even within gay publications and HIV-centered advocacy groups, people continue to write about the “Truvada Whore.”2,3 The use of this term is strongly connected to stigma related to the use of PrEP, which is pervasive even within the medical community4,5 Stigma is exasperated when coupled with the implicit racial bias of providers that causes them to assume that black men who have sex with men engage in riskier sex6 As a result, there is stigma from within the gay community that assumes men who take PrEP are riskier or more likely to have HIV, from outside of the gay community that assumes they’re sluts or whores, and also specifically from the medical community, which assumes that prescribing PrEP will increase risk behaviors, leading to more HIV infections.

 

References

Works Cited

  1. Duran, D. Truvada Whores? Huffinton Post. 2012. https://www.huffingtonpost.com/david-duran/truvada-whores_b_2113588.html
  2. Addison, V. Larry Kramer, Truvada Whores and the Angry Divide Between Two Generations. HIVEqual. n.d. http://www.hivequal.org/homepage/larry-kramer-truvada-whores-and-the-angry-divide-between-two-generations
  3. Logo. Revisiting “Truvada Whore” Three Years Later. NewNowNext. 2016. http://www.newnownext.com/revisiting-truvada-whore-three-years-later/02/2016/
  4. Emory University Rollins School of Public Health. North Carolina. AIDSVu. n.d. https://aidsvu.org/state/north-carolina/
  5. Calabrese SK, Underhill K. How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. American journal of public health. 2015;105(10):1960-1964.
  6. Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS and behavior. 2014;18(2):226-240.
  7. Rosenberg ES, Grey JA, Sanchez TH, Sullivan PS. Rates of Prevalent HIV Infection, Prevalent Diagnoses, and New Diagnoses Among Men Who Have Sex With Men in US States, Metropolitan Statistical Areas, and Counties, 2012-2013. JMIR Public Health Surveill. 2016;2(1):e22.
  8. Britz JJ. To Know or not to Know: A Moral Reflection on Information Poverty. Journal of Information Science. 2004;30(3):192-204.

 

The Continuing HIV Disparity for Black Men

Despite only making up 2% of the U.S. population, men who have sex with men (MSM) account for 52% of the U.S. population of individuals living with HIV, and these rates don’t seem to be decreasing.[1] In 2013, MSM accounted for 65% of new HIV diagnoses.[2] Among MSM, black men are disproportionately at risk of contracting HIV, accounting for 30% of MSM living with HIV and almost 40% of new HIV diagnoses in 2012 though black people only constitute about 13% of the U.S. population.[3] Of these black MSM newly diagnosed, 38% were between the ages of 13 and 24 in 2015.[4] Of black gay and bisexual men living with HIV, only 54% received continuous HIV care.[5]

These statistics illustrate the stark disparity in HIV treatment and prevention for queer black men, especially younger queer black men. According to a 2018 CDC report, black men are not receiving PrEP prescriptions or being provided PrEP at the rate that they should be.[6] Some health professionals will likely attempt to target black MSM, claiming that they are less likely to be aware of PrEP, are more likely to have sex with other black men and are thus more likely to contract HIV because of the higher prevalence rate in black communities, are more likely to participate in riskier sexual behaviors, are less willing to take medications, etc. Many of the reasons for lower PrEP usage among black MSM will likely be attributed to decisions made by black MSM themselves.

However, in 2014, Calebrese et al found, in a nationally representative sample of medical students, that students were less likely to prescribe PrEP to a black man than a white man.[7] A pervasive logic surrounding PrEP, exacerbated by the stereotype of the Truvada Whore, is that people who take PrEP will participate in riskier sex.[8] However, PrEP should be the answer to protecting individuals who are participating in riskier behavior.[9] Ultimately, this logic is backwards and slut-shaming, and it puts black MSM at greater risk because it keeps them from being prescribed PrEP.

We should be looking to medical schools to better prepare their students to provide necessary care to LGBTQ+ people more broadly, but also from this example more specifically to black MSM. We should also be targeting current providers to combat issues of implicit bias, homophobia, and heterosexism that are preventing LGBTQ+ individuals, especially black MSM, from accessing the best possible care.

[1] “MSM Population Profile.” AIDSVu, 9 Mar. 2018, aidsvu.org/aidsvu-in-use/msm-population-profile/. AIDSVu is maintained by faculty and staff at Emory University’s Rollins School of Public Health in partnership with Gilead Sciences, Inc. and the Center for AIDS Research at Emory University (CFAR) with assistance from members of other institutions. Some of the data and statistics presented on the AIDSVu website is provided from other medical and health surveillance institutions, such as the CDC.

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] “HIV among African American Gay and Bisexual Men.” Centers for Disease Control and Prevention, 14 Feb. 2018, www.cdc.gov/hiv/group/msm/bmsm.html.

[6] “HIV prevention pill not reaching most Americans who could benefit – especially people of color.” Centers for Disease Control and Prevention, 6 Mar. 2018, www.cdc.gov/nchhstp/newsroom/2018/croi-2018-PrEP-press-release.html.

[7] Calabrese, S. K., Earnshaw, V. A., Underhill, K., Hansen, N. B., & Dovidio, J. F. (2014). The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav, 18(2), 226-240. doi:10.1007/s10461-013-0675-x

[8] Calabrese, S. K., & Underhill, K. (2015). How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. Am J Public Health, 105(10), 1960-1964. doi:10.2105/ajph.2015.302816

[9] Calabrese, S. K., Magnus, M., Mayer, K. H., Krakower, D. S., Eldahan, A. I., Hawkins, L. A. G., . . . Dovidio, J. F. (2017). “Support Your Client at the Space That They’re in”: HIV Pre-Exposure Prophylaxis (PrEP) Prescribers’ Perspectives on PrEP-Related Risk Compensation. AIDS Patient Care STDS, 31(4), 196-204. doi:10.1089/apc.2017.0002

Bed shortages result in waiting for days in North Carolina ED’s

In recent years the phenomenon of boarding psychiatric patients in emergency departments has not only become a nationwide problem but a growing problem here in North Carolina. Psychiatric boarding refers to the phenomenon of patients with primary behavioral health complaints experiencing excessive waiting times in emergency departments (EDs). Many claim that the root of this problem arises from the continued cutting of funding for psychiatric institutions. Currently, North Carolina falls below the national average with the number of available inpatient psychiatric beds and ranks 40th number of beds per person in the country. An addition, the average wait time for a patient with a psychiatric compliant to be either discharged or be admitted is 2.5 days. This number is even worse for individuals who are waiting to be admitted to an inpatient bed at one of the psychiatric hospitals in the state, patients wait almost 4 days. How do we go about fixing this problem? This is a question that psychiatrists, policymakers and mental health professionals are striving to answer but with limited funding from the state it is challenging to do so.

References

http://www.charlotteobserver.com/news/local/article161034564.html

http://www.treatmentadvocacycenter.org/evidence-and-research/studies

 

Looking at Our Health Care System

By now, we’ve probably all heard statements comparing United States’ health care against other countries- we have the most expensive healthcare (1), we have many suffering due to lack of access (2), medical bills are the leading cause of bankruptcy  (3), etc.  Then we’re met with opinions who like our healthcare system stating that Americans have choice (4), we have better technology (5), we treat patients quickly (6), and the list goes on.

Many Americans seem to take pride in our capitalist healthcare system. I know that I grew up hearing that all other systems were socialized medicine which removed the incentives to innovate and increased wait times for patient care.  However, I have recently looked more closely into other health care systems, and it has caused me to re-examine the stories of my youth.

For today, I would like to examine Germany’s healthcare system.  Even though everyone has health insurance, they still use a mix of public and private insurance companies (7), their costs are lower than American healthcare (8), they have similar wait times (8), no one is going bankrupt due to medical bills (9), and they continue to innovate (10).

I don’t presume to know how to change our health care system, but I do believe it is time to turn it upside down.  In the 1990’s, Switzerland successfully moved away from a system structured like ours to one that granted universal coverage (11).  I believe that if they can take care of their own, then so can we.

I know that an overhaul will take lots of conversations and time.  For now, I ask that we start questioning if this really is the best health care system for all Americans or is it just the best one for the healthy and wealthy.  If you think that we are no longer serving everyone, then I encourage you to be part of the conversation.  Even if you don’t have to wait a long time for a doctor, should another American have to wait because they don’t have insurance?

 

References

  1. Peterson-Kaiser. Total Health Spending. Kaiser Family Foundation. [Online] March 19, 2017. https://www.healthsystemtracker.org/indicator/spending/health-expenditure-gdp/.
  2. Centers for Disease Control and Prevention. Access to Health Care. Centers for Disease Control and Prevention. [Online] May 3, 2017. https://www.cdc.gov/nchs/fastats/access-to-health-care.htm.
  3. Backman, Maurie. This is the No. 1 reason Americans file for bankruptcy. USA Today. [Online] May 5, 2017. https://www.usatoday.com/story/money/personalfinance/2017/05/05/this-is-the-no-1-reason-americans-file-for-bankruptcy/101148136/.
  4. Speaker Ryan Press Office. The American Health Care Act: Fact Sheet. Speaker Paul Ryan. [Online] March 7, 2017. https://www.speaker.gov/general/american-health-care-act-fact-sheet.
  5. Evans, Maria. What Are the Benefits of the United States Health Care System? Pocket Sense. [Online] October 25, 2017. 2017.
  6. Dhand, Suneel. 5 things that make U.S. health care great. KevinMD.com. [Online] August 5, 2014. https://www.kevinmd.com/blog/2014/08/5-things-make-u-s-health-care-great.html.
  7. Carroll, Aaron E. and Frakt, Austin. The Best Health Care System in the World: Which One Would You Pick? The New York Times. [Online] September 18, 2017. https://www.nytimes.com/interactive/2017/09/18/upshot/best-health-care-system-country-bracket.html.
  8. Bernstein, Lenny. Once again, U.S. has most expensive, least effective health care system in survey. The Washington Post. [Online] June 16, 2014. https://www.washingtonpost.com/news/to-your-health/wp/2014/06/16/once-again-u-s-has-most-expensive-least-effective-health-care-system-in-survey/?noredirect=on&utm_term=.a2ef07f4a443.
  9. Underwood, Anne. Health Care Abroad: Germany. The New York Times. [Online] September 29, 2009. https://prescriptions.blogs.nytimes.com/2009/09/29/health-care-abroad-germany/.
  10. German Foreign Ministry for Economic Affairs and Energy. Innovative German medical technology a key healthcare industry driver. German Foreign Ministry for Economic Affairs and Energy. [Online] January 5, 2018. https://www.exportinitiative-gesundheitswirtschaft.de/EIG/Redaktion/EN/Kurzmeldungen/News/2018/2018-01-05-innovative-german-medical-technology.html.
  11. Thacher, Emily. Switzerland: Regarding Health System Reform. The Yale Global Health Review. [Online] October 3, 2015. https://yaleglobalhealthreview.com/2015/10/03/switzerland-regarding-health-system-reform/.

 

 

 

Free Lyft to the Pharmacy

Blue Cross and Blue Shield Institute has started a partnership with the ride sharing company Lyft to provide their members with free rides to pick up their medications. The Blue Cross Blue Shield Institute is a new organization that’s mission is to reduce the barriers of accessing healthcare. One of the largest identified barriers to accessing healthcare is transportation. Last year, their big initiative was a similar program with Lyft to provide free transportation for their patients to their doctors’ appointments. By investing in these types of programs, the organization is hoping to reduce costs in the long -term and improve the health outcomes of their consumers. With this newest imitative they are also partnering with pharmaceutical organization such as CVS Health and Walgreens to increase medication adherence. These programs are still under pilot testing and are currently funded by CVS and Walgreens in Chicago and Pittsburgh with patients who are living in “transportation deserts”. These types of unique partnerships are allowing for creative solutions and addressing the social determinants of health in order to solve the most dire healthcare problems. Let’s hope to see more of these types of collaborations in the future.

References

https://www.forbes.com/sites/brucejapsen/2018/03/14/cvs-and-walgreens-partner-with-lyft-to-get-blue-cross-patients-to-pharmacies/#34f4fa0f76c8

https://www.bcbs.com/news/press-releases/blue-cross-and-blue-shield-and-lyft-join-forces-increase-access-health-care

California: The Robin Hood of Mental Health

This week’s blog post was inspired by a reading from my health policy and management course about California’s tax on the wealthy and using the revenue to fund community based services for mental health. The state of California is acting as Robin Hood for mental health to take from the wealthy to help those who need the most. According to the article published by Kaiser Family Foundation, The Mental Health Services Act (or formerly known as Proposition 63) taxes 1% of California citizens whose annual income exceeds $1 million. It was passed into law in January 2005. Annually, this tax generates around $2 billion and since its inception has raised around $16.53 billion. The two major initiatives that are funded by this endeavor include prevention and early intervention for young adults and outcome improvement in individuals with severe mental health conditions. Results have shown that this tax has had a positive effect on the outcomes of individuals with mental health conditions. Hopefully we start to see more results come out of California and the positive outcomes that may encourage other states to adopt similar policies and move towards a culture of prevention instead of treatment of mental health.

To learn more about the law here is a link to the bill: http://www.dhcs.ca.gov/services/mh/Pages/MH_Prop63.aspx

References

https://khn.org/news/californias-tax-on-millionaires-yields-big-benefits-for-people-with-mental-illness-study-finds/

 

Doctors are humans too

In binge watching the newest medical show “The Resident” this past weekend, the show made me consider the role of medical error and transparency. The show portrays an arrogant surgeon with a secret tremor unwilling to give up his career despite his inability to perform successful surgeries. While the story plot line is dramatized and designed to pull viewers in for higher ratings, it highlights the importance of medical error and transparency. According to The BMJ, medical error is the third leading cause of death in the United States. Examples of medical error include medication errors (wrong dose, wrong drug) and hospital infections. Medical errors are challenging to comprehend since healthcare providers are only human and they are bound to make mistake just like the rest of us. The amount of stress and pressure these providers face all while working at all hours undoubtedly will result in mistakes. However, their mistakes have much more severe consequences. The show discusses transparency as a way to address the stigma surrounding medical error and by having more transparency could result in lower rates of medical error. An interesting fact to note is that these are errors are not recognized as cause of death on death certificates. To me, this further stigmatizes the errors and places blame on the healthcare provider and doesn’t change the narrative that providers are human and errors will happen. We treat these healthcare providers as superhuman but we need to remember that they are just like us and as a humans we make mistakes and hopefully we learn from them.

References:

https://health.usnews.com/health-news/patient-advice/slideshows/5-common-preventable-medical-errors?slide=4

https://www.bmj.com/content/353/bmj.i2139.full

Medicaid Expansion and the Opioid Epidemic in the U.S.

As the United States continues to be embattled in an ongoing opioid overdose epidemic, new research is showing the benefits that Medicaid expansion has had under the Patient Protection and Affordable Care Act (ACA). According to a recent study out of the Center on Budget and Policy Priorities, the rate in which patients who were hospitalized due to opioid-related health issues, who were uninsured dropped in states that expanded Medicaid, from 13.4% in 2013 to 2.9% the following year. The same study also showed that Medicaid expansion had not contributed to the ongoing opioid crisis, showing that opioid-related hospitalizations were higher in states that expanded Medicaid three years before expansion occurred, and that the rates had been steady in expansion and non-expansion states. As we can see, Medicaid expansion has had a profound impact in reducing the rate of uninsured, and in the case of the ongoing Opioid epidemic, Medicaid plays a key and vital role in working to help curb the epidemic. For more information on this study from the Center on Budget and Policy Priorities, please check out the link below.

Sources:

Center on Budget and Policy Priorities, Medicaid Expansion Dramatically Increased Covered for People with Opioid-Use Disorders, Latest Data Shows – https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use

Wearable Health: Who Benefits and Who is Left Out?

By Shazia Manji

There’s no denying the ubiquity of wearable health technology. The global wearables market is expected to grow by more than 15% this year alone, with projected sale of 310.4 million devices worldwide and $30.5 billion generated in revenue. These technologies generate real-time personalized data with the promise to improve individual health by helping to track, manage, incentivize, and improve healthy behaviors and decision making. As wearable tech finds success in the market, it’s important to consider where they can be most effective and where do they face barriers in impact. For example, a device such as a FitBit may be helpful in motivating an individual to make small changes to their diet when they have the necessary resources to make that happen. But what happens if you can’t afford a gym membership and you don’t feel safe running around your neighborhood at night? How well will these devices work for people who live in food swamps, neighborhoods or areas with many fast food and liquor stores but few places to buy healthy foods such as fresh fruits and vegetables?

The overall efficacy and effectiveness of wearable tech is still being determined. A 2015 study published in the Journal of the American Medical Association noted that while these kinds of tracking devices were increasing in popularity, there has been little evidence to show that they are successful in actually changing behavior. Still another suggested that wearables are more likely to be purchased by those who already live a relatively healthy lifestyle, and are less in use by those who might most benefit from a shift in physical activity, or by those with an existing and related health condition. Few studies or initiatives have looked at connecting these mobile health technologies with lower-income individuals in the US or at increasing their prevalence across socioeconomic status. This is largely in part because cost can be prohibitive for those at the lower end of the spectrum. Low-income populations are most at risk for diabetic complications, and may be less likely to have easy access to a physician, but the tools to help improve compliance and self-care have not been made with them in mind. The digital divide in healthcare technology is yet another example of how opportunities and resources for health are inequitably distributed. If we truly want to increase the effectiveness and relevance of wearable health tech, there needs to be a shift in their development and distribution.

A great first step to reducing the cost barrier would be working to get more health tech to be covered by insurers – and not just more robust private or employer-provided insurance plans, but by the insurance plans used by targeted populations, including Medicare and Medicaid. Tech companies could forge partnerships with community-based initiatives working to understand and shift the more structural barriers to health in low-income neighborhoods as part of potential multi-level interventions that go beyond individual behavior change. Wearable health tech used in research studies could combine the tracking technology with forms of interviewing or survey collection aimed at better understanding the barriers to behavior change in the most vulnerable populations, to help collect participant data that can in turn inform chronic disease prevention efforts. At the very least, developers could recognize that tech developed and marketed towards more affluent populations will differ from tech tailored for the most vulnerable.

Perhaps most importantly, I think it’s important to approach investment in and development of wearable health technologies with caution. Investment in digital health technologies is rising tremendously – but it’s crucial to understand who benefits from these technologies and who is left out, and then work proactively toward decreasing the digital divide. Investment in new tech should not trump investment in people and investment in improving the places and conditions in which people live, the conditions which shape and constrain quality of life and health behaviors.

Image: Koolme, Andri. “Fitbit Blaze activity tracker / wristwatch / smartband / smartwatch / smartphone.” 16 July 2016. Licensed under Creative Commons Attribution 2.0 Generic (CC BY 2.0). Accessed 31 Jan 2018.