Category: Health Policy

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

 

Local Governments take Legal Action against Opioid Manufacturers

In response to the Opioid Epidemic currently being faced in North Carolina and the US, several local jurisdictions have taken steps towards legal action against the manufacturers and distributors of prescription opioids. Over four hundred federal lawsuits have emerged from local governments across the country, and these have been consolidated into a lawsuit in Ohio.

Yesterday, the City Council of Greensboro voted to join a nationwide lawsuit that targets manufacturers and distributers of prescription opiate painkillers. Later this week, the Davidson County Board of Commissioners will have a hearing and presentation around joining national opioid litigation. In total, more than forty of the State’s 100 counties have joined the lawsuit. In Forsyth County, containing the city of Winston-Salem, a similar lawsuit was filed that included defendants of more than 20 drug manufacturers.

Many of these local jurisdictions cited that the risks for addiction and dependency to prescription opiates were never communicated by drug companies, while manufactures continued to make profits with increasing supply and demand. As more municipalities continue to join litigation of file new lawsuits, while trying to adopt laws and policies to limit overprescribing, further attention should be paid to find and utilize effective strategies to limit opioid overdose deaths.

 

Sources –

 

News & Record: Greensboro joins lawsuit against drug manufacturers over opioid epidemic – http://www.greensboro.com/news/government/greensboro-joins-lawsuit-against-drug-manufacturers-over-opioid-epidemic/article_22ff745e-2002-5c27-a41a-454ab80403b7.html

Winston-Salem Journal: Forsyth County sues opioid manufacturers, distributers, claiming deceptive marketing practices – http://www.journalnow.com/news/local/forsyth-county-sues-opioid-manufacturers-distributors-claiming-deceptive-marketing-practices/article_7f8a2bf3-958f-5462-b63b-4c1affeca27d.html

The Dispatch: County to hear opioid litigation presentation – http://www.the-dispatch.com/news/20180430/county-to-hear-opioid-litigation-presentation

 

STOP Act: Implementation and Effects Part II

Earlier today, The News & Observer reported that thousands of doctors in North Carolina were breaking the recently passed STOP Act, by over-prescribing prescription opioids. In a previous post I briefly explained provisions under the STOP Act, STOP Act: Implementation and Effects on the Opioid Epidemic in North Carolina.

Based on preliminary data from the North Carolina Department of Health and Human Services, and Blue Cross and Blue Shield, showed that many were over-prescribing. The STOP Act limits opioid prescriptions to five days to first time patients, or seven days if the patient had surgery. The state health department presented their findings to staff of the North Carolina Medical Board, who noted that they do not have the capacity to investigate every prescriber reported to determine if prescriptions were legitimate.

Blue Cross and Blue Shield had started to electronically block the filling of prescription opioids for more than seven days at the start of April, noting that this policy had blocked more than 1,100 prescriptions. While there were questions about the precision of the data and its accuracy, these preliminary reports showcase the difficulties of challenging the opioid epidemic by policies limiting prescribing.

 

Sources –

The News & Observer – Thousands of N.C. doctors are over-prescribing opioids, breaking a new state law – http://www.newsobserver.com/news/business/article209824434.html

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/.

 

 

 

No assistance here: drug testing for food assistance

Illegal drug use has been a major topic of concern throughout the 21st century.  In the mid-1980s, we saw an emergence of harsh federal penalties for illegal drug users and strong war-on-drugs messaging. Today, we are seeing increased attention given to illegal opioid use as a public health concern.  While today’s efforts largely focus on helping illicit drug users overcome addiction, drug testing is now being considered as a requirement for participation in food assistance programs.

The Associated Pressed announced earlier this month that the Trump administration “is considering a plan that would allow states to require certain food stamp recipients to undergo drug testing.” These plans could require a negative drug test before receiving aid through programs like the Supplemental Nutrition Assistance Program (SNAP), a program which provided food assistance to over 40 million people in January 2018 alone (1). While a war-on-drugs approach has been used to criminalize individuals who suffer from addiction, states, including SC, GA, AL, and FL, have consistently ruled that drug testing as a requirement for participation in assistance programs unconstitutional. In Lebron v. Florida Department of Children and Families, the state established that the government does not have bases for suspicionless drug testing among recipients of the Temporary Assistance for Needy Families program and that such requirements are unconstitutional.

In my opinion, this requirement would unnecessarily portray welfare recipients as drug abusers who are undeserving of assistance. I am curious to learn more about this current administrations’ cause for the drug testing requirement. Would testing encourage drug users who need assistance to stop using drugs? Is the requirement meant to reduce federal spending? How will drug test be funded when programs such as SNAP cost over $64 billion in 2017 alone (2)? Would assistance programs offer resources to people who fail drug tests?

Reference: 1) https://fns-prod.azureedge.net/sites/default/files/datastatistics/january-performance-report-2018.pdf

(2) https://fns-prod.azureedge.net/sites/default/files/ops/Reaching2015.pdf

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