Category: Social Determinants

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

Primary Care Access in Rural Areas

Rural areas of the U.S. face unique barriers to healthcare that must be approached with a systematic framework. One access issue is a lack of primary care practitioners (PCPs) in rural areas: despite existing incentive structures for PCPs to complete residencies in rural areas, there is still a provider shortage, leading to limited access to providers for rural residents. A lack of providers in a given area could manifest itself in fewer appointment slots or longer wait times, for example. Poor access to primary care has been found to be both an effect of poverty and a cause of further health disparities.

A study of barriers to preventative screenings in Appalachia found that “lack of knowledge about prevention and cost” were the primary obstacles, impacting 51% and 36% of participants, respectively. In Graham County, NC, a county in Appalachia that is 100% rural, the local Department of Public Health asked key informants about healthcare issues in their community. When asked how much they believed physical environment and social determinants of health contribute to health problems in the county, most ranked social determinants (such as alcohol/drug abuse, economy, and education) as a major contributor. However, their top health priority was access to care. This suggests that residents are aware of the importance of primary care as an upstream factor impacting their overall ability to access healthcare. To address this issue, we cannot overlook the socioeconomic barriers that individuals face to access, as well as the other challenges happening in their lives simultaneously.

Sources:

http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx

https://news.harvard.edu/gazette/story/2016/02/money-quality-health-care-longer-life/

https://www.ncbi.nlm.nih.gov/pubmed/7848026

http://www.grahamcounty.org/Departments/Health/Forms/2015 Graham County CHA.pdf

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

Discrimination and Health Part II: People of Color

Last week, I talked about how discrimination faced in healthcare settings can impact LGBTQ+ individuals’ attitudes towards healthcare, and how facing discrimination in everyday life can negatively impact their health outcomes. People of color (PoC) in the U.S., including immigrants, refugees, and Indigenous Peoples, face this double-barreled oppression as well.

Of course, one way racism affects health is through the broad structures that have placed many PoC groups at disadvantaged positions, intersecting with poverty – one study found that almost 100,000 black people die prematurely each year who would not die were there no racial disparities in health.

But discrimination itself, even on an individual level, can impact the health and healthcare experiences of PoC. Microaggressions, or everyday interactions rooted in racism, are a daily stressor for PoC, and these stressors can lead to premature illness and mortality.

Of course, this discrimination doesn’t just happen in daily interactions, but also in medical settings, which rightfully leads to mistrust and under-use of healthcare for PoC. Language and cultural barriers faced by immigrants can have similar effects.

Because race, socioeconomic status, and health are so intertwined, it may never be possible to know what levels of discrimination have the greatest ultimate effects on health outcomes. But we know they all have at least some, which should be enough to demand action.

Sources: https://www.ncbi.nlm.nih.gov/pubmed/12042611

https://www.hindawi.com/journals/tswj/2013/512313/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821669/#!po=2.38095

https://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/

https://www.ncbi.nlm.nih.gov/pubmed/17001262

App Grindr under scrutiny over privacy concerns

In an article published yesterday by BuzzFeed News, it was released that Gay Dating App Grindr has been sharing its users’ HIV status with two outside companies, a move which many consider dangerous to the queer community that the app claims to serve.

The sites, Apptimize and Localytics, work with Grindr to optimize the app and user experience. While it has been noted that these companies do not share information with third parties, there are still concerns with the sharing of sensitive information of a historically vulnerable population. This could raise flags for users sharing their HIV status on the app, which could negatively impact public health interventions that work to reduce HIV transmission and stigma.

Grindr recently announced that they would remind users to get tested for HIV every three to six months, offering a cue to action for users to be more aware of their HIV status. Knowing ones status is a crucial component for reducing the number of new HIV infections, such as by offering the opportunity to those who are living with HIV to be connected to care and achieve viral suppression.

 

Sources:

BuzzFeed News: Grindr Is Sharing The HIV Status Of Its Users With Other Companies –https://www.buzzfeed.com/azeenghorayshi/grindr-hiv-status-privacy?bfsplash&utm_term=.eu9v16ZaQ#.akvOQgNJj

Discrimination and Health Part I: LGBTQ+ Americans

Past research has suggested that discrimination can impact health outcomes – perhaps through vehicles such as stress of daily interactions and negative experiences with the healthcare system. One group whose experiences with discrimination can be linked to negative health outcomes is LGBTQ+ Americans. A study found that over half of LGBTQ people have experience slurs and offensive comments, and over half have been sexually harassed or experienced violence, or had an LGBTQ friend or family member experience such trauma.

We can make the connection between discrimination and trauma through various factors. One is through microaggressions –  seemingly harmless daily interactions with others who express, in this case, homophobic or transphobic views. These have been found to negatively impact health. Another is through discrimination within the healthcare system that lead LGBTQ Americans to seek healthcare less frequently. 18% of this population has avoided necessary medical care. Various forms of discrimination they face at the hands of medical professionals, police, and community members are much worse for those of color and those who are transgender.

Unfortunately, we can already see the health outcomes of discrimination to this population – they have higher rates of psychiatric disorders, substance dependence (including higher tobacco use), and suicide; lesbian women are less likely to get preventative services for cancer, and gay men are at higher risk for certain STIs.

How can we work to eliminate these gaps, even when interpersonal discrimination may take longer to tackle as our culture continues to evolve? HealthyPeople2020 provides several recommendations. First, healthcare providers should discuss sexual orientation and gender identity (SOGI) respectfully with patients, and collect data on it. Medical students should be trained in LGBTQ culturally-responsive care. In addition, we must be spokespeople against legal discrimination of this population in social services such as employment, housing, and health insurance.

Sources:

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

https://www.npr.org/documents/2017/nov/npr-discrimination-lgbtq-final.pdf

https://www.centerforhealthjournalism.org/2017/11/08/how-racism-and-microaggressions-lead-worse-health

https://www.psychologytoday.com/us/blog/microaggressions-in-everyday-life/201011/microaggressions-more-just-race

http://www.apa.org/topics/health-disparities/fact-sheet-stress.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2747726/pdf/nihms134591.pdf

Khat: Dangerous drug, cultural pastime, or self-medication?

Khat is made from young leaves from the khat tree that are commonly chewed in the Horn of Africa and the Arab Peninsula. The drug produces stimulating effects and is said to make the chewer animated, energized, and social. Chewing can be done individually or as a social activity – in these gatherings, a communal tobacco pipe is placed at the center of the circle and passed around in addition to the khat. Khat chewing has become an extremely popular practice in the Horn of Africa – an estimated 90 percent of Somali men partake. Research suggests that this practice is associated with physical, psychological, and social risks, and the Somali diaspora is already one that faces high rates of PTSD and other mental health issues. Khat chewing may worsen these issues in the long run, but can also serve as a source of self-medication for those without resources for dealing with trauma.

There is controversy over khat in the countries where Somali refugees are resettling. Abukhar Awale, a Somali TV talk show host, suffered khat addiction himself and became a proponent of the ban. He called khat “the biggest barrier to our integration…segregating Somali youngsters from wider society…they do not contribute, they don’t speak English, they don’t feel they are part of the society.” On the other side, many argue that khat itself is not the problem, but the symptom of a society ravaged by war and trauma. They point to over-policing of people of color and the fact that the ban was associated very little support for those who were made to quit.

Sources:

http://www.itv.com/news/wales/2015-06-24/communities-criticise-lack-of-support-in-year-since-herbal-stimulant-khat-was-banned/

https://www.aljazeera.com/indepth/features/2015/03/somaliland-abuzz-ethiopia-khat-convoys-150325100843701.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075009/

Image retrieved from: TripSavvy

Changes to HIV Criminalization Laws in NC

According to a report updated in August 2017, 34 states in the US had HIV criminalization laws still on the books, written at least twenty years ago at the height of the AIDS epidemic [1]. According to the Human Rights Campaign, 25 states in the US have “laws that criminalize behaviors that carry a low or negligible risk of HIV transmission” [2]. Most of these laws require disclosure of HIV status for those living with HIV, and in some states, failure to disclose or follow other laws could result in a felony.

There are various examples of these laws being put to work, including a man living with HIV being convicted of a felony and sentenced for 35 years for spitting on a police officer because his saliva was considered a deadly weapon though HIV transmission doesn’t occur through saliva [3].

In North Carolina, HIV criminalization laws are contained in the health code, and the North Carolina Commission for Public Health recently voted to update the laws in order to better reflect our current understanding of HIV and the current methods available for HIV treatment and prevention [4].

According to the previous law, any individual living with HIV was required to disclose their HIV status to any sexual partners and to use a condom during sex, and anyone living with HIV was unable to donate organs. With the changes to the law, an HIV positive individual who is virally suppressed for at least 6 months does not have to disclose their HIV status to sexual partners or use a condom during sex, and even if they aren’t virally suppressed, if their partner is taking PrEP, they don’t have to use a condom. Also, an individual living with HIV doesn’t have to use a condom when having sex with another individual living with HIV, and individuals living with HIV can donate organs to other individuals living with HIV [5]

This is an exciting step forward for North Carolina that will hopefully make changes for HIV stigma while also representing current options for HIV treatment and prevention. These changes also recognize that HIV is an ongoing issue, especially with high rates of new diagnoses of HIV in the South.

Nonetheless, some activists are still worried that this is only a step forward for those who are already at an advantage. Many individuals are still unable to access healthcare and the medical system for various reasons, limiting their access to PrEP for HIV treatment to attain viral suppression. Only 50% of individuals living with HIV stay in care. Further, Black and Latinx individuals still receive worse care and have less access to care. This results in a continued disparity. Though the changes to these laws are a step forward in creating evidence-based laws and hopefully decreasing stigma and unjust prosecution, there are still significant barriers for individuals seeking HIV treatment and prevention care [6].

“Chart: State-by-State Criminal Laws Used to Prosecute People with HIV, Center for HIV Law and Policy (2017).” The Center for HIV Law and Policy, 1 Aug. 2017, www.hivlawandpolicy.org/resources/chart-state-state-criminal-laws-used-prosecute-people-hiv-center-hiv-law-and-policy-2012

Jackson, Hope. “A Look At HIV Criminalization Bills Across The Country.” Human Rights Campaign, 26 Feb. 2018, www.hrc.org/blog/a-look-at-hiv-criminalization-bills-across-the-country.

Kovach, Gretel C. “Prison for Man With H.I.V. Who Spit on a Police Officer.” The New York Times, The New York Times, 16 May 2008, www.nytimes.com/2008/05/16/us/16spit.html.

Adeleke, Christina. “Choose Science over Fear.” QNotes, 24 Feb. 2018, goqnotes.com/58326/choose-science-over-fear/.

“HIV Criminalization Laws Change in North Carolina.” WNCAP, 20 Feb. 2018, wncap.org/2018/02/20/hiv-criminalization-laws-change-north-carolina/

Salzman, Sony. “Updated HIV Laws May Only Protect the Privileged.” Tonic, 20 Mar. 2018, tonic.vice.com/en_us/article/wj7e9z/updated-hiv-laws-may-only-protect-privileged.

Achieving Health Equity and Justice through the Reproductive Justice Framework: keynote by Monica Raye Simpson

This past Friday marked the 39th annual Minority Health Conference, which is the largest and longest run student-led health conference in the world. This year’s 20th annual William T. Small Jr. keynote speaker was Monica Raye Simpson, who is the executive director of SisterSong Women of Color Reproductive Justice Collective, gave a keynote address titled: “Achieving Health Equity and Justice through the Reproductive Justice Framework”. In the talk, Simpson gave an energetic and powerful where she gave a history of the Reproductive Justice framework, and how her own life experiences shaped how she approaches her work. One of her main points was how the Reproductive Justice Framework’s focus on centering those who are the most marginalized is critical for the field of Public Health, in order to overcome health inequities. In case you were not able to attend the event in person, the keynote speech is available for broadcast in the link below, moderated by yours truly.

Sources: https://sph.unc.edu/sph-webcast/2018-02-23_mhc/

Just Trust Me (Part IV)

In the past few weeks, I have illustrated how trust (or lack thereof) shapes the relationship between individuals and healthcare, and how mistrust is historically justified. In this last segment, I want to talk about potential solutions from a social justice standpoint.

Trust is often cited in public health from the angle of paternalism, something that public health is often associated with. When we think of optimal paternalism – using scientific knowledge to influence the health decisions of the general public – we ask ourselves: are we abusing trust, or using it for good?

Public health, while sometimes paternalistic, already stresses to its students the importance of working with oppressed communities as equals to identify and solve problems. Medicine needs to catch up. Many medical students already participate in racial and cultural training, but they need to be trained from a structural angle – to gain an understanding of oppression and policy – too.

We need to support training for healthcare providers that doesn’t shy away from the tough stuff. Hands-on learning, such as tactful poverty simulations, can help. This will allow them to understand things like how the cycle of poverty makes some patients less talkative with authority figures (such as doctors) than others. We need to support minority students in medicine, so that patients can see representation of themselves and feel understood. We need to provide incentives for students to stay in their own communities for residencies. Of course, broad class mobility-enabling policy is the ultimate solution.

Many times, our work seeks to increase trust, but that puts the burden on the patient instead of addressing the reasons behind mistrust. Teaching trust in and of itself is a paternalistic objective: we should instead focus on deserving it.

Sources:

http://commonhealth.legacy.wbur.org/2012/02/minority-doctors-diversity

https://campus.fsu.edu/bbcswebdav/institution/academic/social_sciences/sociology/Reading%20Lists/Social%20Psych%20Prelim%20Readings/IV.%20Structures%20and%20Inequalities/2002%20Lareau%20-%20Invisible%20Inequality.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2156058/