Tag: health disparity

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

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.

Health Disparity in Alameda County

By Elleni Hailu

In Alameda county, African Americans have the lowest life expectancy, compared to all other racial groups [1]. This trend in adverse health outcomes is also correlated with income levels, as individuals with lower incomes have higher morbidity and mortality rates, not only in the U.S. but also everywhere in the world. Combined with biologic and behavioral factors, ensuring health care access can reduce health disparities. However, having access to a health care professional and adequate medical care is simply not enough for many individuals, as they are not able to follow through with their doctor’s recommendations to improve their health and to prevent adverse outcomes. This is because there are a number of underlying factors besides access to care that affect a person’s well being such as neighborhood effects (i.e. access to fresh produce and parks). Here in the Alameda county alone, 23% of the Black population lives in poverty, compared to 8% of White residents who live in poverty [1]. This gap in income is what affects the health status of many Americans and their ability to maintain their health. Hence, creating ways to ensure income equality, such as passing bills that encourage public and private sector partnerships to build more affordable housing, would be instrumental in promoting healthy living.

Reference:

[1] Lee, T. (2017, September). Epidemiology as a Tool for Social Justice. Lecture presented at Seminar for MPH Students in UC Berkeley.

A Multi-Level Analysis of Barriers to Care: Micro Level (Individual)

I argued in a previous post that public health should look at factors impacting health using a multi-level approach. In this post, I attempt to outline the various multi-level barriers to medical care (specifically access to PrEP, HIV prevention, and AIDS care) for black queer men (or black men who have sex with men).

At the individual level (the micro level), queer men are skeptical of medication for healthy individuals and wary of the potential side effects caused by these medications (Philbin et al., 2016). These ideas seem to go hand-in-hand. If you don’t want to take medication as a healthy person, you’d be worried about the potential side effects that would ultimately make a health person sick in order to prevent something that you might or might not contract. In this sense, it might be important to make people recognize the real possibility of contract the disease. We’re treating risk here, but preventing the disease is important. Further, the side effects of PrEP are fairly uncommon.

Queer men might think that this medication would be useful for others but not for them. Here, we have to think about assessing the individual patient to decide whether or not PrEP is right for them (Philbin et al., 2016). We’re not treating someone because they’re black and queer, and black queer men have the highest rates of HIV. It’s obviously possible for black queer men to have low associated risk of HIV. Treating high risk means treating patients with high risk factors not treating everyone from a population that has high rates of the disease. However, this presents an added barrier for providers to convince patients with high risks that this is the right drug for them.

Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers. AIDS Patient Care and STDs, 30(6), 282-290. doi:10.1089/apc.2016.0037

 

 

Multi-level Models of Health Behavior for HIV

In a post about public health and epistemologies of ignorance, I argued that public health interventions have focused solely on the individual rather than looking at other factors impacting health. Moving forward, we need to develop multi-level models of health behavior, so here are a few examples of a multi-level analysis and multi-level models related to HIV prevention and AIDS care. Kaufman et al (2014) present a multi-level analysis of factors impacting HIV-related behavior and behavior change and review a few recent models for looking at HIV-related health behavior from multiple levels. The transtheoretical and health belief models and the theories of reasoned action and planed behavior have been used repeatedly in public health literature about HIV-related health behaviors, but all of these models and theories focus on the individual rather than looking at the individual as part of a larger system.

Kaufman et al (2014) looked at four multi-level models that expand on the individual models of health behavior to look at a more holistic picture:

  1. The Multiple Domain Model: Zimmerman, R. S., Noar, S. M., Feist-Price, S., Dekthar, O., Cupp, P. K., Anderman, E., & Lock, S. (2007). Longitudinal test of a multiple domain model of adolescent condom use. Journal of Sex Research44(4), 380-394.
  2. The Network-Individual-Resource Model: Johnson, B. T., Redding, C. A., DiClemente, R. J., Mustanski, B. S., Dodge, B., Sheeran, P., … & Carey, M. P. (2010). A network-individual-resource model for HIV prevention. AIDS and Behavior14(2), 204-221.
  3. The Dynamic Social Systems Model: Latkin, C., Weeks, M. R., Glasman, L., Galletly, C., & Albarracin, D. (2010). A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS and Behavior14(2), 222-238.
  4. The Transmission Reduction Intervention Project: Friedman, S. R., Downing, M. J., Smyrnov, P., Nikolopoulos, G., Schneider, J. A., Livak, B., … & Psichogiou, M. (2014). Socially-integrated transdisciplinary HIV prevention. AIDS and Behavior18(10), 1821-1834.

These are just a few examples of models that look at factors on multiple levels, specifically for HIV. More work should be done to expand and perfect these models, though the move towards multi-level models is certainly a move in the right direction. We should attempt to use a social-ecological framework with thinking about other public health interventions as well.

Kaufman, M. R., Cornish, F., Zimmerman, R. S., & Johnson, B. T. (2014). Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach. Journal of Acquired Immune Deficiency Syndromes (1999)66(Suppl 3), S250–S258. http://doi.org/10.1097/QAI.0000000000000236

Public Health & Epistemologies of Ignorance

The field of public health has primarily thought about improving health by making changes for individuals. We try to get individual people to quit smoking, make dietary changes to combat obesity, and start using condoms or other safer sex practices to limit exposure to sexually transmitted infections (STIs). However, all of these interventions focus only on changes that individual people are supposed to make. They don’t think about barriers that impact an individuals ability to make these changes or other factors that could be affecting, positively or negatively, the health of individuals.

In thinking about public health interventions, we should think about a multi level analysis, including the micro level (individual), the meso level (interactional, community), and the macro level (institutional, structural). Factors at each of these levels can positively and negatively impact health; however, by only looking at the individual (the micro level), we miss a significant portion of the picture in terms of health, especially when we start thinking about health disparities.

Lisa Bowleg (2017) argues that this represents an epistemology of ignorance, specifically that the focus on the individual and on health as a characteristic solely of the individual (a very neoliberal position), “obscure[s] the role of social–structural factors (e.g., political, economic, institutional discrimination) that constrain the health of historically marginalized individuals, communities, and societies” (678). She continues to argue that “[e]pistemologies of ignorance illustrate that willful ignorance is functional (Alcoff, 2007; Mills, 1997, 2007). Neglecting the historical legacy of how race (as well as the other marginalized social positions that intersect with race) has structured social inequality for people of color in the United States serves to center the health experiences of White people as normative, “color blinds” White privilege to highlight positive health outcomes among White people as the product of their individual actions, and reifies negative stereotypes about the “irresponsible” health behaviors of people of color (Bowleg et al., 2017).” From a political perspective, she argues that this focus on the individual in public health, and in other spheres, limits the political imperative and pressure to conduct research and enact laws that would address the social-structural factors in order to alleviate health disparities.

Bowleg, L. (2017). Towards a Critical Health Equity Research Stance: Why Epistemology and Methodology Matter More Than Qualitative Methods. Health Educ Behav, 44(5), 677-684. doi:10.1177/1090198117728760