Confronting Disparities and Inequality: Role of Prevention Research

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Premises. Global and domestic HIV/AIDS epidemic thrives in conditions of social injustice and oppression, as disparities make clearPrevention strategies must confront these disparities .. Or failMany disparities have yet to be adequately explored by prevention researchIt is the responsibility of

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Confronting Disparities and Inequality: Role of Prevention Research

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1. Confronting Disparities and Inequality: Role of Prevention Research Walt Senterfitt CHAMP 323-441-1552

2. Premises Global and domestic HIV/AIDS epidemic thrives in conditions of social injustice and oppression, as disparities make clear Prevention strategies must confront these disparities .. Or fail Many disparities have yet to be adequately explored by prevention research It is the responsibility of ALL of us to confront the injustice and unequal burden of HIV that affects ANY of us

3. Disparities are Many and Complex Worldwide, HIV impacts women and girls disproportionately In U.S., HIV disproportionately impacts African Americans and Latinos And also MSM (and TGs, IDU, etc.) And people living in poverty, homelessness, incarceration, and so on When combined, the impact of disparities can be almost astronomical (see examples below)

4. What do Disparities Have in Common? They did not just happen They are all the result of structural inequality in society where one group has power over another group ! In other words, inequities/disparities are caused by social oppression They will not go away easily with simple interventions --- because some people (we might call it a “ruling class”) benefit a whole lot from keeping most of us oppressed and all of us divided

5. Focus on African-Americans Rest of this talk will focus on African-Americans, especially MSM but also heterosexual young people Because the oppression of Black people has been the central racial/ethnic reality of US society since it began, and the inequities in HIV impact are sharpest here But that does not mean all the other inequities are not important. Many of the needs to address inequity in prevention research for African-American MSM and heterosexuals can be directly applied to all other disproportionately impacted groups.

6. First, let’s review the CDC numbers The first 2 slides show the number of new cases of HIV or AIDS reported in 2004, for the 33 states with well-established name-based reporting. They also show the “case rate,” or number of cases per 100,000, which you can compare to see disproportionate impact The third slide shows proportion of cases by race/ethnicity compared to proportionate share of the overall population

10. How Inequity Multiplies – Black MSM Earlier, we saw that the case rate was 131.6 per 100,000 for black men, 60.2 for Latino or Hispanic men, and 18.7 for whites – more than 6 times greater impact on black men What if we look at MSM in particular ? (we can only estimate the number of MSM in the total population and by race, as there are no accurate census figures) Most studies estimate between 4% and 6% of adolescent and adult males are MSM, regardless of how they identify. Let’s take 5% as the basis for the estimates on next slide.

11. MSM + Black = Using 2004 incidence data from 33 states It doesn’t just add up .. It multiplies All men 37.6 per 100,000 All black men 131.6 per 100,000 All MSM 509.3 per 100,000 Black MSM 1,552.9 per 100,000 Latino MSM 650.1 per 100,000 Note: These estimates are probably low – they are based only on those who acknowledge same gender sex, and excludes those who are MSM + IDU. They also exclude some large states like CA, DC, PA, GA, MA, MD just switching reporting systems.

12. Another angle: African American MSM have very high HIV prevalence rates A sample of MSM in 5 cities drawn from places where MSM congregate HIV infection and Unrecognized Infection among MSM, 5 US Cities, aged >18: Black, Non-Hispanic 46% (67%) White, Non-Hispanic 21% (18%) Multiracial 19% (50%) Hispanic 17% (48%) Other 13% (50%) MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM – 5 US Cities, June 2005, April, 2005, June 24, 2005.

13. High Rates of HIV infection among African American MSM are NOT News Samuel, M. and Winkelstein, W., “Prevalence of HIV in Ethnic Minority Homosexual/ Bisexual Men” JAMA, 1987 257: 1901-2. HIV Prevalence African American 66% White (non-Hispanic) 49% Hispanic 50% Asian/PI 27% Other 6% From a study of MSM in San Francisco in 1985-1986

14. Despite 20 years of knowing the “what,” we still understand only a little about the “why” Very few studies have been funded by the government and undertaken by researchers to understand the way disproportionate impact of HIV on black MSM Very few interventions specifically targeting black and Latino MSM have been developed Next slides show 12 hypotheses to explain the inequity, and a review of the entire literature for evidence for or against each one

15. Millet, et al. looked for evidence for/against 12 hypotheses (Millet, Peterson, Wolitski and Stall. American Journal of Public Health, June 2006) Not supported Supported Black MSM more likely to engage in high-risk sex, such as more unprotected anal sex, larger number of partners or more likely to engage in commercial sex Less likely to identify as gay or disclose their identity More likely to abuse substances, especially injection drugs Less likely to be tested for HIV More likely to have STDs Less likely to know status, tested later

16. Millet, continued: Not Enough Evidence Black MSM genetically more susceptible Black MSM less likely to be circumcised, increasing risk for infection HIV-positive Black MSM are infectious for a longer period of time (perhaps less access, weaker adherence) Black MSM more likely to have sex with partners known to be HIV positive Sexual networks of Black MSM put them at greater risk (perhaps but only one strong study) Black MSM more likely to be incarcerated (yes, but only one study has examined the association with HIV status) Black MSM more likely to engage in anorectal douching

17. Implications This review addressed the disparity or added burden on Black MSM; that comes on top of the unacceptably high risk burden (infection rates/risks) on MSM. Black MSM generally practice less risk behavior, but still have more than twice the risk of being HIV positive. In other words, a black MSM has to be twice as safe as a white one. Much of the evidence (and its weakness) came from studies that were not designed to address one or both of these disparities “The human toll experienced by Black MSM as a consequence of HIV infection warrants increased research efforts that are specifically designed to identify the underlying causes of the AIDS epidemic among Black MSM. Our findings support the need for effective structural interventions that reduce HIV risk at the community level through better access to and utilization of STD and HIV detection and treatment.”

18. “Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions,” Hallfors, et al. Used data from a nationally representative sample of mostly heterosexual 18-26 year olds to examine whether individuals’ sexual and drug behavior patterns account for racial disparities in STD and HIV prevalence Black vs white prevalence for: Chlamydia (12.5% vs. 1.9%; Trichomoniasis (6.9%, 1.2%); Gonorrhea (2.1%, 0.1%); HIV (0.5% vs. <0.1%); any one (18.8%, 3.1%) Clustered into 16 different “behavior patterns” – odds of having STD/HIV were higher for blacks in 11 of 16 Blacks were much likelier to be in the lowest risk cluster (38% vs 13%). In other words, for mostly heterosexual youth (similar to well as MSM), you can practice safe sex and still be 6 times likelier to have HIV or another STD !

19. Hallfors, et al., continued White young adults are at elevated risk for STD/HIV when they engage in high-risk behaviors Black young adults are at high risk even when their behaviors are relatively low-risk or “normative” Adjustment for gender, marital status, school dropout status, functional poverty and age at first sexual intercourse had little effect on the race disparity Conclusion: Factors other than individual risk behaviors and covariates appear to account for racial disparities, indicating the need for population-level interventions. Suggest further research on role of “mixing patterns” in partner selection, and disproportionate incarceration of Blacks

20. “African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America,” Dr. Robert Fullilove “Why is AIDS hitting black Americans hardest ? While much of the existing literature focuses on quality of care, health care access or individual risk factors, we believe that the HIV/AIDS epidemic in African-American communities results from a complex set of social, individual and environmental factors.”

21. Fullilove, continued Unstable housing High rate of incarceration among African-American males The highly disproportionate burden born by black MSM (Millet’s findings plus homophobia and stigma >>> negative experiences with health care system >> reluctance to test or seek care) Routinizing testing can make a difference, “but by itself a national testing strategy will not prevent or eliminate HIV/AIDS, particularly if it results in large numbers of individuals who have no access to care.”

22. Fullilove, conclusion “Simply put, the epidemic is rapidly outpacing our efforts to control it using standard public health, infection-control procedures. Given the social and economic characteristics of poor African-American communities, a more systemic approach is needed to help build stable communities. Public policies that address the root causes of the health disparities that devastate the African-American community are urgently needed.”

23. Many implications for prevention research For instance, the role of incarceration In-prison infection – probably plays a small but real part Concentrates a high-burden sub-population, already at high risk of being HIV positive, in a high-stress environment with little access to care and support Community re-entry without support Reduction of partner pool for women and thus reduces women’s power to negotiate relationships Leads to greater “concurrency” – having more than one partner at same time greatly amplifies HIV transmission in a community compared to multiple partners over time, one at a time Social/family disruption/dislocation, by “churning” men in and out of prison and leaving families without male partners Permanent severe handicap for long time – lack of schooling, post-release employment and housing opportunities Which are the most important, and what interventions will have most impact ? We know very little compared to what we need to know

24. What could we do about incarceration? We could: 1) make jails and prisons centers of excellence for HIV prevention and treatment, 2) expand drug treatment and mental health services inside and post-release, 3) develop re-entry services that connect people to jobs and housing, and 4) stop discrimination at the jail gate. But then, why should our research, intervention and policy choice framing be in effect based on the assumption that high rates of incarceration of black males will and should continue? Should we raise the level of our thought to sentencing reform, prison reform, even prison abolition as HIV prevention?

25. We have touched on pushing research into areas it has mostly ignored, and pushing it to think wider and deeper. There are also other strategies to consider, such as: strengthened community involvement in shaping research and holding researchers and funders accountable or community control of the process of combining and interpreting research results and deciding which interventions and policy choices are best. If HIV infection is driven most strongly by social oppression and injustice, then can we expect to prevent it without taking a social justice, human rights perspective as our touchstone ? “Power concedes nothing without a demand. It never did, it never will.” Frederick Douglass

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