HIV/AIDS and Black America: Social Determinates Perspectives

1. HIV/AIDS and Black America:Social Determinates Perspectives Hyman Scott, MD MPH Research Scientist Bridge HIV San Francisco Department of Public Health

2. AIDS in Black America

3. Health Disparities • What I want to do • Define health disparities. • Discuss the a health disparities framework. • Introduce principles of social epidemiology. • Highlight some issues about HIV and Black Americans. • Discuss what you think it would take to end HIV and other health disparities. • What I DON’T want to do • List the health disparities. • Tell you what you already know.

4. Definitions

5. Health Disparities • We DO NOT need yet another study documenting the health disparities. • We know that they exist but we don’t always know the distribution or why they exist • The surveillance and epidemiology are important to track. • Why they are still important to measure.

6. Health Disparities Aren’t New

7. From the beginning… “….The data presented here support the findings of earlier analyses that AIDS patients are disproportionately black and Hispanic and that the proportion of IVDA-associated AIDS cases is substantially greater in U.S. blacks and Hispanics than in U.S. whites. The disproportionate numbers of blacks and Hispanics treated for heroin abuse suggest that they may have a higher prevalence of IVDA than whites. Black and Hispanic communities in the United States and Puerto Rico should be especially targeted for measures to prevent HIV transmission by treating drug abusers and by counseling drug abusers and their sex partners on the risk of HIV infection…” Center for Disease Control and Prevention MMWR 1988 / 37(SS-3);1-3

13. Estimated HIV Incidence Among MSM, 13-29 48% increase among YBMSM Estimated Incident HIV Cases Year Prejean et al. Estimated HIV Incidence in the United States, 2006–2009. 2011PLoS ONE 6(8):

14. HIV Prevalence • Gay and Bisexual Men (MSM) • Injection Drug Users • African American men and women

15. What are the disparities? • Disparities exist across the spectrum of HIV disease • Prevalence, access or utilization of antiretroviral therapy, mortality • Many of the outcomes related to HIV disparities have been focused on race • Particularly among African American and Latino racial/ethnic groups.

16. Why do these health disparities exist?

17. What are the drivers of Health inequities? • Unfair and graded distribution of social resources. • Political power • Economic independence • Social (capital) • Cultural influence • Every aspect of aspect of government and economy affects health equity. • Finance, Education, Housing, Employment, transport, Healthcare. WHO, Commission on Social Determinants of Health, 2005-2008 - final report

18. Structural • Poverty • Unemployment • Homelessness • Incarceration • Stigma • Discrimination • Access to care • Health Literacy • Access to Prevention Social • Denial/Belief in HIV immunity • Social myths • Sexual Networks • Social Capital • Self esteem • Mental Illness Individual • Earlier sexual debut • More sexual partners • Increased drugs & alcohol with sex • High STI rate • Partner Selection • Concurrent Relationships • Income HIV Incidence Millett et al AIDS 2007;21; Millett et al. Lancet 2012;380.; Adimora et al J Infect Dis 2005;191; Poundstone et al Epidemiol Rev 2004;26:22–35

19. The Social Determinates of Health

20. Social Gradient • In general the lower an individual’s socioeconomic position (SES) the worse their health. • Global phenomenon in low, middle, high income countries. WHO, Commission on Social Determinants of Health, 2005-2008 - final report

21. The widening wealth disparity Whites households experienced a 16% decrease in wealth, while Latinos (66%) and Blacks (53%) experienced larger declines. Taylor et al. Wealth Gaps Rise to Record Highs Between Whites, Blacks and Hispanics. Pew Research 2011

22. HIV Prevalence2009 Rate of people living with HIV per 100,000 Source: http://aidsvu.org/map

23. Poverty Source: http://aidsvu.org/map

24. Percent Uninsured Source: http://aidsvu.org/map

25. Income Inequality Source: http://aidsvu.org/map

26. Percent with HS Education Source: http://aidsvu.org/map

27. Antiretroviral Therapy • Antiretroviral therapy has changed the way we view HIV disease -> chronic disease. • However, receipt of ARV in the US is not universally available/recommended or utilized (? Provider bias).

28. Why HIV-related Health Disparities: Access and Utilization • Due to increased poverty, underinsurance and related issues, HIV-infected Black Americans: • Less likely to get prophylaxis for PCP or protease inhibitors • Test later in course of HIV infection & present later to clinic care c/w whites • Die sooner than white counterparts • Half as likely as whites to participate in clinical trials • Less likely than whites to receive HAART • Possibly have lower treatment success than whites • Have more co-morbid conditions – CVD, Renal Disease, DM, HCV • Experience health care systems and provider biases

29. Race Differences in ARV UseAmong HIV-infected Persons in Care 1998-2005 Cox Proportional Hazards Model of Factors Associated with Initiation of ARV a Per 10 years. Lemly DC et al. J Infect Dis. 2009;199:991-998.

30. Reasons Why Women Weren’t on ARVs AA Race predictor of not getting HAART (OR = 2.0) Lillie-Blanton M, Stone VE et al. Am J Public Health 2010; 100 (8): 1493-1499.

31. Total Community Viral Load San Francisco, CA 2005-2008

32. Mean Community Viral LoadSan Francisco, CA 2005-2008

34. HIV-Associated Mortality

35. HIV Survival in the VA System McGinnis et al American Journal of Public Health October 2003, Vol 93, No. 10

36. Survival and Death in the Kaiser System Silverberg et al. J Gen Intern Med 24(9):1065–72 2009

37. Place Matters 2012 ADAP Waiting Lists Florida: 503 Georgia: 957 Louisiana: 368Montana: 4 Nebraska: 220North Carolina: 124 Virginia: 910 Source: kff.org Hanna et al AIDS 2012, 26:95–103

38. Disparities in the Continuum CDC Fact Sheet HIV in the United States: The Stages of Care. July 2012

39. Disparities in the Continuum – Black MSM Lower Income (<20K) OR, 3.42 (1.94-6.01) Health Insurance OR 0.47 (0.29-0.77) Healthcare visits OR 0.61 (0.42-0.90) CDC Fact Sheet HIV in the United States: The Stages of Care. July 2012 Millett AIDS 2012

40. Targeting the Social and Structural Determinants Scott et al AIBE 2013 Raj et al AIDS Care 2013 Moore et al CID 2012

41. Felon Disenfranchisement Rates, 2010 Source:http://sentencingproject.org/doc/publications/fd_State_Level_Estimates_of_Felon_Disen_2010.pdf

42. Example: Felon Disenfranchisement Uggen et al Ameri Soc Rev 67:777-803. 2002 Manza et al Persp on Politics 2:491-505: 2004 • How Felon disfranchisement can affect American politics IF ex-felons who had completed their sentences could vote, • THEN, Gore would have defeated Bush in FL in 2000 IF ex-felons on probation and parole could also vote (between 1978 and 2000) • THEN Gore would have defeated Bush in 2000 AND 5 senate seats would have reversed to democrats.

43. Affordable Care Act • Represents one of the largest structural interventions to provide health care to uninsured Americans • Potential to disproportionately HELP Black Americans.

44. Kaiser Family Foundation http://kff.org/medicaid/

45. What are some solutions • Individual • Household • Community • Local • Regional • National

46. Social Epidemiology Framework for HIV Poundstone et al EpidemiolRev 2004;26:22–35

47. What to Do: Societal • Policies needed to address environmental issues • Policies needed to address incarceration impact • Obama Drug Enforcement Policy changes • Push the dialogue in Black community about HIV, avoid labels (can lead to “othering”) • all at risk given prevalence, role of church leaders • Decrease stigma and distrust of healthcare system • VOTE!!! HIV/AIDS in U.S. Communities of Color. Stone, Ojikitu, Rawlings, and Smith. Springer; 1st Ed., 2009.

48. What to Do: Clinical Setting • Test all and immediately link to care • Diversify clinical staff • Provide culturally competent care • Cultural competence framework (Carillo et al, 1999) • Enhance communication in clinical setting • More time with patient • Use non-physician staff to spend more time with patient and answer questions • Identify and Address Myths HIV/AIDS in U.S. Communities of Color. Stone, Ojikitu, Rawlings, and Smith. Springer; 1st Ed., 2009.

49. What to Do: Clinical Setting (cont.) Management Strategies • Multi-morbidity & Medical Home Model • Start HAART, enhance adherence, minimize missed visits use medical case management team • Aggressive health maintenance & prevention! who should do this – health maintenance nurse? • Low threshold to treat HTN, hyperlipidemia, diabetes use specialists like dietitian, pharmacist • Low threshold to do renal w/u e.g. for Cr up >0.3 treat/refer – don’t forget ACEI and statins • Stay tuned for evolving news such as vitamin D • Smoking cessation for now!

50. What to Do: Clinic-Community • Meaningful partnerships between health institutions and community organizations and community • Engage groups that have extensive relationships with patients – “transfer of trust” • Become part of patient’s perceived community – meet them “where they’re at” • Engage community organizations in doing research in population • Do more research specifically focused on HIV-positive Blacks • Refer Black and other minority patients to HIV trials