SDoH Contribute to Increased HIV Infection, Poorer Outcomes

Courtenay Sprague, PhD, associate professor of global health, University of Massachusetts, Boston, MA, highlights which populations in the United States are most at risk for contracting HIV and offers insight into the social determinants of health driving worse outcomes.

Which populations are most at risk of contracting HIV?

In terms of the global picture, two-thirds of people living with HIV are based in sub-Saharan Africa and more than 60% are women. However, the global picture differs a bit from the United States’ picture, where primarily 5 populations are affected.

Based on CDC data, the first population in the United States who is highly affected are gay and bisexual men, or men who have sex with men (MSM), of all races and ethnicities. MSM accounted for 61% of new HIV infections in 2009. HIV particularly affects young MSM aged between 13 and 29.

The second population is Black and African Americans, who comprise 14% of the total US population but 44% of new HIV infections. The rate of HIV infection among Black patients is nearly 8 times higher than White patients, and 15 times higher for Black women compared to White women.

The third main population disproportionately affected by HIV in the United States is Latino individuals, who comprise 16% of the US population but account for about 20% of new HIV infections.

And the fourth would be transgender populations. I think the data are still underreported, but roughly 1 of 7 (14%) transgender women in the United States have HIV. This figure is higher among Black (44%) and Latino (26%) populations. It is also important to note this patient population faces many barriers to HIV care, which are increasingly being documented.

And lastly, the fifth most commonly affected population is people who inject drugs, which historically has been associated with high incidence of HIV, both in the United States and globally.

Geographically, within the United States, where are populations most vulnerable?

The National HIV Strategic Plan has had a special focus on the South, which comprises 17 states. The South represents about 47% of all HIV-related deaths, which is very high, and these deaths are preventable.

In addition to high HIV mortality in the South, there are also lower rates of viral suppression and worse patient outcomes across the entire HIV care continuum, relative to people living with HIV in other geographic locations. When we see these long-term, systematic differences in HIV outcomes between populations, we can identify health inequities among social groups that are unfair, unjust, and avoidable.

Such differences in outcomes are associated with underlying social disadvantage, meaning there is a social basis to ill health. The good news is social factors—social determinants of health (SDoH)—can be addressed through long-term policies and interventions which cater to needs of populations on the ground.

In the southern states, we tend to see lower rates of health spending; a lower tax base to invest in health infrastructure and services; fewer policies supporting financial protection for people living with HIV; higher uninsured rates; lack of Medicaid expansion; and other factors. For example, due to political conservatism in southern states, there is often less information circulating about safe sexual practices and HIV, with high stigma surrounding LGBTQ+ populations, and even structural racism stemming from historical links dating back to slavery. These are examples associated with many southern states that affect the opportunities to be healthy for people living with HIV. These factors emerged prominently during our research in Mississippi.

In our study, a participant said there are support groups in the capital of Jackson, but in north Mississippi, they do not exist. In Boston, for example, you would find HIV support groups routinely, and people can access social support easily. However, there are fewer providers in Mississippi and less information generally available about HIV.

We also spoke to another participant who is working in the health system and must find their own information about HIV, like modes of HIV transmission. They said they had to dig for information that should be provided as part of their work in health care. Other factors mentioned by people living with HIV include an absence of comprehensive sexuality education in school and other settings. All these resources and services, or lack thereof, affect people's ability to protect themselves from HIV and access needed services and support.

What other SDoH increase risk?

We have also conducted research among adult women living with HIV in Alabama. We mapped their family histories and found many had experienced sexual abuse as children or adolescents. These family histories of child sexual abuse or intimate partner violence, violent victimization, and trauma, really shape a person’s future behaviors and well-being.

An affected person may have anxiety and depression that preclude them from connecting to care. Factors like unemployment, food insecurity, and lack of housing create a lot of difficulty and complexity in people's lives and may preclude them from seeking clinical appointments altogether.

Incarceration histories may also disrupt people’s access to the HIV care continuum. Ironically, we know that incarcerated persons may be able to access HIV medications in prison more easily because they are there for longer stays, but people cycle in and out of these systems, and jail stays are much shorter. The prevalence of incarceration is high in the South, which adds a co-occurring or intersecting stigma. Stigma is one of the most important influences on the positive and negative health behaviors of people, their social interactions, their self-esteem, and trust in health care providers.

There are other intersectional types of stigma against social groups. For example, LGBTQ+ individuals are stigmatized, as are injecting drug users. These stigmatized social identities may intersect with people's HIV status. Research has found that individuals with HIV can anticipate stigma, experience stigma, and engage in self-stigmatization. In one example of experienced stigma, one person in our study said they can contribute every negative behavior they now have to becoming HIV positive and coping. They said, "I had a different life before I was HIV positive."

Another person in our study said people in Mississippi would caution against sitting, drinking, and eating with those living with HIV. Eating and drinking with friends, family, or colleagues are normal, ritual things people do daily.  That individuals living with HIV would be barred from taking part in those common activities is quite striking and can create opportunities for increased negative outcomes and care, while undermining people’s human dignity.

HIV stigma in health care settings also has a profound effect. Stigma can undermine a person’s relationship with the health care setting, which could delay treatment for years and drive people away from care, and this may diminish their HIV outcomes as well.

What should stakeholders keep in mind when considering members with HIV?

SDoH create barriers to HIV care. Stakeholders should keep in mind the complexity of patients’ lives when receiving care. Having that understanding will help inform why people may struggle or lapse in care, delay their care, or not be adherent.

Is there anything else you would like to add?

When we asked people in Mississippi what their needs were, what was striking is they mentioned all these SDoH. They did not say, "I want more clinical appointments or HIV medication." They said, "I want stable housing, secure transportation, acceptance and love, and social support."

We saw how SDoH impacted medical care, which people living with HIV absolutely need for optimal outcomes. All the research indicates how important it is for people living with HIV to have a therapeutic alliance, a trusting relationship, with their provider. SDoH and medical practice do fundamentally reinforce one another.

About Dr Sprague

Courtenay Sprague, PhD, is an associate professor of global health at the University of Massachusetts, Boston. She has a joint faculty position in the Department of Conflict Resolution, Human Security, and Global Governance and the Department of Nursing. She also has a joint staff appointment and has been affiliated for over 20 years at the University of the Witwatersrand in Johannesburg, South Africa.

Dr Sprague is a social health scientist whose work has focused largely on SDoH and their impact on HIV outcomes for the last 17 years. Her research is centered in Southern Africa and the Southern United States, with an emphasis on understanding the structural and social factors that affect opportunities to be healthy for low-income individuals and other marginalized populations living with HIV, particularly women.