Examining and Addressing HIV-Related Disparities Social Determinants of Health Examining and Addressing HIV-Related Disparities Tim Vincent OA Conference 2016 CAPTC

NHAS Goal 3 Reduce HIV-Related Disparities & Health Inequities The Nation cannot meet the strategy goals without reducing disparities Structural approaches can reduce risk of HIV transmission at community and societal levels Stigma and discrimination must be eliminated in order to diminish barriers to HIV prevention There is much stronger language in the updated NHAS…must address disparities! GOAL 3…stated “the Nation cannot meet the Strategy goals without reducing disparities”. - high rates of HIV among certain populations in geographic areas contribute to growing HIV disparities. Stated – the conditions in which people live, work learn play and pray should facilitate their ability to lead healthy lives. PrEP – much needed new biomedical tool that helps reduce risk of infection….clinical guidelines issued in 2014. ACA - opens access to preventative services and testing w/o co-pay. PLWH can no longer be discriminated against with pre-existing condition Other updates – 10 quantatative indicators – including PrEP; stigma and HIV among trans

Definition of Health A state of complete physical, mental and social, and spiritual well-being not merely the absence of disease or infirmity. Physical Mental Spiritual Social Preamble to the Constitution of the World Health Organization 1946,with amendment.

https://www.polleverywhere.com/multiple_choice_polls/Kd8r98ye1NRieUx

Health Equity Is attainment of the highest level of health for all people.” (U.S. Department of Health and Human Services [DHHS] definition) Centers for Disease Control and Prevention. Establishing a Holistic Framework to Reduce Inequities in HIV, Viral Hepatitis, STDs, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; October 2010. www.cdc.gov/socialdeterminants 5

Health Inequity Refers to those inequalities in health that are deemed to be unfair or stemming from some form of injustice. Example: the disproportionate numbers of poor and minority citizens in the U.S. that do not have inadequate access to health care Is it a health disparity? Yes, since there is a difference in rates of access to health care amongst segments of the population Is it a health inequity? Depends on whether your idea of justice involves “the right to health care”; if so, then yes, it is unfair and unjust that there are differences in this fundamental right, the right to health care The important difference is that we must make a value judgment in the case of health inequities Kawachi,I., Subramanian, S., & Almeida-Filho (2002). A glossary for health inequalities. Journal of Epidemiology and Community Health: 56 6

Health Disparity Is the term used in epidemiology to describe differences, variations and disproportions in the health status of individuals or groups. It is a descriptive term. No value judgment is necessarily implied. What were some health disparities that you saw in the upstream downstream stories, or in the case of diabetes or child obesity? Adapted from: Kawachi,I., Subramanian, S., & Almeida-Filho (2002). A glossary for health inequalities. Journal of Epidemiology and Community Health: 56: 647 -652 Carter-Pokras, O., & Baquet, C. (2002). What is a health disparity? Public Health Reports, 17: 426 - 434

Determinants of Health 2. Biology & Genetics 1. Individual Behaviors 5. Health Services 3. Social Environment What were some health disparities that you saw in the upstream downstream stories, or in the case of diabetes or child obesity? 4. Physical Environment

Social Determinants of Health Are conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national and local levels, which are themselves influenced by policy choice, that impact quality of life for better or worse.

Life is all about how we see things Perspectives Life is all about how we see things Our point of view or perspective is really important when we think of health outcomes…we know that there are genetic factors that come into play, there are individual factors and there are larger factors that play a part in health. Take heart disease for example…we know that many folks have a genetic predisposition for heart disease or cardiac problems…so people make poor choices of diet and lifestyle and others live in areas where the opportunity for wellness and heart fitness are near impossible… If you think of HIV where do you see the problem steming from? Ask them to move to the appropriate chart (bio/indiv/social) Starting with Obesity? Is a huge problem and is becoming a national epidemic in our society - knowing how it plagues individuals how do you see the problem… How do you think it gets responded to? Process…. Now lets look at HIV….same discussion? Biological/Genetic – Age (Sex, HIV status, Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis, Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer, Family history of heart disease) Individual/Behavioral – actions/behaviors Social/Environmental – larger factors/where one lives

Viewing the Problem Personal Choice Social Context How does this impact the way you see the issue?

Ta-Nehisi Coates Our point of view or perspective is really important when we think of health outcomes…we know that there are genetic factors that come into play, there are individual factors and there are larger factors that play a part in health. Take heart disease for example…we know that many folks have a genetic predisposition for heart disease or cardiac problems…so people make poor choices of diet and lifestyle and others live in areas where the opportunity for wellness and heart fitness are near impossible… If you think of HIV where do you see the problem steming from? Ask them to move to the appropriate chart (bio/indiv/social) Starting with Obesity? Is a huge problem and is becoming a national epidemic in our society - knowing how it plagues individuals how do you see the problem… How do you think it gets responded to? Process…. Now lets look at HIV….same discussion? Biological/Genetic – Age (Sex, HIV status, Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis, Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer, Family history of heart disease) Individual/Behavioral – actions/behaviors Social/Environmental – larger factors/where one lives

https://www.polleverywhere.com/multiple_choice_polls/fiHqTMtxfg1PI7G

https://www.polleverywhere.com/multiple_choice_polls/38kNQ6G0rYNg6Z8

and the list continues… What are some of the reasons for current disparities related to HIV These may be similar to what they brainstormed…. and the list continues… 15

HIV Prevention & Health Equity Stigma and other social determinants influence the HIV care continuum before ah HIV diagnosis is even made

Determinants of Health (HIV example) Socio-economics & Environment: Power, wealth, poverty, homophobia, racism, gender equity, stigma Social Neighborhood, health care, housing conditions, job security and work environment , access to education Living & Working Conditions: Community Networks: Social norms in the community, family acceptance, cultural affiliations, social connectedness, participation and support What social determinants may distinguish HIV from other diseases? Behavioral & Psychosocial Factors: Perception of risk, self-efficacy, self-esteem, coping mechanisms, unprotected sex, stress Individual Physiology of HIV transmission and acquisition, ART Biology & Genetics: 17 This framework is an adaptation of the model presented by SYPP and CHIPTS in: http://www.chla.org/atf/cf/%7B1CB444DF-77C3-4D94-82FA-E366D7D6CE04%7D/SYPP_Social_Determinants_FINAL.pdf

https://www.polleverywhere.com/free_text_polls/Rostthrk1CIIyjS

Questions: What are the significant SDH that impact HIV prevention in your community? How can we work to address them in order to promote health equity re: HIV? What is needed in California to be more successful at incorporating SDH in HIV prevention efforts? There is much stronger language in the updated NHAS…must address disparities! GOAL 3…stated “the Nation cannot meet the Strategy goals without reducing disparities”. - high rates of HIV among certain populations in geographic areas contribute to growing HIV disparities. Stated – the conditions in which people live, work learn play and pray should facilitate their ability to lead healthy lives. PrEP – much needed new biomedical tool that helps reduce risk of infection….clinical guidelines issued in 2014. ACA - opens access to preventative services and testing w/o co-pay. PLWH can no longer be discriminated against with pre-existing condition Other updates – 10 quantatative indicators – including PrEP; stigma and HIV among trans

Creating Change 20 Describe the 3 limitations of this perspective: What are you doing? What would you like to do? Promote Health Equity Address Social Determinants Describe the 3 limitations of this perspective: We live in a “downstream” society. As we move upstream and get closer to the root causes of the problem, we find that it gets to be more political, more controversial, and less scientific from a traditional view, while also becoming more contentious. Specifically, it becomes more: • Political, because we begin to confront powerful vested interests (e.g., food producers, alcohol and tobacco industries, gun lobbyists, the prison industry). • Controversial, because we start to move away from the standard way that people think about health and social behavior in our society (that health is simply a matter of individual choice). • Less scientific, because the distance between cause and effect becomes greater. For example, teen pregnancy can be primarily understood as an effect of lack of knowledge about birth control, or as a response to a lack of opportunity, hopelessness, and lack of community infrastructure. One view suggests a relatively simple solution, the other a much greater level of complexity. Reference: From: Dorfman,L., Sorenson, S., & Walack, L.,(2009). Working Upstream: Skills for Social Change 20

Resilience Resilience is the ability to withstand, recover or adapt in difficult conditions; or recover quickly from illness, trauma, change, or tragedy Describe the 3 limitations of this perspective: We live in a “downstream” society. As we move upstream and get closer to the root causes of the problem, we find that it gets to be more political, more controversial, and less scientific from a traditional view, while also becoming more contentious. Specifically, it becomes more: • Political, because we begin to confront powerful vested interests (e.g., food producers, alcohol and tobacco industries, gun lobbyists, the prison industry). • Controversial, because we start to move away from the standard way that people think about health and social behavior in our society (that health is simply a matter of individual choice). • Less scientific, because the distance between cause and effect becomes greater. For example, teen pregnancy can be primarily understood as an effect of lack of knowledge about birth control, or as a response to a lack of opportunity, hopelessness, and lack of community infrastructure. One view suggests a relatively simple solution, the other a much greater level of complexity. Reference: From: Dorfman,L., Sorenson, S., & Walack, L.,(2009). Working Upstream: Skills for Social Change 21

Strategies to Address Inequities Increase Individual Resiliency Foster a Supportive Community Improve Access to Quality Health Care Transform the Environmental Context There is much stronger language in the updated NHAS…must address disparities! GOAL 3…stated “the Nation cannot meet the Strategy goals without reducing disparities”. - high rates of HIV among certain populations in geographic areas contribute to growing HIV disparities. Stated – the conditions in which people live, work learn play and pray should facilitate their ability to lead healthy lives. PrEP – much needed new biomedical tool that helps reduce risk of infection….clinical guidelines issued in 2014. ACA - opens access to preventative services and testing w/o co-pay. PLWH can no longer be discriminated against with pre-existing condition Other updates – 10 quantatative indicators – including PrEP; stigma and HIV among trans

CAPTC offers SDH trainings both online and in person and can provide client directed TA

Thanks For Attending Tim Vincent tim.vincent@ucsf.edu www.facebook.com/californiaptc @CaliPTC California Prevention Training Center 300 Frank Ogawa Plaza, Suite #520 Oakland, Ca. 94612 (510) 625-6000 www.stdhivtraining.org