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

2. 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

3. 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.

5. 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 5

6. 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

7. 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:
Carter-Pokras, O., & Baquet, C. (2002). What is a health disparity? Public Health Reports, 17:

8. Determinants of Health2.
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

9. 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.

10. 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

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

12. 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

15. 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

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

17. 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:

19. 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

20. 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

21. 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

22. 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

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

24. Thanks For Attending Tim Vincent tim.vincent@ucsf.edu
@CaliPTC
California Prevention Training Center
300 Frank Ogawa Plaza, Suite #520
Oakland, Ca
(510)