Michel Sidibe, the Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), conformed to such behavior by exclaiming (with no avail) that, whenever AIDS has won, stigma, shame, distrust, discrimination and apathy was on its side. Every time AIDS has been defeated, it has been because of trust, openness, dialogue between individuals and communities (Avert, 2018).
For years, there has been sufficient evidence supporting the hypothesis that provider behavior contributes to racial disparities in careto warrant a more intensive policy focus on the solutions that actually address this issue. One encouraging intervention has been the way some private sector and the government entities have responded in recent years: a notable multi-million dollar initiative was just announced by ViiV Healthcare to address the HIV epidemic among black gay and other MSM in Baltimore, Maryland, and Jackson, Mississippi, two U.S. cities hit hard by HIV/AIDS (Kalichman Matthews & Adler, 2013). The program takes a holistic view of racial minority-MSM’s lives by exploring ethnographic research and identified community opportunities. At another institution, HealthPartners, equity is a standing topic at every meeting. That has helped keep us on track, said Brian Lloyd, who oversees the company’s equity initiatives (Latkin et al., 2013). The health system has trained more than 170 equitable care champions (employees who go through training on implicit bias and then take responsibility for explaining the rationale for equity initiatives to colleagues). The health system also takes advantage of opportunities to facilitate open discussions about racial biasas it did in July 2016 after Philando Castile, an African American MSM, was shot by a police officer during a traffic stop (Latkin et al., 2013). Publically, on the other hand, in July of 2011, President Obama fulfilled his campaign promise to develop a National HIV/AIDS Strategy (The CDC, 2018). Its launch marked the first time in the history of the HIV pandemic that the U.S. has had a plan for a coordinated response in holding decision makers accountable for results. But while the administration has set out clear and concise goals so that we finally have a picture of where our nation is heading, the devil lies in details like determining how we get there, who holds the roadmap, how we protect the most vulnerable and how it addresses the unique challenges facing Black America.
While certain preventative services, such as routine HIV screening and public health insurance, have expanded and indeed reduced the discrepancies in diagnoses between black and white MSMsevere obstacles still remain. Given the fact that a substantial number of Blacks are uninsured/underinsured in the U.S., the passage of the Affordable Care Act (ACA) in 2010 has been a crucial policy development. Historically, many people in the U.S. with HIV were screened and subsequently denied health services; now, health insurance programs expanded under the ACA are prohibited from refusing coverage on the basis of any preexisting condition(s). While Medicaid was intended to be national, the 2012 Supreme Court decision nonetheless stated that it would only be available to uninsured people living in states that choose to implement the expansion efforts. Medicaid expansion, moreover, the single largest source of coverage for people with HIV in the U.S. varies, with twenty states currently opting out; in these twenty states, Black Americans have been twice as likely to be uninsured and six times as likely to be HIV-positive than their White counterparts (The CDC, 2010). This epidemic is most notable in the Deep South, where the nine states that have opted out of Medicaid expansion experienced the nine highest diagnostic rates in HIV (The CDC, 2010). Nonetheless, it seems that over time, the salience of such critical disparitiesas well as the awareness of the lack of initiatives directed at addressing the socioeconomic determinants of HIV-related differences in racial minority MSMhas increased among the public, the academic circle (researchers), and even policy makers alike.
For Black Americans, racism/discrimination and segregation are constant features of the contextual landscapewhich also differ dramatically for black versus white populations. Racial segregationlegal and extralegalhas characterized all sectors of U.S. society since the commencement of America itself: marked residential segregation by race persists despite advances since the Civil Rights Era, maintained not only by individual actions but also by long-standing structural patterns (such as those by realtors in deducing mortgage rates, credit, and subsequent steering). Segregation concentrates poverty and other deleterious social and economic influences within racially isolated groups and thus increases the risk of socioeconomic failure of the segregated group. As just one example, compared with the children of middle-income white families, children of middle-income black families are more likely to be exposed to violence, poverty, drugs, and teenage pregnancy in the neighborhoods where they live (Adimora & Schoenbach 2005). In another analysis, unmet basic needs such as shelter and food were found to have the greatest impact on overall mental health and disease trajectories for HIV-positive homeless and unstably housed men (Riley et al., 2007). In fact, unmet basic needs had a greater impact on overall health outcomes than medication non-adherence. With respect to food security, as many as half of all HIV-positive MSM in inner cities lack sufficient food in the U.S. (Kalichman et al., 2013). Food insecurity in people with HIV is related to low medication adherence and poor health outcomes. In Vancouver, British Columbia, for example, lacking adequate food and having a low body-mass index predicted mortality in people with HIV over and above medication adherence (Mackenroth, 2015). Residential segregation is thus crucial to the structure of sexual networks, because people tend to choose sex partners from the neighborhoods where they live. This may be especially critical to the networks of young persons, since, in many areas of America, residence dictates the school district students attend; this, in turn, influences the social (and sexual) networks of adolescents.
There is both theoretical and empirical evidence that social networks exert strong social influence on the behavior of network members. Social influence occurs in the form of both external and internal dynamics. Persons with common attributes, interests, or activities tend to associate with one another. These commonalities may be a basis for how networks form, and also on how networks affect the views, norms, and behaviors of network members. For example, among homeless MSM youth, having social network members who regularly attend school and do not drink heavily predicts significantly less likelihood of engaging in high-risk sex (Tobin & Latkin, 2008). When an opinion about a certain theme prevails among network members, it is likely that other network members will eventually share similar views. In the HIV/AIDS field, members of the same network often have in common not only similar views and attitudes about risk but also shared levels of risky sexual practices or drug use (Tobin & Latkin, 2008). To reduce racial and ethnic health disparities, advocates say health care professionals must explicitly acknowledge that race and racism factor into health care. Less directed efforts to improve health outcomes, ones that for instance that fail to consider the particular factors that may lead to worse outcomes for blacks, Hispanics, or other patients of color, may not lead to equal gains across groups. One study found that people living with HIV who received Medicaid reported similar levels of health status as those who did not have any insurance (UN Programme, 2016). Efforts to increase quality and access to health care through public programs are vulnerable to economic downturns and shifts in public policy. Addressing health disparities in HIV infection may, however, require different approaches than other chronic diseases. HIV infection is so closely enmeshed in conditions of poverty that it is indeed a pandemic of the poor.
I thus argue, that in order to most effectively and comprehensively reduce the structural disadvantages and subsequent stigma in healthcare in the U.S., to focus on reducing existing racial segregation. Namely, since we are talking about structural racismsomething that is such a broad and deep force in our societywe cannot recommend eliminating residential segregation to small health care providers/insurers. Without the power to control national policy and address these underlying forces, it is important to start small, by explicitly addressing what can feasibly be done at the business-level. This includes making racial equity a strategic priority, by making efforts that go above and beyond cultural competency and workforce diversity initiatives. Attempting to reduce neighborhood disparities by race can also be done at the individual-level by building community-health care organization partnerships, to enable patients to play a meaningful role in developing solutions. Many health care organizations partner with community advisory boards or collect patient-reported experiences and outcome measures to identify potential problems. Southern Jamaica Plain Health Center, for instance, convened teen workshops to gain insights about the struggles they facetapping into HIV survivors’ expertise to identify ways the health system didn’t serve them (Earnshaw et al., 2013). Work like such may lead to customized interventions rather than standardized protocols and ambiguously directed moral codes of behavior. As health care organizations, payers, and others focus on social determinants and population health, we have a responsibility to ask: to what degree are our approaches grounded in a framework that addresses structural racism and equity? says Rishi Manchanda, M.D., CEO of Health Begins, a nonprofit that helps community organizations address the social determinants of health (UN Programme, 2016). If we can’t answer that question with rigor and candor, then even our most innovative solutions might perpetuate inequity and illnessnot prevent it. Closing the gap on racial disparities in the HIV/AIDS epidemic in the United States will thus require that we confront the underlying, local factors that fuel the epidemic among black Americans and tackle them head-on, with the urgency they deserve.
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