美國需要更多的結構性介入措施來解決系統性種族主義對愛滋病毒的影響
資料來源：瑪麗亞·威爾伯格/2022 年 12 月 14 日/aidsmap/財團法人台灣紅絲帶基金會編譯
圖片由 Ryan McGuire/Bells Design 提供。 知識共享許可。
美國制定了雄心勃勃的目標，透過國家愛滋病毒策略和終結愛滋病毒流行倡議在國內終結愛滋病毒。 如果不刻意努力解決少數種族和族裔面臨的健康不平等問題，這些目標將無法實現。
2018 年，儘管黑人僅佔總人口的 13%，但黑人佔 HIV 新診斷病例的 43%。 西班牙裔占美國人口的 18%，但占同年新診斷的 HIV 患者的 26%。
在具有多重邊緣化身份的人群中，例如性別和性少數群體，不平等現象加劇。 2010 年至 2018 年間，美國的愛滋病毒發病率總體下降。 但同期西班牙裔人的新診斷增加了 30%，這是由 25-34 歲的西班牙裔男同性戀和雙性戀男性增加 68% 推動的。
如果目前的趨勢繼續下去，黑人男同性戀和雙性戀男性終生感染 HIV 的風險為 50%。 根據凱瑟琳·里奇 (Katherine Rich) 及其哈佛醫學院同事在 IDWeek 2022 上發表的研究，而他們平均會比白人男同性戀和雙性戀男性少活 6.3 年。
這些不公平現象並非由個人行為驅動。 與白人相比，黑人更有可能透過性行為和共用注射器感染 HIV，儘管他們的行為與白人相似或更少，但這些行為構成了 HIV 傳播的風險。
相反，美國社會和政治制度中種族主義的累積效應加劇了這種差異。 這經常被密切相關的系統性種族主義和結構性種族主義的概念所提及。 這兩個術語都指制度、法律、政策、態度和信仰對助長種族歧視和少數民族財富和資源分配不均的影響。
一些學者認為，系統性種族主義強調政治、法律、經濟、刑事司法等相輔相成的制度的作用，而結構性種族主義則強調更大系統中結構的作用，例如法律、政策、規範。
這些術語在文獻中經常互換使用。 本文將始終使用系統性種族主義，與涵蓋的研究中使用的語言保持一致。
系統性種族主義是一個關鍵障礙
南卡羅來納大學的 Sayward Harrison 博士及其同事今年夏天在後天性免疫缺陷症候群雜誌上發表的一項研究顯示，系統性種族主義一再被視為解決愛滋病毒的主要障礙。
他們綜合了 2021 年進行的三項定性研究的結果，這些研究讓當地利益相關者參與通知 PrEP 計畫之實施，作為在加利福尼亞、北卡羅來納州和南卡羅來納州結束 HIV 流行倡議的一部分。 這些研究側重於城市、郊區和農村地區的不同人群，包括有色人種變性人、年輕男同性戀者和雙性戀男性，以及年輕變性女性。
雖然不是研究的目的，但持續的系統性種族主義成為這三者的主要障礙。
參與者描述了系統性種族主義的陰險本質：
「你在談論愛滋病毒信息、信息獲取、醫療保健系統時，我們不能不去談論種族主義。 你不能把[種族主義]排除在談話之外」。
參與者反映了獲得優質照護的不公平現象：
「南薩克拉門託的照護品質與富裕地區的照護品質不同。 所以，就個人而言，你知道，即使我有一家醫院，從字面上看，離我家 5 分鐘路程，但我不會去那裡，因為我知道我不會得到……我所需要的照護品質」。”
受訪者報告說，醫療保健提供者根本沒有聽取他們的意見。 他們描述了他們所關心的和症狀都被消除了，更帶來了可怕的後果：
「黑人和棕色人種，不會說英語的人……，當他們正在尋求醫療時，就像他們是沒有在尋求醫療一樣。他們的經驗是（或者只是）被留在走廊裡，被拒絕，沒有得到藥物。其中一位是黑人跨性別女性……死在醫院的候診室裡，因為醫生不給她治療」。
多個級別的員工不被視為他們所服務社區的代表：
「屬於領導階層的人和屬於領導階層並為他們所服務的社區做出決定的人，儘管他們都不在社區中，但都是白人，且是全面性的」。
參與者分享了邊緣化身份交叉的增強作用：
「好吧，貧窮。 只是，當您開始添加其他創建交叉性的東西時。 就像是種族， 好的；這不僅僅是貧窮，現在是一個貧窮的黑人。這不僅僅是一個貧窮的黑人，還是一個貧窮的、黑人的、跨性別女人……這些問題中的任何一個都很難單獨解決。成為跨性別者，成為跨性別女性，成為黑人，成為窮人——當你把這些因素結合起來時，是的，這要困難得多。這會增加壓力、抑鬱、健康狀況不佳和自殺。有這麼多的事情」。
在整個研究中，參與者描述了系統性種族主義的包羅萬象、陰險的本質，並指出「系統性種族主義是我們如何應對這些問題的一部分」。 然而，健康差異的根本原因與解決這些差異的建議之間存在脫節。 參與者推薦的克服不平等的策略主要集中在人際和個人層面。
以衛生保健提供者為重點的介入措施
在這些研究中，最常見的與種族相關的建議是透過不斷努力理解，和解決對種族和少數民族的偏見和恥辱，來提高員工和提供者的文化能力。
醫療保健提供者與其患者之間的關係和溝通的重要性已得到充分證明。 例如，一項研究發現，提供者的溝通極大地影響了感染愛滋病毒的黑人和西班牙裔婦女的健康結果。
在另一項定性研究中，感染 HIV 的黑人和西班牙裔婦女確定有一位了解並尊重她們的提供者，並將清晰的溝通作為幫助她們繼續接受照護和治療的關鍵促進因素。
「種族不是感染 HIV 的危險因素。但種族主義是」。
解決提供者溝通中的偏見顯然是一個未滿足的需求。 一系列針對 HIV 門診預約期間交流的研究發現，提供者對患者情緒的反應存在明顯的種族差異，這些情緒通常透過口頭和非口頭暗示隱含地傳達。
研究人員發現，人們表達情緒的方式存在文化差異，與白人患者相比，提供者更有可能阻止與黑人患者的交流，並且不太可能以邀請進一步對話或闡述的方式做出回應。
作者呼籲對提供者進行更多培訓，以改善他們的跨文化交流，並提高對盲點和隱性偏見的認識，參與定性研究的人也表達了同樣的看法。
但是，正如不平等不能歸因於個人行為一樣，系統性種族主義也不能歸因於個體提供者之間的種族主義和偏見。
以種族和族裔少數群體為重點的介入措施
定性研究的參與者還提出了一系列改善結果的策略，這些策略側重於經歷不平等的個人。 其中包括提供經濟激勵、改善在教堂等環境中的外展活動，以及讓優先人群更多地參與介入和計畫的開發。
這些類型的介入措施可能是有效的，尤其是當旨在提高文化相關性、吸引力和響應能力時。 2021 年的一項審查確定了 14 項介入措施，這些介入措施可有效改善感染愛滋病毒的黑人男同性戀者和雙性戀男性的一個或多個愛滋病毒照護連續結果。
定性研究中建議的幾種使用策略，大多數側重於個人層面（個人因素，如健康素養）、人際關係層面（社會因素，如個人的支持系統），或兩者的結合。
當包容性變得過飽和
然而，關注正在經歷不平等現象的人群並非沒有風險。 定性研究的參與者敦促決策者考慮所使用的廣告和節目材料是否會進一步污名化邊緣化群體。
他們的擔憂是有道理的。 約瑟夫·羅森 (Joseph Rosen) 發表在《文化、健康與性》(Culture, Health, and Sexuality) 雜誌上的一項研究回顧了 2012 年至 2021 年美國的 PrEP 活動和廣告，其中包括順性別女性、變性女性和/或女性介紹人。
他們發現，93% 的活動以種族或少數民族為特色，包括黑人順性別女性 (49%)、黑人跨性別女性 (27%)、西班牙裔順性別女性 (17%) 和西班牙裔跨性別女性 (16%)。
研究人員警告說，無論用意如何，試圖包容和吸引那些更常受愛滋病毒影響的人可能會產生相反的效果。一個群體或社區的過度飽和會導致不準確和有害的陳述，從而加劇恥辱感，導致人們對 PrEP 的用途感到困惑，正如一位競選觀眾所說，導致「愛滋病毒風險的種族化」。
種族不是風險因素。但種族主義是。 那麼我們如何在美國有效地解決它呢？
以系統因素為重點的介入措施
考慮到這種普遍存在的不平等是美國社會的一個決定性特徵，關於如何有效抵制系統性種族主義的經驗證據很少。相反地，許多與健康不公平相關的研究和介入措施反而側重於個人層面的策略。
但是，再多的營銷或以個人為中心的介入措施也無法克服無法觸及或服務於美國社會中最邊緣化、因此最脆弱的人群的系統的失敗。
「如果目前的趨勢繼續下去，美國的男同性戀和雙性戀黑人將有 50% 的機會在一生中感染 HIV」。
系統本身也需要介入。
通常稱為結構性介入，這些類型的介入不關注個人。 相反，他們尋求解決影響健康的更廣泛的環境、社會和經濟因素。
上述 2021 年審查涵蓋的針對感染 HIV 的黑人男同性戀和雙性戀男性的 14 項介入措施中，有三項重點關注系統層面的障礙。
兩個是多層次的，既關注系統因素又關注個體因素。 其中之一是 IN-CARE，它透過改善社會和醫療服務之間的協調來解決讓男性接受 HIV 照護的系統性因素。
一旦接受照護，這些人就會透過專注於存留的個人介入獲得額外支持。在研究期間，與照顧黑人同性戀和雙性戀男性的聯繫從 0% 增加到 90%，存留率從 0% 增加到 73%。
另一種有效的介入措施——REACH——透過改進行政規程和消除阻礙 HIV 治療啟動的官僚障礙，僅關注系統因素。在六個月的時間裡，在研究人群中，病毒抑制的中位時間從 77 天減少到 57 天，首次預約提供者的時間從 17 天減少到 5 天，開始 ART 的時間從 21 天減少到 7 天，研究人群90 ％為黑人。
重要的是要注意，許多改善黑人男性 HIV 相關結果的介入措施並不是專門為這一人群設計的，儘管有少數是。 許多人關注的範圍更廣，例如所有感染愛滋病毒的男同性戀者和雙性戀者。
該評論的作者確實呼籲採取更多專門為黑人男性設計的介入措施，這一建議可以更廣泛地應用於其他受影響的少數族裔。目前，結構性介入措施很少針對特定種族或族裔群體量身定制，更不用說專門為應對系統性種族主義的影響而設計的介入措施。
實現資金公平
一個有潛力幫助「消除」由系統性種族主義引起的與愛滋病毒相關的健康不公平現象有前途的重點領域是，改變為愛滋病毒預防和照護服務分配資金的方式。
2021 年的成本效益模型描繪了一幅引人注目的畫面。 它顯示，針對系統性種族主義的影響實際上是預防愛滋病毒和改善整個社區、所有種族和族裔群體健康的最有效方法。
研究人員著手比較投資資金以擴大愛滋病毒預防和照護服務的不同策略的有效性。
「再多的營銷或針對個人的介入措施也無法克服無法觸及或服務邊緣化人群的系統性的失敗」。
第一個測試的方法是增加資金並根據現有服務水平擴大愛滋病服務，這意味著已經接受更高水平服務的群體將受益最多。 第二種方法是利用新確診 HIV 的種族和民族分佈來指導 HIV 預防和關懷資金的分配。
該模型顯示，第二種方法將大大減少少數種族和族裔所經歷的與愛滋病毒相關的健康不平等現象。 這種公平的方法還將防止更多新的愛滋病毒感染，並為所有種族和族裔群體帶來更大的生活品質改善，並使消除愛滋病毒的國家目標觸手可及。
此外，該模型預測這是最有效和最高效的資源利用。與全面擴大現有水平的服務相比，預計資金公平的增量成本更低。
在某些情況下，與沒有服務擴展的現狀相比，對服務擴展的公平投資甚至可以節省成本。總體而言，預計 6 個不同城市在10年期間可節省 23 至 2.45 億美元的成本。
結論
系統性種族主義比任何個人、政策或機構都要嚴重。 解決愛滋病毒內外健康不平等的根本原因可能令人望而生畏。衛生官員、政策制定者和其他決策者可以將注意力和資源用於改善他們可以影響的系統性因素，而不是被全部問題所淹沒。
旨在加強衛生和社會服務提供者之間的協調或改進行政政策的品質改進工作是結構性介入措施，可以而且確實對感染愛滋病毒的黑人和拉丁裔人的健康和福祉做出統計上顯著的改善。
即使不是為改善特定群體的健康而量身定制的介入措施也可以幫助減少種族和民族健康差異。無論是量身定制的還是廣泛的，所有介入措施都應在重點人群有意義的參與下制定，並且應特別注意確保沒有任何群體的代表性不足。
使用數據指導 HIV 預防、照護和相關服務的資金分配與 HIV 診斷的種族和族裔分佈成比例是一種結構性方法，可以減少健康不公平和新的 HIV 診斷。與維持服務水平和資金比例的現狀相比，整個社區的公共衛生將得到更大的改善。
一件事很清楚。 決策者的不作為會帶來可怕的代價。如果目前的趨勢繼續下去，美國的男同性戀和雙性戀黑人男性一生中將有 50% 的機會感染 HIV，而那些感染愛滋病毒的人的預期壽命將比白人同齡人短六年多。
參考文獻：
Harrison S et al. 解決種族主義在美國 HIV 流行病中的作用：三個終結 HIV 流行病預防計畫的定性研究結果。 《後天免疫缺陷症候群雜誌》90：S46-S55，2022 年 7 月（開放獲取）。
doi: 10.1097/QAI.0000000000002965
Rosen J et al. 視覺媒體中的交流呼籲和信息框架，用於向順性別和跨性別女性宣傳 HIV 暴露前預防。《文化、健康與性》。2022 年 9 月 8 日先行在線上發布。doi: 10.1080/13691058.2022.2116111
Goldhammer H et al. 美國男男性行為者的愛滋病毒照護連續介入。《刺胳針愛滋病毒》 8：e776-e786，2021 年。doi:10.1016/S2352-3018(21)00241-1
The US needs more structural interventions to address the effects of systemic racism in HIV
Mariah Wilberg/14 December 2022/aidsmap
Image by Ryan McGuire/Bells Design. Creative Commons licence.
The US has laid out ambitious goals to end HIV domestically through the National HIV Strategy and Ending the HIV Epidemic Initiative. These goals will not be achieved without intentional efforts to address health inequities faced by racial and ethnic minorities.
In 2018, Black people accounted for 43% of new HIV diagnoses, despite representing only 13% of the population. Hispanic people accounted for 18% of the U.S. population and 26% of new HIV diagnoses the same year.
Inequities are exacerbated among those with multiple marginalised identities, such as gender and sexual minorities. Between 2010 and 2018, HIV incidence in the US declined overall. But new diagnoses among Hispanic people rose by 30% during the same period, driven by a 68% increase among Hispanic gay and bisexual men aged 25-34.
If current trends continue, Black gay and bisexual men face a 50% lifetime risk for acquiring HIV. Those who do will live 6.3 years shorter on average than White gay and bisexual men, according to research Katherine Rich and colleagues from Harvard Medical School presented at IDWeek 2022.
These inequities are not driven by individual behaviour. Black people are more likely to acquire HIV through sex and sharing syringes compared to White people despite engaging in similar or fewer behaviours that pose a risk for HIV transmission.
Rather, the disparities are fueled through the cumulative effect of racism within US social and political systems. This is often referred to by the closely related concepts of systemic racism and structural racism. Both terms refer to the effect that systems, laws, policies, attitudes, and beliefs have on fostering racial discrimination and inequitable distribution of wealth and resources for minoritised people.
According to some scholars, systemic racism emphasises the role of mutually reinforcing systems – political, legal, economic, criminal justice, etc. – while structural racism emphasises the role of structures within the larger systems, such as laws, policies, norms.
The terms are often used interchangeably in the literature. This article will use systemic racism throughout, aligning with the language used in the covered studies.
Systemic racism a key barrier
Systemic racism is repeatedly raised as a key barrier in efforts to address HIV, according to research published this summer in the Journal of Acquired Immune Deficiency Syndromes by Dr Sayward Harrison and colleagues from the University of South Carolina.
They synthesised results of three qualitative studies done in 2021 that engaged local stakeholders to inform PrEP implementation as part of the Ending the HIV Epidemic initiative in California, North Carolina, and South Carolina. The studies focused on different populations, including transgender people of colour, young gay and bisexual men, and young transgender women, in urban, suburban, and rural areas.
While not the aim of the studies, persistent systemic racism emerged as a key barrier in all three. Participants described the insidious nature of systemic racism:
“You’re talking about HIV information, access to information, healthcare systems, we cannot not talk about racism. You just can’t leave [racism] out of the conversation.”
Participants reflected on inequitable access to quality care:
“The quality of care is not the same in South Sacramento (as) in the better-off areas. So, personally, you know, even though I have a hospital that is literally, like, 5 minutes away from my house, I do not go there because I know I’m not going to get the… quality of care that I need.”
Interviewees reported that healthcare providers did not listen to them. They described having their concerns and symptoms dismissed, with dire consequences:
“Black and Brown folks, folks who don’t speak English… their experiences (of being) just left in the hallway, turned away, not given medicine, treated like they’re med seeking when they’re not. One of them, there was a Black trans woman… died in the waiting room at a hospital because the doctors would not treat her.”
Staff at multiple levels were not seen as representative of the communities they served:
“People that are part of leadership and people that are part of the leadership and making decisions for the community that they’re serving, although they’re not in the community, are White people, and that’s across the board.”
Participants shared the potentiating effect of intersecting marginalised identities:
“Okay, poverty. Just that. You start adding other things that create intersectionality. Like race. Okay. It’s not just poverty, now it’s an impoverished Black person. Not just an impoverished Black person, it’s an impoverished Black Trans woman… any one of those issues is difficult to deal with by itself. Just being Trans, just being Trans women, just being Black persons, just being poor persons—when you combine those factors, yeah, that’s much more difficult. That increases stress, depression, poor health, suicide. So many things.”
Across the studies, participants described the all-encompassing, insidious nature of systemic racism, noting that “systemic racism is built into how we combat these issues”. However, there was a disconnect between the root cause of health disparities and the ideas suggested to address them. The strategies participants recommended to overcome inequities largely focused on the interpersonal and individual levels.
Interventions focusing on health care providers
In these studies, the most common race-related recommendation was to increase the cultural competency of staff and providers through ongoing efforts to understand and address bias and stigma towards racial and ethnic minorities.
The importance of the relationship and communication between healthcare providers and their patients is well documented. For example, one study found that provider communication greatly influenced the health outcomes of Black and Hispanic women living with HIV.
In a separate qualitative study, Black and Hispanic women living with HIV identified having a provider who knew and respected them as a person and used clear communication as a key facilitator helping them stay in care and on treatment.
“Race isn’t a risk factor for HIV. Racism is.”
Addressing biases in provider communication is clearly an unmet need. A series of studies that looked at communication during HIV clinic appointments found stark racial disparities in how providers responded to the emotions of patients, which were most often conveyed implicitly through both verbal and non-verbal cues.
The researchers found that there were cultural differences in how people expressed their emotions, and that providers were more likely to block communication from their Black patients and less likely to respond in a way that invited further dialogue or elaboration, compared to with White patients.
The authors called for more training for providers to improve their cross-cultural communication and to bring awareness to blind spots and implicit biases, sentiments echoed by those participating in the qualitative studies.
But, just as inequities cannot be attributed to individual behaviour, neither can systemic racism be attributed to racism and bias among individual providers.
Interventions focusing on racial and ethnic minorities
Participants from the qualitative studies also suggested a range of strategies to improve outcomes that focused on individuals experiencing the inequities. These included providing financial incentives, improving outreach in settings such as churches, and greater involvement of the priority population in intervention and programme development.
These types of interventions can be effective, especially when designed to increase cultural relevance, appeal, and responsiveness. A 2021 review identified 14 interventions that were effective at improving one or more HIV care continuum outcomes among Black gay and bisexual men living with HIV.
Most focused on an individual level (personal factors such as health literacy), interpersonal level (social factors such as a person’s support system), or a combination of both. Several used strategies suggested in the qualitative studies.
When inclusivity becomes oversaturation
However, honing in on the population that is experiencing inequities is not without risk. Participants from the qualitative studies urged decision makers to consider whether the advertising and programme materials being used could further stigmatise marginalised groups.
Their concerns are warranted. A study by Joseph Rosen published in Culture, Health, and Sexuality reviewed US PrEP campaigns and advertisements from 2012 to 2021 that included cisgender women, transgender women, and/or femme presenting people.
They found that 93% of the campaigns featured racial or ethnic minorities, including Black cisgender women (49%), Black transgender women (27%), Hispanic cisgender women (17%), and Hispanic transgender women (16%).
The researchers cautioned that however well-intentioned, attempts to be inclusive and appeal to those more often impacted by HIV can have the opposite effect. Oversaturation of a group or community can lead to inaccurate and harmful representations that reinforces stigma, cause confusion about who PrEP is for, and as one campaign viewer put it, lead to “racialisation of HIV risk”.
Race isn’t a risk factor. Racism is. So how are we to effectively address it in the US?
Interventions focusing on systemic factors
Empirical evidence on how to effectively counteract systemic racism is scant considering that such pervasive inequality is a defining feature of US society. Instead, much of the research and interventions related to health inequities focus instead on individual-level strategies.
But no amount of marketing or individually focused interventions can overcome the failures of systems that don’t reach or serve the people who are most marginalised, and therefore most vulnerable, in US society.
“If current trends continue, gay and bisexual Black men in the US will have a 50% chance of acquiring HIV in their lifetime.”
The systems themselves also need intervention.
Often called structural interventions, these types of interventions do not focus on individuals. Instead, they seek to address the broader environmental, social, and economic factors that influence health.
Three of the 14 interventions for Black gay and bisexual men with HIV covered in the 2021 review mentioned above included a focus on system level barriers.
Two were multi-level, focusing on both system and individual factors. One of these was IN-CARE, which addressed systemic factors to get men into HIV care through improved coordination among social and medical services.
Once in care, the men received additional support through an individual intervention focused on retention. Linkage to care for Black gay and bisexual men increased from 0% to 90% during the study, and retention increased from 0% to 73%.
Another effective intervention – REACH – focused only on system factors by improving administrative protocols and removing bureaucratic barriers to HIV treatment initiation. Over a six-month period, median time to viral suppression decreased from 77 to 57 days, time to first provider appointment decreased from 17 to 5 days, and time to ART initiation decreased from 21 to 7 days among the study population, which was 90% Black.
It is important to note that many of these interventions that improved HIV-related outcomes for Black men were not specifically designed for this population, although a handful were. Many had a broader focus, such as all gay and bisexual men with HIV.
The authors of the review do call for more interventions that are specifically designed for and with Black men, a recommendation that can be applied more broadly to other impacted minorities. At present, structural interventions are rarely tailored for a specific racial or ethnic group, and even less frequently are they specifically designed to counter the impacts of systemic racism.
Towards equity in funding
A promising area of focus with potential to help “undo” HIV-related health inequities stemming from systemic racism is to change how funding is allocated for HIV prevention and care services.
A 2021 cost effectiveness model paints a compelling picture. It suggests that targeting the impacts of systemic racism is actually the most effective way to prevent HIV and improve health for the entire community, across all racial and ethnic groups.
The researchers set out to compare the effectiveness of different strategies for investing funding to scale up HIV prevention and care services.
“No amount of marketing or individually focused interventions can overcome the failures of systems that don’t reach or serve marginalised people.”
The first approach tested was to increase funding and scale up HIV services in proportion to existing service levels, meaning that groups already receiving a higher level of services would benefit most. The second approach was to use the racial and ethnic distribution of new HIV diagnoses to direct allocation of HIV prevention and care funding.
The model showed that the second approach would drastically reduce HIV-related health inequities experienced by racial and ethnic minorities. This equity approach would also prevent more new HIV infections and lead to greater quality of life improvements for all racial and ethnic groups and put national goals to end HIV within reach.
Further, the model predicted that it was the most effective and efficient use of resources. Equity in funding was predicted to have a lower incremental cost than scaling up services from existing levels across the board.
In some cases, equitable investments in service expansion represented cost savings even compared to the status quo of no service expansion. Overall, predicted cost savings in six different cities ranged from $23 to $245 million over a 10-year period.
Conclusion
Systemic racism is larger than any single person, policy, or institution. Tackling this root cause of health inequities in and beyond HIV can feel daunting. Rather than being overwhelmed by the totality of the issues, health officials, policymakers, and other decision makers can direct attention and resources towards improving the systemic factors that they can influence.
Quality improvement efforts to increase coordination among health and social service providers or improve administrative policies are structural interventions that can and do make statistically significant improvements to the health and wellbeing of Black and Latino people living with HIV.
Even interventions that are not tailored to improve health in specific groups can help reduce racial and ethnic health disparities. Whether tailored or broad, all interventions should be developed with the meaningful involvement of the population of focus, and particular care should be taken to ensure that no group is underrepresented.
Using data to direct the allocation of funding for HIV prevention, care, and related services proportionate to the racial and ethnic distribution of HIV diagnoses is a structural approach that should reduce health inequities and new HIV diagnoses. There will be greater public health improvements for the whole community than if we maintain the status quo of service levels and funding proportions.
One thing is clear. Inaction by decision makers carries a dire price. If current trends continue, gay and bisexual Black men in the US will have a 50% chance of acquiring HIV in their lifetime, and those who do will have a life expectancy over six years shorter than their White peers.
References
Harrison S et al. Addressing racism’s role in the US HIV epidemic: qualitative findings from three Ending the HIV Epidemic prevention projects. Journal of Acquired Immune Deficiency Syndromes 90: S46-S55, July 2022 (open access).
doi: 10.1097/QAI.0000000000002965
Rosen J et al. Communicative appeals and messaging frames in visual media for HIV pre-exposure prophylaxis promotion to cisgender and transgender women. Culture, Health & Sexuality. Published online ahead of print, 8 September 2022.
doi: 10.1080/13691058.2022.2116111
Goldhammer H et al. HIV care continuum interventions for Black men who have sex with men in the USA. The Lancet HIV 8: e776-e786, 2021.
doi: 10.1016/S2352-3018(21)00241-1