1. WHAT TO DO WITH SOCIAL DETERMINANTS OF HIV? Dula F. Pacquiao, EdD, RN, CTN-A, TNS Professor, Rutgers University School of Nursing Newark, NJ

2. OBJECTIVES 1. Describe social determinants of health in vulnerable populations affected by HIV. 2. Analyze evidence of the pathways by which social determinants create differential epidemiological vulnerability in population groups. 3. Evaluate current strategies and initiatives in HIV prevention and management using research evidence on social determinants of health. 2

3. HIV- RELATED HEALTH DISPARITIES  Despite prevention efforts, some groups of people are affected by HIV/AIDS, viral hepatitis, STDs, and TB more than other groups of people.  Differences may occur by gender, race or ethnicity, education, income, disability, geographic location and sexual orientation among others.  Social determinants of health like poverty, unequal access to health care, lack of education, stigma, and racism are linked to health disparities.

4. HIV-RELATED HEALTH DISPARITIES  Poorer communities have higher rates of HIV/AIDS  Patients with low SES have lower rates of survival  Patients without adequate insurance are less likely to be on ART  Substance abusers and minorities are more likely to delay medical care  Minorities continue to experience higher death rates, even after introduction of combination therapy  Patients who are homeless or unstably housed do not have regular source of care and less likely to receive or stay on ART

5. RACIAL/ETHNIC DISPARITIES IN TB: 2010 (CDC, 2013)  Compared with whites, TB rates were approximately:  7x higher among Hispanics  8x higher among Blacks  25 x higher among APIs  Compared with whites, the relative difference in TB rates was:  614% for Blacks  429% for APIs  286% for Hispanics  757% for AI/ANs

6. TB DISPARITIES BASED ON NATIVITY 1993-2010  TB cases among foreign-born increased from 29% to 60%. 2006–2010  59% of reported TB cases occurred among foreign-born.  Relative difference in TB rates among foreign-born vs. US born was 857% in 2006 and 1,031% in 2010. 2010: Among foreign-born, the relative difference in TB rates compared with whites was:  2,271% for APIs  1,771% for Blacks  836% for Hispanics

7. TB DISPARITIES BY EMPLOYMENT  TB cases among unemployed persons was 53% in 2006 and 59% in 2010.  Relative difference in reported TB cases among unemployed persons compared with those employed in fields other than health care was 74%, a change of 44.2% over time  Relative difference in reported TB cases among persons whose primary health-care provider for TB disease was a health department compared with persons whose primary health-care provider for TB disease was private/other providers was 217%, a change in the relative difference of 109% over time.

8. HEALTH DISPARITY (CDC, HRSA, DHHS)  A type of difference in health closely linked with social or economic disadvantage that negatively affect groups of people who have systematically experienced greater social or economic obstacles to health.  Obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or geographic location.

9. INEQUALITY VS. INEQUITY (Sadana & Blas, 2013)  Health inequalities- differences in access to a range of promotional, preventive, curative, or palliative health services or differences in outcomes including disability, morbidity, and mortality spanning physical, mental, and social health.  Health inequities -differences in health that are judged to be avoidable, unfair, and unjust; often revealed through systematic patterns or gradients in access or outcomes across populations with different levels of underlying social advantage or disadvantage (wealth, power, prestige, or other markers of social stratification).

10. HEALTH DISPARITY AS A CHAIN OF EVENTS 1. Environment 2. Access to, utilization of, and quality of care 3. Health status, or 4. A particular health outcome deserving scrutiny (Carter-Pokras & Baquet, 2002)

11. ENVIRONMENT  Natural and Built environment  Social environment  Linked with:  SES (income, education, occupation) (Babones, 2011)  Race and ethnicity (Kawachi et al 2005)  Social status (Marmot, 2006)

12. SOCIAL DETERMINANTS OF HEALTH (Marmot & Bell, 2009)  Life conditions that tend to be cumulative in their influence on health  Conditions where people are born, grow, live and work

13.  Humans embody their material and social world  Health and disease in populations patterned by:  Societal arrangements of power, property, production, consumption and reproduction  Possibilities of the human body shaped by evolution, ecology, context and history.  These causal pathways create the cumulative interplay of exposure, susceptibility and resistance to diseases or illness.

14.  Health disparities understood by examining the proximal pathway of embodiment stemming from social inequities (race, class, gender, economic and political) that create differences in health and biology.  Pathways of embodiment can occur in multi- level contexts of global, national and local communities or neighborhood, family and individual.

15. ALLOSTATIC LOAD (McEwen, 2008)  Acute stress produces responses that promote adaptation and survival through neural, cardiovascular, autonomic, immune and metabolic systems vs.  Chronic stress promotes and exacerbate pathophysiology through the same systems that are dysregulated.

16. ALLOSTATIC LOAD OR OVERLOAD  Resulting wear and tear from too much stress, inefficient allostasis Inability to turn off the stress response when not needed Ineffective response to stress or not adapting to the same stressor over time. Changes in personal behaviors that aggravate allostatic load as smoking, overeating, drinking, poor quality sleep, violence, risky sexual behaviors. Affects memory, attention, cognition, learning, fear and unlearned fears, anxiety, aggression Health effects: PTSD, HTN, obesity, Type 2 diabetes, cancer, mood disorders

17. Race/ethnicity Residential location Neighborhood resources Community Stressors Structural Factors Environmental Hazards and pollutants Community StressExposure Internal Dose Individual stressors Individual coping Appraisal process Individual stress Biologically Effective dose Residential Segregation Health effect (disparities) Community-level vulnerability Individual-level vulnerability Stress Exposure Disease Framework ( Gee and Payne Sturges,2004)

18. WHAT IS HEALTH (WHO, HEALTH CANADA)  A capacity or resource rather than a state of being  Capacity of people to adapt to, respond to, or control life's challenges and changes" (Frankish et al., 1996).  Being able to pursue one's goals, to acquire skills and education, and to grow.  Recognizes the range of social, economic and physical environmental factors that contribute to health.

19. HEALTH (WHO, 1946)

20. HEALTH PROMOTION WITHIN PHC  Health promotion - the process of enabling people to increase control over, and to improve their health (WHO, 1986).  Enabling or empowering people to address factors that affect their health  Improvement of health rather than just maintenance of health built on a system focused on individuals and the communities where they live.  Health promotion is holistic and integrates mental, physical and social well-being.

21. POPULATION HEALTH  An approach to health that aims to:  Improve the health of the entire population  Reduce health inequities among population groups.  Examines and acts upon the broad range of factors and conditions that have a strong influence on health.

22. CRITIQUE OF POPULATION-APPROACHES (Frohlich & Potvin, 2008)  Population at-risk – individuals with elevated risk for specific disease (biological risk) versus  Vulnerable populations – subgroup or subpopulations at higher risk of risks because of shared social characteristics (social vulnerability; implications for chronic disease)

23. IMPLICATIONS OF ECOSOCIAL THEORY AND ALLOSTATIC LOAD UPSTREAMDOWNSTREAM  Improving education, housing, minimum wage  Occupational and environmental safety  Better zoning and land use  Fair taxation  Early detection of diseases  Disease-prevention education  Disease-based health care  Use of appropriate pharmaceutical agents to combat stress

24. POPULATION FOCUSED AND HEALTH-FOCUSED  Address social determinants  Poverty  Employment, sufficient wages  Residential and work environment  Access to healthy, safe and affordable food  Access to healthy, safe and affordable housing  Access to healthy and safe environment  Access to safe and quality schools  Combat stigma, marginalization and discrimination

25. POPULATION FOCUSED AND HEALTH-FOCUSED  Focus on communities and populations where they live, grow and work  Emphasize health promotion rather than disease-focused prevention alone  Focus on families/populations and communities rather than just individual patients

26. INITIATIVES ON SOCIAL DETERMINANTS  Moving to Opportunity (Leventhal & Brooks-Gunn, 2003)  Health in all policies (Avey, et al 2013)  Primary health care (Chu & Selwyn, 2011)  Project LEAD in Australia to combat racism (Ferdinand, et al 2013)  Community engagement (Hardy, et al 2013).  Community and academic partnership (Ramos, et al 2013)  Health impact assessment of zoning (Thornton et al 2013)  Protecting labor rights (Bhatia, et al., 2013)  Binational collaboration for occupational safety (Flynn et al., 2013)

27. LESSONS LEARNED  Economic improvement  Employment  Education  Wages  Addressing work and residential environments  Safety and quality  Transportation  Access to resources  Combating discrimination  Multisectoral collaboration  Building social capital and social networks  Policy and program development and evaluation  Research and measurements on social determinants