Disparities in HIV Healthcare: An Expert Perspective

Roughly 1.1 million people are living with HIV/AIDS in the United States, and about 15% of those are unaware of their HIV infection.¹ Although prevention efforts have led to a significant decline in new diagnoses among some populations, up to 40,000 people become newly infected each year within the United States.¹ These new infections are not equally distributed across the population. In fact, 2016 Centers for Disease Control and Prevention (CDC) data show that US subpopulations with the largest numbers of new HIV infections are as follows: black men who have sex with men (MSM; 10,223 new infections), Hispanic MSM (7425), white MSM (7390), black heterosexual women (4189), and black heterosexual men (1926), followed by white heterosexual women (1032) and Latino heterosexual women (1025).¹

In addition, people who inject drugs (PWID), sex workers, and incarcerated people are particularly vulnerable and underserved key populations who are at high risk for HIV infection.

During the annual CFAR Research Day at the University of California, San Diego, Sara Gianella Weibel, MD, on behalf of Infectious Disease Advisor, talked with the keynote speaker Nabila El-Bassel, PhD, the Willma and Albert Musher Professor of Social Work at Columbia University, New York City, about factors that affect HIV health disparities, particularly in PWID, sex workers, and incarcerated people, as well as possible intervention strategies.

Infectious Disease Advisor: Dr El-Bassel, can you tell us a little more about why PWID, sex workers, and incarcerated people are particularly vulnerable to contracting HIV?

Nabila El-Bassel, PhD: PWID are significantly affected by the HIV epidemics. In 2016, 9% of the HIV diagnoses (n=3425) in the United States were attributed to injection drug users.¹ The recent epidemics of prescription and nonmedical opioids has led to increased numbers of injection drug users, placing new populations at significant risk for HIV. In particular, nonurban areas with limited HIV services and substance use disorder treatment programs were formerly areas at low risk for HIV; during the last years, those areas have been disproportionately affected by the opioid epidemic, and HIV has started to spread rapidly.² Control of these outbreaks requires coordinated efforts by state, federal, local, and academic institutions. This should include the implementation of on-site programs and services, contact tracing, testing and syringe exchange programs, rehabilitation, insurance enrollment, care coordination, preexposure prophylaxis (PrEP), and HIV treatment.³ 

Unfortunately, PWID are often viewed as criminals rather than as having a medical issue that requires treatment. Stigma and mistrust in the healthcare system may prevent PWID from seeking HIV testing and treatment. Injecting drugs can also cause other severe illnesses, such as viral hepatitis, or result in overdose, which further complicates HIV treatment.

Similarly, persons who exchange sex are at significantly increased risk for HIV (and other sexually transmitted infections). Many persons who exchange sex face stigma, poverty, and lack of access to healthcare and other social services even within the United States. The illegal nature of exchanging sex for money or drugs makes it difficult to gather population-level data on HIV risk among sex workers. Therefore, few large-scale studies have been performed on HIV among this group of people. Lack of data creates barriers to developing targeted HIV prevention and intervention strategies. Further, previous or current drug use, homelessness, unemployment, incarceration, mental health issues, violence, and abuse by clients, intimate partners, and the police complicate screening and treating this population.

Another underserved group at high risk for HIV infection is the incarcerated population. One in 100 Americans is behind bars.⁴ One in 3 black men and 1 in 6 Latino men will spend time behind bars compared with 1 of every 17 white males.⁵ US prisons include one-third of the world’s incarcerated women.⁶ In 2015, the rate of HIV infection among inmates in state and federal prisons was more than 5 times greater⁷ than the infection rate among those not incarcerated, and unfortunately, HIV testing programs are not systematically implemented in this setting. This is partially the result of a lack of resources for HIV testing and treatment in correctional facilities and the necessity of prioritizing other needs for the allocation of resources. In addition, rapid turnover among jail populations (often less than 72 hours) makes it hard to test inmates for HIV and help them initiate adequate treatment.⁷ Finally, inmates also have concerns about privacy and fear of stigma. Many do not disclose their high-risk behaviors, such as anal sex or injection drug use, because they fear being stigmatized.

Community corrections settings, jails, and prisons represent an untapped venue to reach and engage historically undeserved key populations who are at increased risk for HIV.⁸ Systematic HIV testing is important to identify inmates with HIV before they are released. Early diagnosis and treatment can potentially reduce the level of HIV in communities to which inmates return.⁷ Also, healthcare providers should keep inmate’s healthcare information confidential and inform them about the public health confidentiality and reporting laws.

Infectious Disease Advisor: Which are the most important factors that affect health disparities in the setting of HIV in the United States?

Dr El-Bassel: In addition to risk behaviors, a range of social and economic factors places certain people in the United States at increased risk for HIV infection.

Key affected populations are confronted with a myriad of structural and social barriers to HIV testing and accessing antiretroviral therapy (ART) and services that prevent the propagation of the HIV/AIDS epidemic. These barriers include gender inequality and harmful gender norms that are deeply rooted in cultural practices and laws, the influence of masculine ideology on risk-taking behaviors, and stigma, racism, heterosexism, poverty, unemployment, and homophobia. In many cases, the United States is as regressive as less developed countries by failing to overturn HIV criminalization laws. In this country, more than 30 states support laws to prosecute people living with HIV.⁹ For example, a number of these laws criminalize HIV transmission if a person does not disclose their HIV-positive status before sex, whether or not the person transmits the virus to another. Most of those discriminatory laws were passed before science demonstrated that ART reduces HIV transmission risk, and most laws do not account for HIV prevention tools that reduce transmission, such as condom use, ART, or pre- or postexposure prophylaxis.

Infectious Disease Advisor: What are some additional factors that affect health disparities in the setting of HIV in the United States?

Dr El-Bassel: Poverty, discrimination, incarceration, language barriers, and opioid addiction are some additional factors fueling the HIV epidemic.

Poverty limits access to healthcare, HIV/STI testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford basic life necessities are more likely to end up in circumstances that increase their risk for HIV infection (eg, engaging in survival sex work). Poverty is a key factor associated with HIV infection.¹⁰ Individuals below the poverty line are twice as likely to be HIV infected as those who live in the same community but are above the poverty line (2.3% vs 1.0%).¹⁰ HIV infection is also more common among those who are unemployed and have less than a high school education.¹⁰

Discrimination, stigma, and homophobia remain prevalent against racial/ethnic and sexual minorities, PWID, and HIV-positive individuals. These factors may discourage individuals from seeking testing, prevention, and treatment services.

Higher rates of incarceration among men, especially black men, disrupts social and sexual networks in the broader community and decreases the number of available partners for women, which can fuel the spread of HIV.

Language barriers and concerns about immigration status present additional challenges to accessing HIV testing, prevention, and treatment.

Rising rates of opioid addiction increase the risk for HIV acquisition and transmission. Lack of appropriate harm reduction and drug treatment services is a barrier to reducing the spread of HIV.