Social Determinants of Disease: HIV and COVID-19 Experiences

Medical sociologists Phelan and Link [18] described racism as a “fundamental cause of health inequality” that can lead to persistent and differentiated health outcomes among racial and ethnic groups, independent of their socioeconomic status. Recent research findings on COVID-19 and HIV, substantiate Phelan and Link’s assertion [18]. For COVID-19–related cases [19‐23], hospitalizations [7, 24‐26], and deaths [27‐30], communities of color had higher rates than their white counterparts. One such study assessed ten major US cities that experienced COVID-19 surges and found that counties with more poverty and a substantial non-white population had a COVID-19 incident infection rate at 8 times higher and death rate at 9 times greater than similar counties with a substantial white population [11•]. More specifically, Black Americans, who account for only 13% of the total US population, carry a greater COVID-19–related burden in positive cases [5, 31‐33]. A hospital-based study in Milwaukee found positivity rates of up to 59% among Black Americans [34]. As for hospitalization [8, 34, 35], a California-based study found that they had 2.7 times higher odds of being hospitalized than their White counterparts [8]. Additionally, some studies indicated a higher mortality rate for Black Americans [4••, 36], with one study indicating mortality rates among Black Americans at 15 to 51% in varied midwestern cities [5]. Hispanic/Latino patients were also found to be more susceptible to COVID-19 [37], having the highest number of positive cases among 33 identified hotspots across the country [19] and a higher hospitalization rate (46%) in comparison to Black Americans treated for COVID-19 in a Boston-based hospital sample [7]. Additionally, Hispanic/Latino patients may have presented COVID-19 related symptoms at later stages possibly due to undocumented status and limited English ability [12, 38]. Those with lower English proficiency were shown to be particularly vulnerable as studies demonstrated that monolingual or non-English speakers were at increased odds for COVID-19–related cases [39] and hospital admissions [38, 40] but not deaths [39]. An exception to these findings of the disparate impact on racial minorities is a cohort study of 5900 patients admitted to a New York-based academic medical center in the spring of 2020 [41]. While it found that Black and Hispanic/Latino patients were more likely to test positive for COVID-19 compared to non-Hispanic whites, the survival rate from the disease did not differ by race or ethnicity after adjusting for age, sex, and related-comorbidities [41].

As the COVID-19 pandemic raged throughout 2020, Black and Hispanic/Latino communities were already confronting another epidemic, particularly among young gay, bisexual and other men who have sex with men (GBMSM) [14••, 42] and heterosexual women [43, 44]. HIV rates within these racial groups have risen to a staggering rate [42, 45]. In 2018, Black Americans accounted for 42% and Hispanic/Latino Americans for 27% of new HIV diagnoses, despite comprising only 13% and 18% of the total US population, respectively [46]. In-depth qualitative interviews conducted among 50 racial minority GBMSM community and organizational leaders described the need for more awareness about biomedical HIV interventions, such as PrEP, to help reduce HIV transmission [47]. Black and Hispanic/Latina women are also at increased risk for HIV accounting for 57% and 18% at of all new HIV diagnoses among all women in the USA, respectively [46]. Previous studies showed that a 93% excess of incident HIV infections occur among Black women in comparison to the HIV incidence rate among White women [43], and that these disparities are most evident in the Northeastern and Southern USA [48]. Black community and organizational leaders indicated that gender equity, social capital, and cultural mores, such as monogamy and abstinence, were viewed as protective and could be leveraged to lower HIV risk, particularly among Black women [49]. Finally, among people living with HIV (PLWH), one study found no significant difference between White men and Hispanic/Latino Americans regardless of gender, and a small difference among Black Americans, on their engagement with HIV care, after adjusting for factors including disease stage, age, and poverty [50]. Gender may be a be factor as antiretroviral (ART) adherence and viral suppression appear to be lower among Black women, compared to Hispanic/Latina and white women [51].

COVID-19 brought to light the importance of the built environment in mitigating infectious disease [10•, 11•, 77]. Previous studies demonstrated that higher household density, defined as residences with more than one person per room, multigenerational households, or overcrowded homes increased the transmission risk of COVID-19 among Hispanic/Latino Americans [12, 23, 39, 52, 78]. While both Black and Hispanic/Latino residents were found to have a higher likelihood of receiving a COVID-19 diagnosis if they lived in more densely populated communities [79], a spatial analysis of COVID-19 hotspots indicated that housing density had a stronger association with hotspots than population density [23]. Additionally, low-income families situated in more coveted and gentrified urban areas with rising property and rental rates find themselves being led to crowd in or “double up” within tightly spaced homes [58, 80]. Communities of color are particularly vulnerable to housing displacement, as Black women often face eviction after a job loss [81] while up to 70% of African and Southeast Asian refugee families living in the Southeast USA reported fear of income loss during the pandemic [82]. Hispanic/Latino adults were also found to have higher prevalence of psychosocial stress compared to other racial groups, due to concerns of not having enough food or stable housing during the COVID-19 pandemic [83]. The lack of housing stability was also found to be associated with COVID-19, as 24% of COVID-related hospital admissions were among those experiencing homelessness [7]. With lower access to hygiene facilities, living with others in congregate settings, and higher rates of chronic physical and mental illness, those experiencing homelessness were shown to be at higher risk for COVID-19 acquisition [84].

While high housing density has not shown to be a significant factor in mitigating HIV transmission, housing stability has been found to help improve HIV care engagement among PLWH [72, 77, 85‐87]. Among PLWH who received housing support, 86% indicated viral suppression success [72]. Stable housing offers PLWH increased access to social support and health care services as well as lowers their risk of assault and coercion [77, 85]. Additionally, in a study that examined a 2018 outbreak of HIV among people who inject drugs (PWID), increased homelessness was cited as one of the likely factors behind the outbreak [86]. Demographic density also appears to reduce HIV acquisition, particularly for men who have sex with men (MSM). MSM living in areas with a higher percentage of lesbian, gay, bisexual and transgender (LGBT) persons were found to have a lower HIV diagnosis rate compared to MSM living in less LGBT-populous communities, suggesting that living in more LGBT-friendly communities can be protective against HIV transmission [61].

Infectious diseases have long been viewed as “foreign” entities brought to the USA by non-citizens who are believed to be “different” from the general population [14••, 88]. In the 1980s, initially Black Haitian foreigners then eventually young, predominantly white gay men, were stigmatized owing to a then-emerging virus now known as HIV and AIDS [88, 89], while in 2020, the former US president aimed to characterize COVID-19 as a “Chinese virus,” which lead to a wave of xenophobic acts across the country [89, 90, 91]. Specific populations who are viewed to be “carriers” of particular infectious diseases are subjected to discriminatory behavior by the general public, which can lead to isolation and overall poorer quality of life. In a study conducted at the start of the COVID-19 pandemic, individuals who reported experiencing COVID-19–related discrimination, including being treated with less courtesy and respect or feeling that others are afraid of them, went up among Black and Asian US residents, from 9 to 15% and 11 to 17%, respectively [92•]. Another study reported that Asian Americans’ anxiety, depressive symptoms, and sleep difficulties rose 40% and experienced discrimination increased 30% since the beginning of the COVID-19 pandemic, with social support shown to buffer the negative effects of discrimination in this population [93]. A robust social network has also proven to ameliorate stigmatization and negative outcomes of COVID-19 among Black Americans, despite a study finding that collective engagement in predominately Black residential areas was associated with a higher COVID-19 diagnosis rate [94]. Within the community context, studies indicate that building a network of trusted community sources, largely via word-of-mouth, can help dispel the uncertainty and myths surrounding COVID-19 prevention and treatment among Black Americans [95, 96]. The role of trusted social networks to provide accurate information may be particularly important as Black communities have often been subjected to various unsubstantiated characterizations of being immune to certain diseases and infectious agents due to their genetic make-up [97].

Among these enduring myths is that Black Americans are not susceptible to HIV [97]. Despite the alarming rate of HIV among Black women and Black GBMSM in particular, previous studies noted that the deep religiosity, conservatism, and homophobia within the Black community have allowed this myth to thrive, thus generating intense stigma surrounding HIV [65•, 67, 73]. In fact, stigma related to HIV and same sex sexual behaviors is found to be high among Black Americans compared to other racial groups [65•, 67, 98•], which has impacted HIV prevention and care engagement efforts such as the willingness to test and treat HIV [67, 89]. Hispanic/Latino and Indigenous communities have also seen a rise in HIV and attribute the rapid transmission among its members to HIV stigma and discrimination [99, 100]. Indeed, stigma has been associated with perceived loss of status, ostracization and devaluation [89], and PLWH are acutely aware of these negative effects [73, 101, 102]. PLWH have reported reduced life chances in the form of unemployment or under-employment [67, 73], poor to fair self-rated health [103], and unfair treatment by health and social service professionals [47, 102].

Conversely, social support has helped mitigate HIV stigma and discrimination among PLWH [69, 73, 104]. In one study, young gay and bisexual men (GBM) and transgender women of color reported that increased interaction with other members of the LGBT community via group and community activities, such as local Pride festivals, and building informal support networks composed of allies and partners are effective in reducing stigma and can help improve HIV prevention and care engagement for this population [47]. Among Black PLWH, instrumental support from family members was shown to be beneficial in filling the gaps left by governmental social service agencies as well as in reducing stigma, as some participants stated that their interaction with family members was surprisingly positive when their HIV status was discussed [73, 105]. Yet greater societal and institutional support may also have an effect on population-level HIV incidence and treatment engagement [65•, 67, 101]. Laws permitting same-sex marriage were associated with lower HIV incidence among MSM [65•], while the mortality rate among PLWH was found to be lower in US states with anti-discrimination laws [101], compared to other states without similar regulations.

Long before COVID-19 became a global pandemic, the documented discrimination, harm and abuse of authority within the US medical, health, and social services institutions against low-income racial minorities have generated a deep distrust among communities of color [1••, 12, 89]. The generational distrust of such institutions has weakened its ability to communicate appropriate and relevant COVID-19 information to racial minority communities disproportionately affected by the disease [95, 106], which has led to lower testing [96] and potentially later stage presentation of COVID-19 at the hospital [12, 107]. Early in the COVID-19 pandemic, most of the testing centers were situated in largely White and more affluent neighborhoods [10•, 54], which only exacerbated the multiple healthcare-related barriers facing minority communities with increased risk for COVID-19 exposure [33, 108]. Retaining comprehensive health insurance is a significant factor, particularly for individuals who are at risk of job loss, as they may have difficulty in seeking care for COVID-related symptoms without employer-issued health insurance [12, 53, 82]. In a review of medical records for patients admitted during the early months of the pandemic, Hispanic/Latino patients were shown to have a higher percentage of self-pay health insurance as well as having higher odds of testing positive for COVID-19 compared to other racial groups [109]. Finally, while telehealth services, defined as the provision of health services via telecommunication technologies, have been shown to improve health access for disparate and marginalized populations [107], new evidence indicates that low-income rural, racial minority, and elderly communities may be excluded from this novel service due to patients’ lower digital technology literacy and insufficient resources of underfunded clinics and hospitals [96, 110].

Mistrust of healthcare and social services institutions is particularly evident among PLWH, with a focus on provider-level issues and interactions [47, 111]. Previous studies demonstrated that HIV stigma perpetuated by health care and social services providers is a source of concern among racial minority PLWH [102] and is associated with low linkages to care after an HIV diagnosis [112]. Additionally, community clinics facing fiscal constraints, especially in low-income and racially segregated neighborhoods, have left PLWH with restricted choices for HIV services due to reduced clinic hours and minimum staff availability [98•]. Low-income PLWH must also contend with the limited availability of health services for public health insurance recipients, which has been shown to influence the availability and quality of HIV care in this population [2••, 68, 101]. For example, previous studies indicated that optimal HIV viral suppression is associated with the use of private versus public health insurance and clinics [51], while the mortality risk among PLWH was lower for those living in states with greater health care coverage [68, 101]. Yet not all areas of the country are afforded equal healthcare availability as evidenced in the southern US states, wherein physician visits and pharmacy benefits are heavily regulated due to restrictive Medicaid provisions [67]. These southern US states must rely on other federal programs, such as the Ryan White Care program, to provide sufficient HIV care for PLWH [67].