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Journal ArticleDOI

A pandemic of the poor: social disadvantage and the U.S. HIV epidemic.

TL;DR: The interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics are discussed and the social positions of those most affected by HIV and AIDS are described, particularly racial and gender groups.
Abstract: The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.

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Journal ArticleDOI
TL;DR: Rural and urban health care disparities require an ongoing program of reform with the aim to improve the provision of services, promote recruitment, training and career development of rural health care professionals, increase comprehensive health insurance coverage and engage rural residents and healthcare providers in health promotion.

570 citations


Cites background from "A pandemic of the poor: social disa..."

  • ...In their review of HIV in the USA, Pellowski et al. observed that ‘poverty, discrimination, inequality and other social conditions’ were facilitators of HIV transmission and incidence, as well as ‘an individual's risk behaviors,’ describing an ‘HIV sub-epidemic’ occurring in the rural USA.28...

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  • ...observed that ‘poverty, discrimination, inequality and other social conditions’ were facilitators of HIV transmission and incidence, as well as ‘an individual's risk behaviors,’ describing an ‘HIV sub-epidemic’ occurring in the rural USA.(28)...

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  • ...Notably absent are the central states in the USA....

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  • ...Study design: This literature review was based on a comprehensive search for all literature researching rural health care provision and access in the USA....

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  • ...There is clear evidence for the continued existence of inequalities in health care services and for differences in healthseeking behavior between urban and rural populations in the USA....

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Journal ArticleDOI
TL;DR: Understanding how alcohol use affects PLWH in the era of HIV as a chronic condition should inform how to mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
Abstract: Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

207 citations

Journal ArticleDOI
TL;DR: It is argued that class signals are a frequent, rapid, and accurate component of person perception, and new data and analyses are provided demonstrating the accuracy of class signaling in 60-s interactions, Facebook photographs, and isolated recordings of brief speech.
Abstract: By some accounts, global economic inequality is at its highest point on record. The pernicious effects of this broad societal trend are striking: Rising inequality is linked to poorer health and well-being across countries, continents, and cultures. The economic and psychological forces that perpetuate inequality continue to be studied, and in this theoretical review, we examine the role of daily experiences of economic inequality-the communication of social class signals between interaction partners-in this process. We theorize that social class signals activate social comparison processes that strengthen group boundaries between the haves and have nots in society. In particular, we argue that class signals are a frequent, rapid, and accurate component of person perception, and we provide new data and analyses demonstrating the accuracy of class signaling in 60-s interactions, Facebook photographs, and isolated recordings of brief speech. We suggest that barriers to the reduction of economic inequality in society arise directly from this class signaling process through the augmentation of class boundaries and the elicitation of beliefs and behaviors that favor the economic status quo.

169 citations


Cites background or result from "A pandemic of the poor: social disa..."

  • ...…research is suggestive of this possibility: As we mentioned previously, environments where inequality is more visible elicit greater threat-related aggressive tendencies (DeCelles & Norton, 2016; Greitemeyer & Sagioglou, 2016) and more negative health outcomes for the poor (Pellowski et al., 2013)....

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  • ...Future research could uncover the extent that class signals are causal in eliciting these patterns, and some research is suggestive of this possibility: As we mentioned previously, environments where inequality is more visible elicit greater threat-related aggressive tendencies (DeCelles & Norton, 2016; Greitemeyer & Sagioglou, 2016) and more negative health outcomes for the poor (Pellowski et al., 2013)....

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Journal ArticleDOI
TL;DR: Media has underlined COVID-19 as rather an exclusive threat, which has added to panic and stress in masses which can lead to several mental health issues like anxiety, obsessive compulsive disorder and post-traumatic stress disorder which should be contained immediately in its initial phases.
Abstract: The increase in organisms transference and infectious pandemics across the globe have been accelerated by an increase in travel, international exchange and global changes in earth's climate. COVID-19, a virus caused by the novel coronavirus that was initially identified on December 2019, in Wuhan city of China is currently affecting 146 territories, states and countries raising distress, panic and increasing anxiety in individuals exposed to the (actual or supposed) peril of the virus across the globe. Fundamentally, these concerns ascend with all infections, including those of flu and other agents, and the same worldwide safeguards are compulsory and suggested for protection and the prevention of further diffusion. However, media has underlined COVID-19 as rather an exclusive threat, which has added to panic and stress in masses which can lead to several mental health issues like anxiety, obsessive compulsive disorder and post-traumatic stress disorder which should be contained immediately in its initial phases.

157 citations


Cites background from "A pandemic of the poor: social disa..."

  • ...Additionally this mistrust of health facilities has also been linked to variety of diseases and disorders involving autism, cancer and HIV and disparities based on ethnicity and race (Pellowski et al. 2013, Good et al. 2005)....

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Journal ArticleDOI
TL;DR: This manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV to inform efforts to effectively address HIV in the South.
Abstract: The Southern United States has been disproportionately affected by HIV diagnoses and mortality. To inform efforts to effectively address HIV in the South, this manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV. The manuscript focuses on a specific Southern region, the Deep South, which has been particularly affected by HIV. Epidemiologic data from the Centers from Disease Control and Prevention indicate that the Deep South had the highest HIV diagnosis rate and the highest number of individuals diagnosed with HIV (18,087) in 2014. The percentage of new HIV diagnoses that were female has decreased over time (2008-2014) while increasing among minority MSM. The Deep South also had the highest death rates with HIV as an underlying cause of any US region in 2014. Despite higher diagnosis and death rates, the Deep South received less federal government and private foundation funding per person living with HIV than the US overall. Factors that have been identified as contributors to the disproportionate effects of HIV in the Deep South include pervasive HIV-related stigma, poverty, higher levels of sexually transmitted infections, racial inequality and bias, and laws that further HIV-related stigma and fear. Interventions that address and abate the contributors to the spread of HIV disease and the poorer HIV-related outcomes in the Deep South are warranted. Funding inequalities by region must also be examined and addressed to reduce the regional disparities in HIV incidence and mortality.

144 citations

References
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Journal ArticleDOI
TL;DR: For example, this article found a strong relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

12,712 citations

Journal ArticleDOI
TL;DR: Research shows that this threat dramatically depresses the standardized test performance of women and African Americans who are in the academic vanguard of their groups, that it causes disidentification with school, and that practices that reduce this threat can reduce these negative effects.
Abstract: A general theory of domain identification is used to describe achievement barriers still faced by women in advanced quantitative areas and by African Americans in school. The theory assumes that sustained school success requires identification with school and its subdomains; that societal pressures on these groups (e.g., economic disadvantage, gender roles) can frustrate this identification; and that in school domains where these groups are negatively stereotyped, those who have become domain identified face the further barrier of stereotype threat, the threat that others' judgments or their own actions will negatively stereotype them in the domain. Research shows that this threat dramatically depresses the standardized test performance of women and African Americans who are in the academic vanguard of their groups (offering a new interpretation of group differences in standardized test performance), that it causes disidentification with school, and that practices that reduce this threat can reduce these negative effects.

6,069 citations

Journal ArticleDOI
TL;DR: In this paper, the authors argue that racial segregation is crucial to explaining the emergence of the urban underclass during the 1970s and that a strong interaction between rising rates of poverty and high levels of residential segregation explains where, why and in which groups the underclass arose.
Abstract: This article argues that racial segregation is crucial to explaining the emergence of the urban underclass during the 1970s. A strong interaction between rising rates of poverty and high levels of residential segregation explains where, why and in which groups the underclass arose. This argument is developed with simulations that replicate the economic conditions observed among blacks and whites in metropolitan areas during the 1970s but assume different conditions of racial and class segregation. These data show how a simple increase in the rate of minority poverty leads to a dramatic rise in the concentration of poverty when it occurs within a racially segregated city. Increases in poverty concentration are, in turn, associated with other changes in the socioeconomic character of neighborhoods, transforming them into physically deteriorated areas of high crime, poor schools, and excessive mortality where welfare-dependent, female-headed families are the norm. Thus, policies to solve the socioeconomic pr...

5,621 citations

Journal ArticleDOI
TL;DR: It is argued that social factors such as socioeconomic status and social support are likely 'fundamental causes" of disease that affect multiple disease outcomes through multiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change.
Abstract: Over the last several decades, epidemiological studies have been enormously successful in identifying risk factors for major diseases However, most of this research has focused attention on risk factors that are relatively proximal causes of disease such as diet, cholesterol level, exercise and the like We question the emphasis on such individually-based risk factors and argue that greater attention must be paid to basic social conditions if health reform is to have its maximum effect in the time ahead There are two reasons for this claim First we argue that individually-based risk factors must be contextualized, by examining what puts people at risk of risks, if we are to craft effective interventions and improve the nation's health Second, we argue that social factors such as socioeconomic status and social support are likely 'fundamental causes" of disease that, because they embody access to important resources, affect multiple disease outcomes throughmultiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change Without careful attention to these possibilities, we run the risk of imposing individually-based intervention strategies that are ineffective and of missing opportunities to adopt broad-based societal interventions that could produce substantial health benefits for our citizens

3,483 citations

Journal ArticleDOI
TL;DR: Given the critical importance of adherence to therapy to patient outcome, secondary prevention of HIV infection, and willingness of providers to prescribe therapy, this prospectively investigated the association between protease inhibitor adherence and patient outcome and factors related to adherence.
Abstract: Background: Combination antiretroviral therapy with protease inhibitors has transformed HIV infection from a terminal condition into one that is manageable. However, the complexity of regimens makes adherence to therapy difficult. Objective: To assess the effects of different levels of adherence to therapy on virologic, immunologic, and clinical outcome; to determine modifiable conditions associated with suboptimal adherence; and to determine how well clinicians predict patient adherence. Design: Prospective, observational study. Setting: HIV clinics in a Veterans Affairs medical center and a university medical center. Patients: 99 HIV-infected patients who were prescribed a protease inhibitor and who neither used a medication organizer nor received their medications in an observed setting (such as a jail or nursing home). Measurements: Adherence was measured by using a microelectronic monitoring system. The adherence rate was calculated as the number of doses taken divided by the number prescribed. Patients were followed for a median of 6 months (range, 3 to 15 months). Results: During the study period, 45 397 doses of protease inhibitor were monitored in 81 evaluable patients. Adherence was significantly associated with successful virologic outcome (P < 0.001) and increase in CD4 lymphocyte count (P 5 0.006). Virologic failure was documented in 22% of patients with adherence of 95% or greater, 61% of those with 80% to 94.9% adherence, and 80% of those with less than 80% adherence. Patients with adherence of 95% or greater had fewer days in the hospital (2.6 days per 1000 days of follow-up) than those with less than 95% adherence (12.9 days per 1000 days of follow-up; P 5 0.001). No opportunistic infections or deaths occurred in patients with 95% or greater adherence. Active psychiatric illness was an independent risk factor for adherence less than 95% (P 5 0.04). Physicians predicted adherence incorrectly for 41% of patients, and clinic nurses predicted it incorrectly for 30% of patients. Conclusions: Adherence to protease inhibitor therapy of 95% or greater optimized virologic outcome for patients with HIV infection. Diagnosis and treatment of psychiatric illness should be further investigated as a means to improve adherence to therapy.

3,306 citations

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