Ending the HIV epidemic for all, not just some: structural racism as a fundamental but overlooked social-structural determinant of the US HIV epidemic

Abstract

Purpose of reviewWe review the recent theoretical and empirical literature on structural racism, social determinants of health frameworks within the context of HIV prevention and treatment, and criticism of the national responses to the US epidemic. Recent findingsIn line with growing mainstream attention to the role of structural racism and health inequities, recent editorials and studies cite ending structural racism as an essential step to ending the US HIV epidemic. Recent studies demonstrate that barriers rooted in structural racism such as incarceration, housing instability, police discrimination, neighborhood disadvantage, health service utilization and community violence, and poor or no access to social services, transportation, and childcare, are barriers to HIV prevention. Recent articles also criticize national responses to HIV such as the ending the HIV epidemic (EHE) and National HIV/AIDS Strategy plans for failing to address structural racism and prioritize community engagement in EHE efforts. SummaryCollectively, the articles in this review highlight a growing consensus that the US has no real chance of EHE for all, absent a meaningful and measurable commitment to addressing structural racism and intersectional discrimination as core determinants of HIV, and without more equitable engagement with community-based organizations and communities disproportionately affected by HIV.

Recognizing and disrupting stigma in implementation of HIV prevention and care: a call to research and action

“…In column 4 of Table 1, we provide a series of questions for each stigma component to guide reflection on how HIV service implementation strategies may activate intersectional stigma and affect clients' care in different ways based on their social positioning within intersecting systems of power and oppression [32,33]. An intersectional approach to HIV stigma begins by examining its interaction with other forms of societal stigma, for example sexism, heterosexism, racism and classism [12,33,34], and the ways these systems determine who is most vulnerable to and negatively impacted by HIV [16,35,36] and who is most able to benefit from existing HIV service implementation [37]. Additionally, HIV is frequently experienced in the context of other stigmatized health conditions and behaviours, such as substance use and sexual behaviour, which are themselves situated in intersecting power systems [12,33].…”

“…Thus, sexual minority men of colour may be more likely to experience risk-focused assessments as stereotyping, contributing to harmful healthcare experiences. On the other hand, behaviour-based risk screens may fail to identify cisgender heterosexual women as in need of HIV-related services, because they neglect structural, community and network factors that affect HIV acquisition [36,41]. Because Black women comprise a disproportional percentage of new HIV diagnoses in the United States [16,42], practices that neglect women perpetuate disparities at the intersection of racism, sexism and homophobia.…”

Toward a Theory of the Underpinnings and Vulnerabilities of Structural Racism: Looking Upstream from Disease Inequities among People Who Use Drugs

“…This might erroneously be considered to be outside the purview of public health as a discipline, though the critical epidemiology of Jaime Breilh [ 156 ] and others [ 157 , 158 , 159 ] would clearly see it as an integral part of epidemiological research and public health action and also see it as requiring new approaches to research frameworks and methodologies. Nonetheless, as our discussion so far indicates, and as the evidence for a vast range of other conditions and diseases has shown, racism continues to be a major cause of health disparities in the US and many other countries [ 160 ], including for HIV and other morbidities among people who use drugs [ 161 , 162 , 163 , 164 , 165 , 166 ]. Thus, we think it is important to consider why this upstream cause of morbidity and mortality (which is not only upstream, since racism manifests itself fairly ubiquitously) persists and to suggest why research is needed about more effective ways to get rid of it.…”

Editorial: Critical social and behavioral sciences perspectives on ending the HIV epidemic

“…), it is imperative to better define, operationalize, measure, and analyze how these inequalities concretely affect HIV outcomes in order to redress them. Inequalities are not simply ideas and beliefs manifest in humans' behavior to each other, they are structured and institutionalized in ways that make them core determinants of HIV, although, as Bowleg et al [2] argue in the case of structural racism in the United States, this has not been sufficiently recognized.…”