1. Write a paragraph describing the extent to which an socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework?
The socioecological framework is increasingly being used to examine disparities in PrEP uptake among the highest risk groups for HIV acquisition, including African-American men having sex with men (MSM), adolescents and young people, and African-American women (Philbin et al. AIDS Patient Care and STDs 2016). At the structural level, racism is a factor which may impact health care access, particularly for African-Americans. Medicaid formulary and insurance coverage are important structural factor for many patients accessing PrEP, particularly in the South where the HIV epidemic is shifting and medicaid coverage is poor. Community factors such as community norms affecting acceptance of PrEP, medical mistrust, and health care settings available play a role. Interpersonal factors such as perceptions of HIV and perceptions of stigma for certain types of sex and sex with specific partners may limit access to PrEP. At an individual level, perceived HIV risk and its discordance with actual risk, a particularly acute issue for black MSM for whom the CDC criteria have poor sensitivity and specificity for HIV risk, as well as other factors such as health status, attitudes about preventive health care, and HIV-related knowledge all influence PrEP uptake. In terms of life course factors, as many of the patients I see are youth, parental education and attitudes play a large role in acceptability of PrEP for young people. Although PrEP implementation research is relatively new, the socioecological model is a powerful construct for understanding the disparities that have in some ways been highlighted by this exciting new technology.
2. In the WHO reading, A conceptual framework for action on the structural determinants of health, the authors describe structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances. Pick 3 of these factors (at least one structural and one intermediary). Explain why you chose the factors (might use Braveman article to provide justification) and describe how each could be an important determinant of a health outcome of your choosing. The association could be reported in published research or it could be your hypothesized relationship. Consider whether how these factors might function over the lifecourse and/or intergenerationally.
For one of the most important outcomes in the field of PrEP implementation research, PrEP uptake, structural and intermediary determinants play an important role in PrEP uptake and access. From the structural factors, the literature strongly supports race/ethnicity as an important determinant of PrEP uptake. There are significant disparities in uptake among African-American MSM and women. These are unfortunately groups in many regions who are at the highest risk of HIV acquisition. This may interact with other of the structural factors, namely both individual and parental education, which affects knowledge about HIV, attitudes towards HIV and HIV prevention, and acceptance of individuals, peers, and family members taking an HIV prevention medication. The impact of race/ethnicity may be particularly pronounced at lower education attainment. For instance, limited education attainment may lead to limited exposure to health promotion and prevention messages, compounded by structural racism and poor treatment from the healthcare system (i.e. less pain medication provided to African-Americans, poor colon cancer and other preventative health screening rates in African-Americans) engendering limited health access. Accessing PrEP requires navigating complex aspects of the health system, applying for assistance, advocating for prior authorization from pharmacies and from physicians. As the Braveman article indicates, there can be significant variation among strata when examining different aspects of socioeconomic status, and a test of interaction is essential when creating health models or performing analysis. As PrEP users are a younger population, both individual educational attainment and parental educational attainment may have significant impact on acceptability of medical prevention strategies.
Lastly, in terms of intermediary determinants, one particular psychosocial stressor is stigma towards HIV, HIV prevention, and discussion of sexual health. There is ample literature discussing the impact of stigma in people living with HIV on treatment outcomes, care retention, and mental health. Initial research suggests that stigma plays an important role in PrEP acceptability and uptake. Future research will need to quantify the impact of stigma and explore qualitatively the ways in which it interferes with PrEP uptake. Interventions seeking to address stigma have been of limited success in HIV care outcomes, but addressing stigma may be critical to ensuring populations at highest risk of HIV receive this highly effective intervention.