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Podcast

Joseph Logan, PhD, on Structural and Social Determinants of Health Associated With HIV Care for Black and White Adults

04/22/2021

In this podcast, Joseph "J" Logan, PhD, highlights his session at CROI 2021, including 3 structural social determinants of health— residence in a census tract with redlining, residence in a Medicaid expansion state, and usage of the Ryan White HIV/AIDS program— associated with HIV care outcomes for Black people with HIV.

Additional Resources: 


Joseph "J" Logan, PhD, is an epidemiologist and health scientist in the division of HIV/ AIDS Prevention at the Centers for Disease Control and Prevention in Atlanta, Georgia. 

 

TRANSCRIPTION:

Jessica Bard: Hello, everyone. Welcome to another installment of "Podcasts360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

According to the Centers for Disease Control and Prevention, the Black and African American population account for a higher proportion of new HIV diagnoses and people with HIV compared to other races and ethnicities.

Dr J Logan is here to speak with us about that today. Dr Logan is an epidemiologist and health scientist in the division of HIV/AIDS prevention at the CDC. Thank you for joining us today, Dr. Logan. You presented your research, Structural Factors Associated with HIV Care for Black and White Adults With Diagnosed HIV, 2017 at CROI 2021. Can you please give us an overview of your session?

Dr J Logan: Sure. This research was in the area of social determinants of health and HIV. Just to give you some background, social determinants of health are the conditions in the environments where people are born, where they live, learn, work, play, worship, and age.

The interactions between the individuals and their environments can affect a wide range of health, and functioning, and quality of life outcomes. What this study does, it looked into some of the risks related to the social determinants of health because they will be a key component in our efforts to reduce health inequities related to HIV.

Jessica: What are the three structural factors that your team examined? You mentioned a few different things there, but why did you focus specifically on those factors?

Dr Logan: We looked at some key factors that influence the social determinants of health. There's been a large amount of research that looked at factors such as lack of health insurance, absence of local health facilities, stigma, how annual income can impact HIV care outcomes, and how housing instability can impact HIV care outcomes.

This study wanted to go beyond that and explore some new factors. In particular, we wanted to focus in on some factors that either, one, widen the gap of wealth across races, or help reduce the financial burden of care and improve access to medical services. We focused on redlining. We looked at the Medicaid expansion policy. We looked at usage of the Ryan White HIV/AIDS Program.

We picked these factors, starting with the first one, to look into understanding more about how wealth inequities may be contributing to health inequities. You want to look at some major contributors to what may be driving the wealth inequities.

Homeownership is probably one of the largest contributor to wealth in a household that's more open and supposed to be equal to everyone. We wanted to look at whether redlining could be potentially related to wealth inequity and health inequities.

Now, what redlining is? Redlining is a practice by mortgage companies that prevents often minority populations from acquiring home loans. Redlining can contribute to the concentration of those impacted by it into poor neighborhoods as well as deprive them of acquiring financial stability and, of course, wealth through homeownership.

The widening of the racial wealth gap, we believe, will be contributing more to health inequities. Homeownership is one of the most common wealth‑generating contributors. Redlining has also been examined in relation to other inequities of public health, especially related to breast cancer inequities, preterm birth, and pregnancy health. It hasn't been examined with regard to HIV care inequities.

We also wanted to look at policies that were implemented that might help reduce financial burden and also improve access to HIV care. These are broad structural factors in the sense that they are policies that are implemented. They are programs that are being used on a large scale.

The first one is the Medicaid expansion policy. Medicaid is one of the largest insurers of people with diagnosed HIV. It also has been found that insurance and access to insurance is a positive predictor for favorable HIV care outcomes.

What we wanted to do was explore whether those who reside in a Medicaid expanded state, whether they are able to acquire more insurance and be able to have more access and favorable HIV care outcomes.

We also wanted to look at the Ryan White HIV/AIDS Program. This is also a program that's widely used. It provides medical care services for low‑income, uninsured people with diagnosed HIV. Among people enrolled in the program, we have found there's some evidence to show that it's been reducing health inequities and creating more favorable health outcomes regarding HIV among minority populations.

We thought this finding was encouraging, and so we wanted to look at this factor as well. We wanted to do a study that looks at all three of these factors simultaneous. When we account for all of these factors, we wanted to see something jump out at us that seemed to be a contributing risk to HIV care from a structural factor level.

Is there something related to these outcomes for the Black African American population? We did in the study also for comparison purposes, we also looked at it among the White adult population who are also been diagnosed with HIV.

Jessica: Ultimately, Dr Logan, what were the results of your study?

Dr Logan: We discovered that structural factors that reduce the financial burden of HIV care and improved care access, just like the Medicaid expansion and the Ryan White Program, were positively associated with improved HIV care outcomes for people with diagnosed HIV.

This was for both, not just Black but also White people with diagnosed HIV. These policies are incredibly promising. We feel that they are definitely worthy of further study. Direct exposure to areas with redlining was not associated with poor HIV care outcomes.

Although we also felt that more research is needed to examine redlining as a potential risk factor. This means that one might believe that what redlining creates is it perpetuates circumstances such as lack of financial independence and even exposure to poverty and it's those factors might be impacting negative HIV care outcomes by those affected.

We want to do some more work in the area of looking at redlining. We also thought that we need to explore more factors about redlining itself. We discovered, first of all, that nearly two‑thirds of Black adults with diagnosed HIV in 2017, in our study, resided in a census tract where redlining against Black mortgage applicants was indicative.

Two‑thirds of Black people with diagnosed HIV were residing in census tracts, but they may be exposed to redlining. We need to look at this more carefully. On average, across the entire study, in all the census tracts, we discovered that Black mortgage applicants had twice the odds of being rejected for a loan as White applicants, even after accounting for loan amount, income, and sex of the applicant.

We still feel that there's a lot there that we need to unpack in how this is possibly sending shockwaves down to the local environments and impacting HIV care outcomes. This is the first study that embarked on this line of work. While we did not see a direct association between redlining and our HIV care outcomes [indecipherable 07:49] , we still feel we need to do more deeper exploration in this area.

Jessica: Those are absolutely important findings. What would you say are the biggest take‑home messages from your session?

Dr Logan: I would say the biggest take‑home messages, first of all, we should definitely be doing more work in understanding how the programs and policies that help reduce financial burden increase access to care work.

So far, this is only one study we see a positive distant association with favorable outcomes. There's more to this linkage, and we can learn from it. Our take‑home study is that let's continue to look at those factors. There is some promising results. Let's see how it works. Let's see why it works and how we can improve other policies and programs.

The other take‑home message is with regard to looking at some of these extreme circumstances. For years, we know that poverty is associated with poor healthcare outcomes.

Now, let's go beyond that. Let's understand and see what might be contributing to inequities in poverty exposure, and what are some policies that might be able to be in place to help with that. This may further help reduce or improve health for all in the future.

Jessica: My next question was, what's next for this topic? You just mentioned some things, but how do you do that? What's the next step?

Dr Logan: The first thing we want to do is we want to more rigorously examine the impact of the medical expansion policy and the Ryan White Program. Like I said, this is one study. It was a snapshot study, just looking at association.

Now we like to take a deeper dive. Let's do a more rigorous study. We might be able to do something with more rigorous or stronger methodologies to fully understand what we're seeing here and how these policies are impacting positively the populations.

The second is that we only looked at one area of redlining, and that is the inequities in mortgage rejections. But redlining takes on a lot of different facets. It can be also just as much that among homeowners, there could be inequities and interest rates.

Interest rates and payments of interest rates can have a huge impact on acquiring financial independence, having disposable income. We want to continue looking at more areas of redlining as well and looking at how this might be connected or linked to health and wealth generation.

Jessica: Is there anything else that you'd like to cover that you think that we missed?

Dr Logan: I think I've given a lot of people a lot to think about. [laughs] I just wanted to say that this is by no means a perfect study of any means, but we are trying to create a line of a new study that hopefully people will replicate and build in future work.

We not only are trying to advance the research, we're hoping at studies, especially into redlining and institutional‑level factors associated with HIV inequities.

We hope that we're building a nice tree trunk of knowledge so that many people can come, and develop, and branch out, and create, and help improve the understanding of this line of research. We hope that people are inspired by the work. We'll think about replicating, or continuing, or creating their own branch of it.

Jessica: Thank you for joining us today, Dr. Logan. We appreciate your time.

Dr Logan: Thank you so much for having me. Thank you to all the interested listeners. I hope you found this to be a very valuable podcast.