Social Determinants of Late Stage HIV Diagnosis and its Distributions among African Americans and Latinos: A critical literature review

ABSTRACT This critical literature review was conducted to identify both individual- and environmental-level social determinants of health using an ecological framework as a way to contextualize risk for, and distributions of, late HIV diagnosis among African Americans and Latinos in the United States. Background: Late diagnosis, defined as a diagnosis of AIDS simultaneously with or within one year of an initial HIV diagnosis,1 disproportionately affects African American and Latino communities;2,3 disparities in this health problem thus represent a preventable inequity. Such disparities affect not only late diagnosed individuals but also population levels of HIV incidence, as transmission is unhindered before diagnosis.4,5 Methods: A total of 26 unduplicated studies in 26 peer-reviewed articles were analyzed within a social ecological conceptual framework. Both quantitative and qualitative studies of factors influencing HIV testing were reviewed. To be included, studies had to have been conducted in the United States, published in English within the past 11 years, and to have focused on Latino or African American populations and/or on racial disparities between these and other populations. Findings: The majority of studies on racial disparities in HIV testing and diagnosis have been either cross-sectional1,2,6–11 or focused on one racial or ethnic group, often in one geographic location.12–18 In all studies that compared racial and ethnic groups (n=17), Latinos and African Americans were more likely to receive a late diagnosis3,19 than non-Hispanic Whites or Asian Americans. 95.8% (n= 23) of the reviewed studies focused on individual level risk factors or investigated structural barriers via measurements at the individual level. Next Steps: Both more quantitative and qualitative studies are needed that will enhance understanding of the social determinants of HIV testing behavior among at-risk groups by measuring variables at the appropriate rung of the ecological model, and not solely on the individual level. Studies that investigate barriers to and facilitators of HIV testing in partnership with communities will help further interventions that can reduce racial/ethnic disparities in late diagnosed HIV/AIDS

The Role of Racial Identity and Implicit Racial Bias in Self-Reported Racial Discrimination: Implications for Depression Among African American Men

Racial discrimination is conceptualized as a psychosocial stressor that has negative implications for mental health. However, factors related to racial identity may influence whether negative experiences are interpreted as instances of racial discrimination and subsequently reported as such in survey instruments, particularly given the ambiguous nature of contemporary racism. Along these lines, dimensions of racial identity may moderate associations between racial discrimination and mental health outcomes. This study examined relationships between racial discrimination, racial identity, implicit racial bias, and depressive symptoms among African American men between 30 and 50 years of age (n = 95). Higher racial centrality was associated with greater reports of racial discrimination, while greater implicit anti-Black bias was associated with lower reports of racial discrimination. In models predicting elevated depressive symptoms, holding greater implicit anti-Black bias in tandem with reporting lower racial discrimination was associated with the highest risk. Results suggest that unconscious as well as conscious processes related to racial identity are important to consider in measuring racial discrimination, and should be integrated in studies of racial discrimination and mental health

Racial Segregation, Income Inequality, and Mortality in US Metropolitan Areas

Evidence of the association between income inequality and mortality has been mixed. Studies indicate that growing income inequalities reflect inequalities between, rather than within, racial groups. Racial segregation may play a role. We examine the role of racial segregation on the relationship between income inequality and mortality in a cross-section of US metropolitan areas. Metropolitan areas were included if they had a population of at least 100,000 and were at least 10% black (N = 107). Deaths for the time period 1991–1999 were used to calculate age-adjusted all-cause mortality rates for each metropolitan statistical area (MSA) using direct age-adjustment techniques. Multivariate least squares regression was used to examine associations for the total sample and for blacks and whites separately. Income inequality was associated with lower mortality rates among whites and higher mortality rates among blacks. There was a significant interaction between income inequality and racial segregation. A significant graded inverse income inequality/mortality association was found for MSAs with higher versus lower levels of black–white racial segregation. Effects were stronger among whites than among blacks. A positive income inequality/mortality association was found in MSAs with higher versus lower levels of Hispanic–white segregation. Uncertainty regarding the income inequality/mortality association found in previous studies may be related to the omission of important variables such as racial segregation that modify associations differently between groups. Research is needed to further elucidate the risk and protective effects of racial segregation across groups

Universal Alcohol/Drug Screening in Prenatal Care: A Strategy for Reducing Racial Disparities? Questioning the Assumptions

Agencies and organizations promoting universal screening for alcohol and drug use in prenatal care argue that universal screening will reduce White versus Black racial disparities in reporting to Child Protective Services (CPS) at delivery. Yet, no published research has assessed the impact of universal screening on reporting disparities or explored plausible mechanisms. This review defines two potential mechanisms: Equitable Surveillance and Effective Treatment and identifies assumptions underlying each mechanism. It reviews published literature relating to each assumption. Research relating to assumptions underlying each mechanism is primarily inconclusive or contradictory. Thus, available research does not support the claim that universal screening for alcohol and drug use in prenatal care reduces racial disparities in CPS reporting at delivery. Reducing these reporting disparities requires more than universal screening

Implicit Racial Bias as a Moderator of the Association Between Racial Discrimination and Hypertension

ObjectivesEmpirical findings on racial discrimination and hypertension risk have been inconsistent. Some studies have found no association between self-reported experiences of discrimination and cardiovascular health outcomes, whereas others have found moderated or curvilinear relationships. The current cross-sectional study examined whether the association between racial discrimination and hypertension is moderated by implicit racial bias among African American midlife men.MethodsThis study examined the data on 91 African American men between 30 and 50 years of age. Primary variables were self-reported experiences of racial discrimination and unconscious racial bias as measured by the Black-White Implicit Association Test. Modified Poisson regression models were specified, examining hypertension, defined as a mean resting systolic level of at least 140 mm Hg or diastolic level of at least 90 mm Hg, or self-reported history of cardiovascular medication use with a physician diagnosis of hypertension.ResultsNo main effects for discrimination or implicit racial bias were found, but the interaction of the two variables was significantly related to hypertension (χ(2)(1) = 4.89, p < .05). Among participants with an implicit antiblack bias, more frequent reports of discrimination were associated with a higher probability of hypertension, whereas among those with an implicit problack bias, it was associated with lower risk.ConclusionsThe combination of experiencing racial discrimination and holding an antiblack bias may have particularly detrimental consequences on hypertension among African American midlife men, whereas holding an implicit problack bias may buffer the effects of racial discrimination. Efforts to address both internalized racial bias and racial discrimination may lower cardiovascular risk in this population

Trends for Reported Discrimination in Health Care in a National Sample of Older Adults with Chronic Conditions

BackgroundDiscrimination in health care settings is associated with poor health outcomes and may be especially harmful to individuals with chronic conditions, who need ongoing clinical care. Although efforts to reduce discrimination are growing, little is known about national trends in discrimination in health care settings.MethodsFor Black, White, and Hispanic respondents with chronic disease in the 2008-2014 Health and Retirement Study (N = 13,897 individuals and 21,078 reports), we evaluated trends in patient-reported discrimination, defined based on frequency of receiving poorer service or treatment than other people from doctors or hospitals ("never" vs. all other). Respondents also reported the perceived reason for the discrimination. In addition, we evaluated whether wealth predicted lower prevalence of discrimination for Blacks or Whites. We used generalized estimating equation models to account for dependency of repeated measures on individuals and wave-specific weights to represent the US non-institutionalized population aged 54+ .ResultsThe estimated prevalence of experiencing discrimination in health care among Blacks with a major chronic condition was 27% (95% CI: 23, 30) in 2008 and declined to 20% (95% CI: 17, 22) in 2014. Reports of receiving poorer service or treatment were stable for Whites (17%, 95% CI: 16, 19 in 2014). The Black-White difference in reporting any health care discrimination declined from 8.2% (95% CI: 4.5, 12.0) in 2008 to 2.5% (95% CI: -1.1, 6.0) in 2014. There was no clear trend for Hispanics. Blacks reported race and Whites reported age as the most common reason for discrimination.ConclusionsFindings suggest national declines in patient-reported discrimination in health care among Blacks with chronic conditions from 2008 to 2014, although reports of discrimination remain common for all racial/ethnic groups. Our results highlight the critical importance of monitoring trends in reports of discrimination in health care to advance equity in health care

Discrimination, racial bias, and telomere length in African-American men.

BackgroundLeukocyte telomere length (LTL) is an indicator of general systemic aging, with shorter LTL being associated with several chronic diseases of aging and earlier mortality. Identifying factors related to LTL among African Americans may yield insights into mechanisms underlying racial disparities in health.PurposeTo test whether the combination of more frequent reports of racial discrimination and holding a greater implicit anti-black racial bias is associated with shorter LTL among African-American men.MethodsCross-sectional study of a community sample of 92 African-American men aged between 30 and 50 years. Participants were recruited from February to May 2010. Ordinary least squares regressions were used to examine LTL in kilobase pairs in relation to racial discrimination and implicit racial bias. Data analysis was completed in July 2013.ResultsAfter controlling for chronologic age and socioeconomic and health-related characteristics, the interaction between racial discrimination and implicit racial bias was significantly associated with LTL (b=-0.10, SE=0.04, p=0.02). Those demonstrating a stronger implicit anti-black bias and reporting higher levels of racial discrimination had the shortest LTL. Household income-to-poverty threshold ratio was also associated with LTL (b=0.05, SE=0.02, p<0.01).ConclusionsResults suggest that multiple levels of racism, including interpersonal experiences of racial discrimination and the internalization of negative racial bias, operate jointly to accelerate biological aging among African-American men. Societal efforts to address racial discrimination in concert with efforts to promote positive in-group racial attitudes may protect against premature biological aging in this population