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McCree DH, Beer L, Crim SM, Kota KK, Baugher A, Jeffries WL, Patel D, Marcus R, Yuan XA, Luke Shouse R. Intersectional Discrimination in HIV Healthcare Settings Among Persons with Diagnosed HIV in the United States, Medical Monitoring Project, 2018-2019. AIDS Behav 2023; 27:3623-3631. [PMID: 37166687 DOI: 10.1007/s10461-023-04076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/12/2023]
Abstract
Experiences with stigma and discrimination in healthcare settings are associated with negative health outcome for persons with HIV (PWH). PWH may experience discrimination due to the intersection of multiple marginalized social identities. Describing these experiences is important for informing interventions and strategies to reduce stigma and discrimination. We report experiences with discrimination in HIV healthcare settings attributed to multiple characteristics, e.g., sexual orientation, race/ethnicity, income, or social class, and/or injection drug use, among a nationally representative sample of persons with diagnosed HIV in the United States using data from the Medical Monitoring Project (MMP). We calculated weighted prevalences and associated 95% confidence intervals for any discrimination and discrimination attributed to multiple characteristics (intersectional discrimination). Among those experiencing discrimination, nearly 1 in 4 persons reported intersectional discrimination, with a higher burden among key populations of focus for HIV prevention and treatment. Discrimination was attributed to HIV status (62.5%), sexual orientation (60.4%), and race/ethnicity (54.3%). Persons who experienced intersectional discrimination were less likely to have a regular HIV care provider, have trust in HIV care or treatment information from healthcare providers, and be antiretroviral treatment or HIV care visit adherent. Future studies should explore methods to operationalize and assess experiences with intersectional stigma and discrimination and use the outcomes to inform qualitative research that provides more context and a deeper understanding of experiences with intersectional discrimination among PWH.
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Affiliation(s)
- Donna Hubbard McCree
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Linda Beer
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stacy M Crim
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Amy Baugher
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William L Jeffries
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deesha Patel
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ruthanne Marcus
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - R Luke Shouse
- National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Kota KK, Luo Q, Beer L, Dasgupta S, McCree DH. Stigma, Discrimination, and Mental Health Outcomes Among Transgender Women With Diagnosed HIV Infection in the United States, 2015-2018. Public Health Rep 2023; 138:771-781. [PMID: 36129230 PMCID: PMC10467496 DOI: 10.1177/00333549221123583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Transgender women with diagnosed HIV experience social and structural factors that could negatively affect their overall health and HIV-related health outcomes. We describe estimates from the Centers for Disease Control and Prevention Medical Monitoring Project (MMP) of sociodemographic characteristics, HIV stigma, discrimination, and mental health outcomes among transgender women with diagnosed HIV. METHODS We analyzed pooled data of all transgender women with diagnosed HIV (N = 217) from the 2015 through 2018 MMP cycles. We reported unweighted frequencies, weighted percentages, and 95% CIs for all characteristics. We post-stratified data to known population totals by age, race and ethnicity, and sex at birth from the National HIV Surveillance System. RESULTS Approximately 46% of transgender women with diagnosed HIV identified as Black or African American, 67% lived at or below the federal poverty level, 18% had experienced homelessness in the past year, 26% experienced mild to severe symptoms of depression, 30% experienced mild to severe anxiety symptoms, 32% reported physical violence by an intimate partner, and 30% reported forced sex during their lifetime. Despite 80% being very satisfied with their current HIV care, 94% experienced current HIV stigma and 20% experienced health care-related discrimination since being diagnosed with HIV. Among transgender women with diagnosed HIV who experienced discrimination, 46% and 51% experienced health care discrimination attributed to their gender and sexual orientation or sexual practices, respectively. CONCLUSIONS Our findings underscore a need to address unmet ancillary services, such as housing, intimate partner violence, and mental health needs, and the need for strategies to reduce experiences with HIV stigma and discrimination in care for transgender women with diagnosed HIV in the United States.
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Affiliation(s)
- Krishna Kiran Kota
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | | | - Linda Beer
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sharoda Dasgupta
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Donna Hubbard McCree
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Hall WJ, McCree DH, Beer L, Luo Q, Carter B. Sociodemographic, behavioral, and clinical characteristics associated with perceived discrimination in healthcare settings among Black persons with diagnosed HIV in the United States. AIDS Care 2022; 35:325-333. [PMID: 36328983 DOI: 10.1080/09540121.2022.2141183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Research that explores the intra-racial socio-demographic and clinical characteristics associated with perceived discrimination in healthcare settings in the US is lacking. We examined the prevalence of self-reported discrimination in HIV care settings during the past 12 months among Black persons from a nationally representative sample of US adults with diagnosed HIV collected 6/2018-5/2019. We assessed the prevalence of self-reported discrimination in HIV care settings during the past 12 months, perceived reasons for discrimination, and factors associated with discrimination among Black persons with diagnosed HIV (n = 1,631). Overall, 22% reported experiencing discrimination in a healthcare setting; discrimination was most often attributed to HIV status. Those reporting discrimination were younger, MSM, and living at or below the federal poverty level. They also experienced homelessness, incarceration and illicit substance use in the past 12 months, and anxiety and depression symptoms in the past 2 weeks. They were less likely to use ART or report 100% ART dose adherence in the past 30 days. No associations were found with viral suppression. Systems are needed to monitor, evaluate reports of, and address discrimination in healthcare settings. Incorporating anti-discrimination policies and continuing education opportunities for providers and staff may reduce experiences of discrimination among persons with HIV.
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Affiliation(s)
- Wendasha Jenkins Hall
- Department of Health Promotion and Physical Education, Kennesaw State University, Kennesaw, GA, USA
| | - Donna Hubbard McCree
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Brittani Carter
- Department of Health Promotion and Physical Education, Kennesaw State University, Kennesaw, GA, USA
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Dasgupta S, Tie Y, Beer L, Weiser J. Unmet needs for ancillary care services are associated with HIV clinical outcomes among adults with diagnosed HIV. AIDS Care 2022; 34:606-614. [PMID: 34180733 PMCID: PMC8712612 DOI: 10.1080/09540121.2021.1946001] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
Ancillary care services are essential for supporting care engagement and viral suppression among persons with HIV. Estimating unmet needs for ancillary care services may help address care barriers and improve clinical outcomes, but recent, nationally representative estimates are lacking. Using CDC Medical Monitoring Project data from 2015-2018, we report representative estimates of unmet needs for ancillary care services and associations with HIV clinical outcomes among U.S. adults with HIV. Data were collected through interview and medical record abstraction. We described weighted percentages for all characteristics and associations with HIV clinical outcomes using prevalence ratios with predicted marginal means, adjusting for potential confounding. Substantial unmet needs were reported; unmet needs were higher among persons with social determinants of poor health, persons who engaged in drug use or binge drinking, and those who experienced depression or anxiety. Having unmet needs for care was associated with adverseHIV clinical outcomes, with a dose response effect between number of unmet needs and outcomes. Expanding ancillary care access based on a comprehensive care model, strengthening partnerships between providers to connect patients to essential services, and tailoring services based on need may help reduce disparities in unmet needs and improve outcomes.
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Affiliation(s)
- Sharoda Dasgupta
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yunfeng Tie
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Baugher AR, Whiteman A, Jeffries WL, Finlayson T, Lewis R, Wejnert C. Black men who have sex with men living in states with HIV criminalization laws report high stigma, 23 U.S. cities, 2017. AIDS 2021; 35:1637-1645. [PMID: 34270489 PMCID: PMC9030111 DOI: 10.1097/qad.0000000000002917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine the association between HIV laws, perceived community stigma, and behaviors and to compare differences between and within Black and White men who have sex with men (MSM). DESIGN/METHODS National HIV Behavioral Surveillance conducted interviews and HIV testing with MSM in 23 U.S. cities in 2017 using venue-based sampling methods. We used weighted cross-sectional data to compare MSM living in states with versus without HIV laws using Rao-Scott chi-square tests. We modeled the association between stigma and state HIV laws within racial groups to obtain adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs). RESULTS Among 7392 MSM, 56% lived in a state with HIV laws. In law states, Black MSM were more likely than White MSM to report their community would discriminate against persons with HIV (PWH) (59 versus 34%), not support the rights of PWH (20 versus 9%), not be friends with PWH (19 versus 10%), believe PWH 'got what they deserved' (27 versus 16%), and be intolerant of MSM (14 versus 5%). Adjusted for confounders, Black MSM in HIV law states were more likely to think their community would discriminate against PWH (aPR, 1.14; 95% CI, 1.02-1.29; P = 0.02) and be intolerant toward MSM (aPR, 2.02; 95% CI, 1.43-2.86; P < 0.001) than Black MSM in states without such laws. CONCLUSIONS HIV laws were related to higher stigma, but only for Black MSM. Future research regarding HIV-related laws should account for racial/ethnic disparities. Modernizing laws can delegitimize stigma and promote focusing on effective HIV prevention strategies.
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Affiliation(s)
- Amy R. Baugher
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ari Whiteman
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, assigned to DHAP, Oak Ridge, TN, USA
| | - William L. Jeffries
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Teresa Finlayson
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rashunda Lewis
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cyprian Wejnert
- Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Wesson P, Vittinghoff E, Turner C, Arayasirikul S, McFarland W, Wilson E. Intercategorical and Intracategorical Experiences of Discrimination and HIV Prevalence Among Transgender Women in San Francisco, CA: A Quantitative Intersectionality Analysis. Am J Public Health 2021; 111:446-456. [PMID: 33476238 PMCID: PMC7893335 DOI: 10.2105/ajph.2020.306055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 11/04/2022]
Abstract
Objectives. To examine differences in HIV prevalence and experiences of discrimination within the trans women community in California's San Francisco Bay Area.Methods. Intersectional positions were constructed on the basis of race/ethnicity (non-Hispanic White, non-Hispanic Black, Latina) and gender identity (female identifying, transgender identifying). We used baseline data from the Trans*National study (2016-2017) to construct regression models that estimated racial/ethnic differences in the attribution of discrimination experienced and, along with surrogate measures for intersectionality, estimated risk among those who were dually marginalized (racial/ethnic minority and transgender identifying). Margins plots were used to visually compare absolute risk across all intersectional positions.Results. Black and Latina trans women were more likely to be HIV positive than non-Hispanic White trans women. In several of the study domains, we estimated a lower risk of reporting discrimination among dually marginalized trans women than among White female-identifying trans women.Conclusions. Quantitative intersectionality methods highlight the diversity of experiences within the trans women community and reveal potential measurement challenges. Despite facing multiple forms of systemic marginalization, racial/ethnic minority trans women report less discrimination than White trans women. Subjective reporting of discrimination likely undercounts risks among racial/ethnic minorities.
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Affiliation(s)
- Paul Wesson
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
| | - Eric Vittinghoff
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
| | - Caitlin Turner
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
| | - Sean Arayasirikul
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
| | - Willi McFarland
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
| | - Erin Wilson
- Paul Wesson, Eric Vittinghoff, and Caitlin Turner are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Sean Arayasirikul, Willi McFarland, and Erin Wilson are with the Center for Public Health Research, San Francisco Department of Public Health
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Weiser J, Dempsey A, Mandsager P, Shouse RL. Documenting Successes 30 Years After Passage of the Ryan White CARE Act: To the Editor. J Assoc Nurses AIDS Care 2021; 32:138-139. [PMID: 33427768 PMCID: PMC7914155 DOI: 10.1097/jnc.0000000000000224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- John Weiser
- Medical Epidemiologist, U.S., Department of Health and Human Services, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
| | - Antigone Dempsey
- Director of Policy and Data, U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, USA
| | - Paul Mandsager
- Health Scientist, U.S., Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Rockville, Maryland, USA
| | - R. Luke Shouse
- Medical Epidemiologist, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia, USA
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Whiteman A, Baugher A, Sionean C. Assessing self-reported discrimination among men who have sex with men (MSM). AIDS 2021; 35:141-146. [PMID: 33048888 DOI: 10.1097/qad.0000000000002711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the prevalence of four forms of sexual identity discrimination among MSM in 23 US metropolitan statistical areas, examine racial/ethnic and socioeconomic disparities in each form of discrimination. METHODS We examined interview data collected during 2017 for National HIV Behavioral Surveillance (n = 10 029 respondents) and used generalized linear models to assess the association between the prevalence of reported discrimination during the previous 12 months and selected sociodemographic groups. RESULTS Overall, 34% of participants reported experiencing verbal discrimination; 16%, discrimination in a workplace, school, or a healthcare setting; and 8%, physical assault. MSM who had reported experiencing discrimination were most likely to be young, had achieved lower education, and had lower incomes. High prevalence of reported discrimination was associated with young age, lower education, lower household income, sexual identity disclosure, and lower perceived community tolerance of gay or bisexual persons. CONCLUSION MSM discrimination affects different groups and occurs in multiple settings. Addressing discrimination should be an integral aspect of multifaceted efforts to improve MSM health.
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Affiliation(s)
- Ari Whiteman
- Oak Ridge Institute for Science and Education, Oak Ridge, Georgia, assigned to the Agency for Toxic Substances and Disease Registry
| | - Amy Baugher
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Catlainn Sionean
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Stein R, Xu S, Williams W, Marano M, Eke A, Finlayson T, Paz-Bailey G, Wejnert C. Factors Associated with HIV Antiretroviral Therapy among Men Who Have Sex with Men in 20 US Cities, 2014. J Urban Health 2019; 96:868-877. [PMID: 31512032 PMCID: PMC6904711 DOI: 10.1007/s11524-019-00386-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.
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Affiliation(s)
- Renee Stein
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA.
| | - Songli Xu
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
| | - Weston Williams
- Public Health Analytic Consulting Services, Inc, Hillsborough, NC, USA
| | - Mariette Marano
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
| | - Adanze Eke
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
| | - Teresa Finlayson
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
| | - Gabriela Paz-Bailey
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
| | - Cyprian Wejnert
- Centers for Disease Control and Prevention, 1600 Clifton Road, US8-2, Atlanta, GA, 30333, USA
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