The same lesson over and over: drugs alone will not get us to 90--90--90

Relationship Between Sexually Transmitted Infections and Social Determinants of Health in Durham County, North Carolina, United States

Background

Sexually transmitted infections (STIs) are increasing in the United States, and certain populations are more at risk than others. One explanation for this is inequities in underlying social determinants of health (SDOH).

Methods

We analyzed chlamydia, gonorrhea, and syphilis cases in Durham County, North Carolina, from 01/01/2020 to 12/31/2020 by select SDOH at the census tract level. We included 48 variables of interest, including variables related to income, education, transportation, and health insurance. For each variable, we modeled STI incidence at the census tract level using Poisson regression. Wald's chi-square was used to determine which variables were significantly associated with STI incidence.

Results

Of 24 variables that were statistically associated with STI incidence at the census tract level, 9 were negatively associated and 15 positively associated with STI incidence. Having employer health insurance was most strongly associated with lower-than-expected STI incidence, and having Medicaid insurance, no health insurance, using public transportation, and income below the poverty level were most strongly associated with higher-than-expected STI incidence. Lastly, STI incidence was not associated with race or ethnicity overall across Durham County, except in historically marginalized areas, where we found higher-than-expected STI incidence.

Conclusions

We found that lacking health insurance, having Medicaid insurance, using public transportation, and income below the poverty level were most strongly associated with higher-than-expected STI incidence. Strategies to combat increasing STIs may include improving access to health insurance, reducing barriers to cost-effective and timely transportation to medical appointments, and raising wages to bring individuals out of poverty.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

The feminist political economy of Covid-19: Capitalism, women, and work

Analysing the pandemic through a feminist political economy lens makes clear how gender, race, and class structures are crucial to the functioning of capitalism and to understanding the impacts of the pandemic. The way capital organises production and reproduction combines with structures of oppression, generating vulnerability among the racialised and gendered populations worst impacted by Covid-19. Using global data, this commentary shows that during the pandemic, women experienced relatively greater employment losses, were more likely to work in essential jobs, and experienced a greater reduction in income. Women were also doing more reproductive labour than men and were more likely to drop out of the labour force because of it. Analyses of capitalism in feminist political economy illustrate how capital accumulation depends on women's oppression in multiple, fundamental ways having to do with their paid and unpaid work. Women's work, and by extension their health, is the foundation upon which both production and social reproduction rely. Recognising the pandemic as endogenous to capitalism heightens the contradiction between a world shaped by the profit motive and the domestic and global requirements of public health.

Linkage to intensive adherence counselling among HIV-positive persons on ART with detectable viral load in Gomba district, rural Uganda

BACKGROUND

Antiretroviral therapy (ART) adherence is a primary determinant of sustained viral suppression, HIV transmission risk, disease progression and death. The World Health Organization recommends that adherence support interventions be provided to people on ART, but implementation is suboptimal. We evaluated linkage to intensive adherence counselling (IAC) for persons on ART with detectable viral load (VL).

METHODS

Between January and December 2017, we conducted a retrospective chart review of HIV-positive persons on ART with detectable VL (> 1000 copies/ml), in Gomba district, rural Uganda. We abstracted records from eight HIV clinics; seven health center III's (facilities which provide basic preventive and curative care and are headed by clinical officers) and a health center IV (mini-hospital headed by a medical doctor). Linkage to IAC was defined as provision of IAC to ART clients with detectable VL within three months of receipt of results at the health facility. Descriptive statistics and multivariable logistic regression analyses were used to evaluate factors associated with linkage to IAC.

RESULTS

Of 4,100 HIV-positive persons on ART for at least 6 months, 411 (10%) had detectable VL. The median age was 32 years (interquartile range [IQR] 13-43) and 52% were female. The median duration on ART was 3.2 years (IQR 1.8-4.8). A total of 311 ART clients (81%) were linked to IAC. Receipt of ART at a Health Center level IV was associated with a two-fold higher odds of IAC linkage compared with Health Center level III (adjusted odds ratio [aOR] 1.78; 95% CI 1.00-3.16; p = 0.01). Age, gender, marital status and ART duration were not related to IAC linkage.

CONCLUSIONS

Linkage to IAC was high among persons with detectable VL in rural Uganda, with greater odds of linkage at a higher-level health facility. Strategies to optimize IAC linkage at lower-level health facilities for persons with suboptimal ART adherence are needed.

COVID-19 Capitalism: The Profit Motive versus Public Health

Market incentives in capitalist economies and public health requirements are contradictory. In the COVID-19 pandemic, market-rewarded self-interested behavior has been exposed as a source of mortality and morbidity. Profit-motivated behaviors can keep people from accessing necessities for health thereby harming individuals and possibly damaging population health. The profit motive can also undermine healthcare system capacity by maldistributing goods that are inputs to healthcare. Furthermore, because profit-seeking is economically rational in capitalism, capitalist imperatives may be incompatible with public health. The ways markets misallocate resources provide a rationale for state responsibility for health, which is a public good.