Toward Health Equity: Addressing Racial & Ethnic Disparities in HIV

A Guide for Providers, Advocates and Health Workers

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Resources on Disparities & Equity

What are health disparities? What is health equity?

According to the United States Office of Disease Prevention and Health Promotion, a health disparity is “a particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” [1].

Health equity is “the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions” [2].

A report by the Robert Wood Johnson Foundation explains key steps necessary in achieving health equity:

  1. Identify important disparities in health (including disparities known to be inequities and disparities whose causes are unknown or contested) that are of concern to key stakeholders, especially those affected. Identify social inequities in access to the resources and opportunities needed to be healthier that are likely to contribute to the health disparities.
  2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in access to the opportunities and resources needed to be as healthy as possible.
  3. Evaluate and monitor efforts using short-, intermediate-, and long-term measures.
  4. Reassess strategies to plan next steps.
How do health disparities affect HIV acquisition rates?

A complex and interrelated set of individual, systematic, societal, and environmental factors contribute to disparities in health [3]. Racism, cisnormativity, sexism/transmisogyny, classism,  and stigma related to HIV, gender nonconformity, substance use, and sex work have been shown to influence HIV-related healthcare access [4]. There are stark disparities in HIV acquisition rates by race in the U.S. For example, Black people of all genders account for approximately 44% of HIV diagnoses, while comprising 12% of the overall population [5]. Additionally, southern states account for 37% of the U.S. population, but 52% of new HIV diagnoses [6] [7] . In 2014, Blacks made up 54% of all new HIV diagnoses and Black women accounted for 69 percent of all HIV diagnoses among women in the South [8].

“Many Black communities affected by HIV in the southern U.S. are also disproportionately affected by social and structural determinants of health (SDH) that have historical and political roots of injustice, poverty, racism and unequal opportunities to access education and employment, all of which contribute to HIV-related racial/ethnic disparities and deter from HIV health equity goals, and which have presented challenges for partnerships with institutions that serve historically underrepresented populations. A legal policy which may also impede health equity and healthcare access to facilitate early HIV screening and/or treatment is the lack of Medicaid expansion in the southern United States, especially in the Deep South States of Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas [9].”

We know that health equity means striving for the best possible standard of health for all people. Yet, Black women in the U.S. are 20 times more likely to acquire HIV than White women and have a 1 in 52 lifetime risk of acquiring HIV [10]. Additionally, fewer Black women have been prescribed pre-exposure prophylaxis (PrEP) [11] for HIV prevention or know about PrEP [10] than white women. Black women face striking disparities in a wide range of women’s health outcomes [11] and report feeling uncomfortable and judged in conversations with healthcare providers about their sexual health[12, 13].

Striving for health equity requires a closer look at the root causes of disparities. In the United States, structural racism has contributed to inequities in housing, education, employment, media representation, healthcare access & services, criminal justice and more. It is essential to contextualize racialized health disparities as a structural failing, not an individual problem. For more on structural racism and its role in widening health disparities, we invite you to watch this one-hour video:

Racial Disparities in Health and Their Impact on Black & Other Marginalized Communities

Below are a variety of resources to learn about and address racial disparities within your organization and in your work. To learn more from organizations/coalitions working to reduce disparities by addressing structural issues, check out: Black AIDS Institute, SisterSong, Sisterlove, Black Mamas Matter Alliance, Southern AIDS Coalition and Black Women’s Health Imperative for more information.

1. [Media Article] Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis by Linda Villarosa

The reasons for the black-white divide in both infant and maternal mortality have been debated by researchers and doctors for more than two decades. But recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.”

2. [Blog] 6 charts showing race gaps within the American middle class by Richard V. Reeves, Dayna Bowen Matthew

This article uses data to illustrates that “the disadvantages and discrimination faced by blacks are not reducible to poverty or economic factors alone. Racial injustice and inequality affect the middle class, too.”

3. [Media Article] Hiring Discrimination Against Black Americans Hasn’t Declined in 25 Years by Lincoln Quillian, Devah Pager, Arnfinn H. Midtboen, Ole Hexel

Authors cite a meta analysis of field experiments to conclude that there is a continuing need for anti-discrimination policies and legislation. “Even among well-intended employers, racial bias may lurk in hiring decisions. Whether conscious or not, bias continues to affect decision making, and we find little evidence that this pattern will diminish on its own.

4. [Journal Article] Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth.

A secondary analysis of focus group data “add[ing] to the growing literature that women of color experience discrimination, racism and disrespect in healthcare encounters and that they believe this affects their health and that of their infants.”

5. [Journal Article] Black Lives Matter: Claiming a Space for Evidence-Based Outrage in Obstetrics and Gynecology

“As subspecialist obstetricians–gynecologists, we use data from our field to demonstrate the significant disparities Black women face across their reproductive lives, and conclude that these outcomes are not only statistically significant, but morally significant and fundamentally unjust. (All reported comparisons and measures of association in this article are for Black women compared to a cohort of White women, unless otherwise indicated.”

6. [Report] Black Lives Matter: What’s PrEP Got To Do With It? Report by Black AIDS Institute.   

“This report aims to further awareness and commitment about rolling out PrEP in Black America where appropriate.”  

7. [Journal Article] Racism as a determinant of health: a protocol for conducting a systematic review and meta-analysis

The aim of this review protocol is to provide a structure from which to conduct a systematic review and meta-analysis of studies that assess the relationship between racism and health.”

8. [Video] The Origins of Black Poverty: Talk by Dr. Zea Malawa

Dr Zea Malawa explores perspectives on how American policies have created a crisis of Black poverty and ill-health nationally and locally in San Francisco.  

9. [Book] Medical Apartheid, by Harriet Washington

“The product of years of prodigious research into medical journals and experimental reports long undisturbed, Medical Apartheid reveals the hidden underbelly of scientific research and makes possible, for the first time, an understanding of the roots of the African American health deficit.”

10. [Committee Report/E-Book] Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care by Institute of Medicine

Confronting Racial & Ethnic Disparities in Health Care.

11. [Book] How We Get Free: Black Feminism and the Combahee River Collective, Edited by Keeanga-Yamahtta Taylor

The Combahee River Collective, a path-breaking group of radical black feminists, was one of the most important organizations to develop out of the antiracist and women’s liberation movements of the 1960s and 70s. In this collection of essays and interviews edited by activist-scholar Keeanga-Yamahtta Taylor, founding members of the organization and contemporary activists reflect on the legacy of its contributions to Black feminism and its impact on today’s struggles.

Toward Health Equity: Frameworks for Examining Organizational Culture and Creating Systems Change

1. [Report] Advancing Equity, by Zuckerberg San Francisco General Hospital and Trauma Center

ZSFG’s efforts at understanding and addressing disparities across the hospital system.

2. [Webpage] Our Approach: How We Work by California Preterm Birth Initiative

PTBi integrates Health Equity & Racial Equity throughout their work by putting communities first.

3. Allyship Means Action by Department of Obstetrics & Gynaecology at San Francisco General Hospital

4. [Toolkit] Racial Equity Impact Assessment Toolkit by Race Forward: The Center for Racial Justice Innovation

A systematic examination of how racial and ethnic groups will likely be affected by a proposed action or decision.

5. [Report & Toolkit] Race-Explicit Strategies for Workforce Equity in Healthcare and IT by Race Forward: The Center for Racial Justice Innovation

This report examines dominant narratives in the public workforce system, perceived barriers in workforce development and opportunities to break down those barriers.

6. [Toolkit/Worksheet] Race Equity Impact Analysis by Annie E. Casey Foundation

A tool to assess specifically what kinds of racial outcomes are likely to be produced by the work you undertake. 

7. [Book] Erasing Institutional Bias by Tiffany Jana & Ashley Diaz Mejias

This book offers concrete ways for anyone to work against institutional bias no matter what their position is in an organization.

8. [Toolkit] Race Equity and Inclusion Action Guide (Annie E. Casey Foundation)

A framework of 7 key steps to advancing race equity and inclusion.

9. [Report/Toolkit] A Roadmap to Reduce Racial and Ethnic Disparities in Health Care, by Robert Wood Johnson Foundation

A road map that can help organizations integrate disparities reduction into all health care quality improvement efforts.

Toward Health Equity: Readings & Tools for Individual Awareness & Action

1. [Essay/Toolkit] White Privilege: Unpacking the Invisible Knapsack by Peggy McIntosh

“To redesign social systems we need first to acknowledge their colossal unseen dimensions. The silences and denials surrounding privilege are the key political tool here.”  

2. [Book] The Person You Mean to Be: How Good People Fight Bias, by Dolly Chugh

A guide on how to confront difficult issues including sexism, racism, inequality, and injustice so that you can make the world (and yourself) better.

3. [Tool] Implicit Associations Test (Harvard)

A test for implicit associations you carry about gender, race, ethnicity, nationality, sexuality, and more.

4. [Glossary] Terminologies of Oppression by The Anti-Oppression Network

A comprehensive list of working definitions.

5. [Course] The Roots of Health Inequity by National Association of County and City Health Officials

The Roots of Health Inequity is an online learning collaborative. The site offers a starting place for those who want to address systemic differences in health and wellness that are, actionable, unfair, and unjust.

6. [Workbook] Me And White Supremacy Workbook by Layla Saad

A 28-day journey to kickstart your life-long anti-racism work.

7. [Course] Hard Conversations: Introductions to Racism. By Patti Digh and Victor Lee Lewis.

This four-week intensive course covers systemic racism, white privilege, colorblindness and microaggressions, and how to be an effective ally.

Frameworks for Supporting Justice-Centered Interpersonal Interactions

1. [Webpage] Reproductive Justice Framework by SisterSong: Women of Color Reproductive Justice Collective

A primer on Reproductive Justice.

2. [Toolkit] Language Matters: Addressing HIV Stigma by using Preferred Language by HIVE

A tool to address HIV Stigma through the use of Preferred Language

3. [Media Article] The Future of Healing: Shifting From Trauma Informed Care to Healing Centered Engagement and [Video] Healing Centered Engagement: Radical Healing In Critical Times by Dr. Shawn Ginwright

Addressing social toxicity and structural violence with more than trauma-informed care – Healing Centered Engagement.

4. [Webpage] Allyship by Anti-Oppression Network

A framework for being an ally, being in solidarity & acting from responsibility.

5. [Tip Sheet] Providing Linguistically Appropriate Care by Allyship Means Action at Department of Obstetrics, Gynecology and Reproductive Sciences – UCSF

Tips on advocating for patients with proficiency in a language other than English.

6. [Tip Sheet] Combating Stereotype Threat by Allyship Means Action at Department of Obstetrics, Gynecology and Reproductive Sciences – UCSF

Tips to recognize and address stereotype threat in interactions with patients.

This webpage was curated by Yamini Oseguera-Bhatnagar with support from Karishma Oza, Shannon Weber & Dominika Seidman. While this page includes a diverse set of resources for providers, advocates, and health workers at various stages of their health equity journey, we recognize this is not an exhaustive list. If you have any feedback or questions, please contact Yamini at yamini@hiveonline.org. This page was last updated on 2/21/19.