The Effects of Previous Experiences of Healthcare Discrimination on HIV Intervention Outcomes.

Although several healthcare interventions have been developed to address HIV among young Black/African American men who have sex with men (YBMSM), the HIV epidemic in the United States continues to disproportionately burden this population. The current study examines previous healthcare discrimination and how it affects HIV intervention delivery. One hundred seventy-two YBMSM participated in the Peer Promotion of Wellness and Enhanced Linkage to Resources (PPOWER) project, which used a short, multi-faceted, community-level intervention based on Community Peers Reaching Out and Modeling Intervention Strategies (Community PROMISE). Data were collected at baseline, a 45-day follow up, and a 90-day follow up. Generalized Estimating Equations (GEE) were used to examine the effects of previous healthcare discrimination on outcomes related to HIV testing, alcohol and drug use, and sexual behaviors. Previous healthcare discrimination was found to moderate the relationship between time and intentions to test for HIV, perceptions of sexual risk, problem marijuana use, and problem other drug use, such that those who had experienced more healthcare discrimination showed greater improvements over time compared to those who had experienced less healthcare discrimination. The results of the current study suggest that a community-level peer intervention, in combination with a component to promote cultural competency and address prior experiences of discrimination in healthcare settings, may be highly effective for people who have experienced a barrier in their continuum of care as a result of racial discrimination.

Healthcare discrimination, anticipated HIV stigma, and income as predictors of HIV testing among a community sample of YBMSM.

Young Black men who have sex with men (YBMSM) are at particular risk for HIV, and knowing one's HIV status is key to preventing new HIV infections. Data were derived from a community-based study involving 250 YBMSM to examine the relationships between race-based discrimination experienced in healthcare settings, anticipated HIV stigma, household income and lifetime HIV testing. Lifetime HIV testing was regressed on racial discrimination in healthcare settings, anticipated HIV stigma, and income, and a significant 3-way interaction was found. To help interpret the 3-way interaction, lifetime HIV testing was regressed on racial discrimination in healthcare settings and anticipated HIV stigma in two separate models; with low-income and higher-income YBMSM. Anticipated HIV stigma was found to predict HIV testing among low-income YBMSM. A significant interaction was detected such that low-income YBMSM with low levels of anticipated HIV stigma were more likely to get tested for HIV regardless of experiences with healthcare discrimination, while low-income YBMSM who reported greater anticipated HIV stigma and more experiences of healthcare discrimination were less likely to get tested for HIV. Understanding the complexity of potential barriers is crucial for developing interventions to increase HIV testing within this population.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement.

BACKGROUND: Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated. OBJECTIVES: The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research. METHODS: Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research. RESULTS: Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies. CONCLUSIONS: At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Marijuana Use and Sexual Risk Behavior Among Young Black Men Who Have Sex with Men in California.

Young black men who have sex with men (YBMSM) are disproportionately affected by HIV and continue to experience higher rates of new HIV infections when compared to other population groups. As part of the Peer Promotion of Wellness and Enhanced Linkage to Resources Project, we examined problem marijuana use and the overall sexual risk profile of 250 YBMSM. Eighty percent reported prior use of marijuana in their lifetime (n = 200). Among those, problem marijuana use was correlated with problem use of alcohol (r = 0.51, p < 0.001) and other drugs (r = 0.29, p < 0.001); lower household income (r = - .22, p < .01); homelessness (r = 0.15, p < 0.05); incarceration (r = 0.16, p < 0.05); exchanging sex for money, drugs, or shelter (r = 0.18, p < 0.05); having sex with someone known or suspected of having HIV and/or an STI (r = 0.20, p < 0.01); having sex with someone known or suspected of being an injector (r = 0.24, p < 0.01); and having unprotected sex while under the influence of alcohol or drugs (r = 0.32, p < 0.001). The complex relationship between marijuana and sexual risk behavior was examined while accounting for the possible moderating effects of alcohol or other drugs. Problem marijuana, alcohol, and other drug use each made unique contributions to predicting risky sex behavior. A significant marijuana and other drug interaction was found to predict sexual risk behaviors. Future efforts should include holistic intervention approaches for YBMSM that consider factors facilitating high-risk sexual behaviors.

Racial and ethnic health disparities: evidence of discrimination's effects across the SEP spectrum.

OBJECTIVES: Perceived discrimination is a psychosocial stressor that plays a role in explaining racial/ethnic disparities in self-reported physical and mental health. The purpose of this paper is: (1) to investigate the association between perceived discrimination in receiving healthcare and racial/ethnic disparities in self-rated health status, physical, and emotional functional limitations among a diverse sample of California adults; (2) to assess whether discrimination effects vary by racial/ethnic group and gender; and (3) to evaluate how the effects of discrimination on health are manifest across the socioeconomic position (SEP) spectrum. DESIGN: Data were drawn from the 2001 California Health Interview Survey adult file (n=55,428). The analytic approach employed multivariate linear and logistic regressions. Discrimination is qualitatively identified into two types: (1) discrimination due to race/ethnicity, language, or accent, and (2) other discrimination. RESULTS: Findings show that both types of discrimination negatively influenced self-rated health, and were associated with a two to three-fold odds of limitations in physical and emotional health. Further, these effects varied by racial/ethnic group and gender, and the effects were mixed. Most notably, for emotional health, racial/ethnic discrimination penalized Latinas more than non-Latina Whites, but for physical health, other discrimination was less detrimental to Latinas than it was to non-Latina Whites. At higher levels of SEP, the effects of racial/ethnic discrimination on self-rated health and other discriminations' effects on physical health were attenuated. DISCUSSION: Higher SEP may serve as an important mitigator, particularly when comparing the medium to the low SEP categories. It is also possible that SEP effects cannot be extracted from the relationships of interest in that SEP is an expression of social discrimination. In fact, negative health effects associated with discrimination are evident across the SEP spectrum. This study highlights the complexity of the relationships between discrimination and racial/ethnic identity, gender, and SEP.

Social Discrimination and Health Care: A Multidimensional Framework of Experiences among a Low-Income Multiethnic Sample.

The study aims to describe the perceived discriminatory health care treatment experiences and its impact on care among minority urban-dwelling adults. Semistructured qualitative interviews (N = 51) were conducted with patients from community-based health care settings, and systematic, grounded theory approach was used. Three distinct themes emerged: (a) the sources of discriminatory experiences, (b) its impact on health care, and (c) the provider/organization recommendations to address discriminatory practices. The study highlights the relevance of perceived discrimination in avoidance of health care services, nonadherence to treatment, and adverse health-related sequelae by low-income urban-dwelling adults with little access to health care.

Does health care setting matter in reports of discrimination?

We investigated the associations between the health care setting types that California adults report as their regular source of care, socioeconomic status, and perceived racial/ethnic medical care-related discrimination. Data were analyzed from the 2005 California Health Interview Survey (n = 36,694). Adults who identified clinics/health centers/hospital clinics or "other settings" as their usual source of health care had increased odds for perceived racial/ethnic discrimination compared with those who utilized private and health maintenance organizations doctors' offices, although this was true only for middle, but not lower or higher, socio-economic respondents. We suggest several explanations for these findings and improvements for assessing health care-based racial discrimination.

Increasing HIV-related knowledge, communication, and testing intentions among Latinos: Protege tu Familia: Hazte la Prueba.

Latinos are less likely to be aware of their HIV seropositivity than African Americans and Whites. 'Protege tu Familia: Hazte la Prueba' is a culturally and linguistically-sensitive HIV/AIDS prevention and testing program targeting Latino families. Using community-based participatory research techniques, Spanish-speaking bicultural community health workers helped develop and then used an educational flip chart and materials to conduct outreach and HIV prevention education in diverse settings. The intervention was created to increase HIV/AIDS-related knowledge, to improve communication regarding sexual risk, and to augment intentions to use condoms and test for HIV. A secondary purpose was to decrease HIV-related stigma by improving knowledge about transmission and reducing homophobia. Participants demonstrated significant increases in HIV knowledge, intention to practice safer sex and communicate sexual risk to partner(s), and intention to test for HIV. Improvements were also found in self-reported comfort levels when interacting with and caring for the HIV positive, thus decreasing HIV/AIDS-related stigma.

Brief counseling for reducing sexual risk and bacterial STIs among drug users--results from project RESPECT.

OBJECTIVE: Project RESPECT's brief risk reduction counseling (BRRC) reduced sexual risk and bacterial STIs among at-risk heterosexuals and has been packaged for use with this population. We assessed BRRC's efficacy with RESPECT participants who used drugs and examined BRRC's applicability to present-day users of heroin, cocaine, speedball, or crack. METHODS: We compared baseline demographic and economic variables, risk behaviors, and prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N=335) and never-injectors ([NIs], N=3963). We assessed changes in risk behaviors and bacterial STIs for EIs and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus (HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates among drug users. RESULTS: At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower among EIs and 18% lower among NIs compared to the informational condition. At 12 months, EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV (41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users. CONCLUSION: Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs and present-day drug users suggest evaluating BRRC with present-day drug users.

Addressing the need for access to culturally and linguistically appropriate HIV/AIDS prevention for Latinos.

This article reports a comprehensive national needs assessment of Latinos' access to HIV/AIDS prevention and education services in 14 cities throughout the United States and Puerto Rico. Interviews and focus groups were conducted with Latinos who were HIV-positive and at risk for HIV infection. The study explored risk behaviors, access to health care services, and exposure to HIV prevention messages. Differences in predictors of risk behaviors were noted by sex. For women, increased age, being married, foreign-born, and a U.S. resident, and having tested for HIV previously, were associated with reduced HIV/AIDS risk. Thematic analysis of qualitative findings revealed limited awareness of risk factors, and a need for culturally and linguistically appropriate, family-centered HIV/AIDS education incorporating Latino values. Findings were incorporated into culturally relevant brochures featuring vignettes and quotes. Brochures were distributed and evaluated by 71 community-based organizations (CBOs) in the U.S. and Latin America. Evaluators responded positively to the brochures, and Latino-serving organizations in 48 states now use them for HIV/AIDS prevention outreach and education.