Addressing Health Equity and Social Determinants of Health Through Healthy People 2030.

The evolution of Healthy People reflects growing awareness of health inequities over the life course. Each decade, the initiative has gained understanding of how the nation can achieve health and well-being. To inform Healthy People 2030's visionary goal of achieving health equity in the coming decade, the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary's Advisory Committee) provided the US Department of Health and Human Services with guidance on key terms, frameworks, and measurement for health equity. Conditions in the environments in which people are born, live, learn, work, play, worship, and age influence health and well-being outcomes, functioning, and quality-of-life outcomes and risks and are mostly responsible for health inequities. No single individual, organization, community, or sector has sole ownership, accountability, or capacity to sustain the health and well-being of an entire population. The COVID-19 pandemic in the United States highlights underlying inequities and disparities in health and health care across segments of the population. Contributing factors that were known prior to the pandemic have led to major discrepancies in rates of infection and death. To reduce health disparities and advance health equity, systems approaches-designed to shift interconnected aspects of public health problems-are needed.

Beyond the discourse of reproductive choice: narratives of pregnancy resolution among Latina/o teenage parents.

Despite the fact that the US teenage birth rate has declined dramatically in recent years, teen births among Latinas are higher than any other racial/ethnic group. Most studies focus on the causes and consequences of early motherhood among Latina teenagers, neglecting other important dimensions of the issue. This study examines how Latina/o teenage parents living in California narrate their experiences with unintended pregnancy resolution. Qualitative analysis reveals three central themes. First, participants expressed shock upon learning they or their partner was pregnant, followed by acceptance about their impending parenthood. Second, participants' views of abortion and adoption largely foreclosed these options as pathways by which to resolve their unintended pregnancies. Third, participants recounted numerous stories of the messages they received from parents, other family members and male partners that were frequently directive regarding how to resolve their pregnancies. These findings have implications for young people's reproductive health and rights, and for reproductive justice more broadly.

Pilot Test of a Culturally Sensitive Hypertension Management Intervention Protocol for Older Chinese Immigrants: Chinese Medicine as Longevity Modality.

Hypertension control in older Chinese immigrants remains a significant health issue because of their unique cultural health practices to manage their hypertension. At present, there are limited culturally sensitive health education materials regarding hypertension management tailored for the older Chinese population available for and feasible to use. Because the San Francisco Bay Area has a large population of older Chinese immigrants, development of a culturally appropriate intervention is important to help this population achieve better blood pressure control. The focus of this study was to develop and test the feasibility of a culturally sensitive hypertension management intervention protocol, Chinese Medicine as Longevity Modality. This intervention protocol is implemented as a patient education health program delivered via video format in combination with an individual consultation provided by a nurse in the initial intervention, followed by four phone calls between the initial intervention and the second follow-up visit. The results of the study showed that the proposed intervention protocol was acceptable for the target population.

Agents of change: peer mentorship as HIV prevention among HIV-positive injection drug users.

This paper presents a qualitative investigation of peer mentoring among HIV seropositive injection drug users in a randomized controlled trial, the INSPIRE study. Qualitative analyses of 68 in-depth open-ended interviews conducted in 2005 in Baltimore, New York, Miami, and San Francisco revealed that these individuals conceptualized themselves as change agents through the identity of peer mentor at the three related domains of individual, interpersonal, and community-level change. Implications for program development and future research of peer mentoring as a mechanism for HIV prevention are discussed. This study was funded by the Centers for Disease Control and Prevention and Health Resources and Services Administration (HRSA).

Is injection serosorting occurring among HIV-positive injection drug users? Comparison by injection partner's HIV status.

Research needs to build evidence for the roles that HIV status of injection partners may or may not play in injection risk behaviors of injection drug users (IDUs). Using baseline data collected from a randomized controlled study (INSPIRE) conducted in four cities (Baltimore, Miami, New York, and San Francisco) from 2001 to 2005, we categorized 759 primarily heterosexual HIV-positive IDUs into four groups based on HIV serostatus of drug injection partners. Thirty-two percent of the sample injected exclusively with HIV-positive partners in the past 3 months and more than 60% had risky injection behavior with these partners. Eight percent injected exclusively with HIV-negative partners and 49% injected with any unknown status partners. The remaining 11% reported having both HIV-positive and -negative injection partners, but no partners of unknown HIV status. Riskier injection behavior was found among the group with mixed status partners. The risk among the group with any unknown status partners appeared to be driven by the greater number of injection partners. No major group differences were observed in socio-demographic and psychosocial factors. Our analysis suggests that serosorting appeared to be occurring among some, but not an overwhelming majority of HIV-positive IDUs, and knowledge of HIV status of all injection partners per se did not appear to be as important as knowledge of sexual partner's HIV status in its association with risk behavior.

The Citizen Psychologist Curriculum-Preparing psychologists for public service: The 2018 American Psychological Association Presidential Initiative.

This article describes a curriculum developed as part of the American Psychological Association President Jessica Henderson Daniel's, 2018 Presidential Initiative-The Citizen Psychologist. The curriculum is designed to prepare the next generation of Citizen Psychologists to provide the broadest sense of service as leaders in their communities and in public service psychology. The curriculum prepares the learner to bring psychological knowledge, science, and expertise to bear on existing challenges to improve community well-being locally, nationally, and globally. This includes addressing the services needs of various vulnerable populations such as veterans, prisoners, the seriously mentally ill, those with substance abuse problems, children, and older adults. Competency-based curricula are presented in a series of modules, each dedicated to a level of education and training from high school through lifelong learning. Each module presents learning outcomes, activities, and resources designed to develop level-specific competencies. Steps for implementation and recommendations at the local and national level are provided. Implications of incorporating the Citizen Psychologist curriculum in education and training programs are discussed including encouraging students to explore volunteer and career opportunities in public service psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Is sexual serosorting occurring among HIV-positive injection drug users? Comparison between those with HIV-positive partners only, HIV-negative partners only, and those with any partners of unknown status.

Using baseline data from a multi-site, randomized controlled study (INSPIRE), we categorized 999 HIV-positive IDUs into three groups based on serostatus of their sex partners. Our data provide some evidence for serosorting occurring in our sample; about 40% of the sample had sex exclusively with HIV-positive partners, and about half of them reported having unprotected sex with these partners. Twenty per cent had sex exclusively with HIV-negative partners; their sexual behaviors tended to be least risky with about two-thirds reporting their sex was protected. However, we also found that another 40% had at least one partner of unknown HIV status and sexual and drug risk was the highest among them. They were also least empowered, showing attributes that may undermine HIV prevention. Some of these findings are consistent with findings from MSM studies, suggesting that partner selection practices are similar between primarily heterosexual IDUs and MSM.

What Will It Take to End the HIV/AIDS Epidemic? Linking the Most Disenfranchised Into Care Through Outreach.

The 2015 National HIV/AIDS Strategy renewed its goal of increasing access to care for people living with HIV/AIDS (PLWHA) and called for an increased focus on linkage to care efforts. As many PLWHA face multiple barriers to care and live on the margins of society, adoption of intensive outreach activities is necessary to engage the most disenfranchised PLWHA into care and to ultimately end the HIV epidemic. The Bay Area Network for Positive Health (BANPH), comprising 12+ agencies, established a network outreach model for our linkage-to-care project to engage the hardest-to-reach populations in the San Francisco Bay Area. During the years 2010-2013, BANPH agencies conducted street outreach, analyzed internal tracking systems to identify out-of-care individuals and individuals experiencing tenuous care, and surveyed participants using Apple iPod Touch devices. During the 3-year project, BANPH agencies engaged 602 out-of-care PLWHA and linked 440 to care. On average, outreach workers made 10 contact attempts with a client to link them to care. Sixty-three percent of participants were linked to care on an average of 56 days after initial contact. Factors, including lack of case management, lack of transportation, competing concerns, substance abuse, and HIV stigma, were significantly associated with linkage-to-care outcomes. Intensive outreach efforts could help to reduce barriers to care for hard-to-reach PLWHA, but these efforts require a tremendous amount of time and resources. A network outreach model could help facilitate sharing of limited resources and increase regional outreach capacity for linkage-to-care programs.

Enabling full representation in science: the San Francisco BUILD project's agents of change affirm science skills, belonging and community.

BACKGROUND: The underrepresentation of minority students in the sciences constrains innovation and productivity in the U.S. The SF BUILD project mission is to remove barriers to diversity by taking a "fix the institution" approach rather than a "fix the student" one. SF BUILD is transforming education, research, training, and mentoring at San Francisco State University, a premiere public university that primarily serves undergraduates and ethnic minority students. It boasts a large number of faculty members from underrepresented groups (URGs), including many of the project leaders. These leaders collaborate with faculty at the University of California San Francisco (UCSF), a world-class medical research institution, to implement SF BUILD. KEY HIGHLIGHTS: Together, the campus partners are committed to creating intellectually safe and affirming environments grounded in the Signaling Affirmation for Equity (SAFE) model, which is based on robust psychosocial evidence on stereotype threat and its consequences. The SAFE model dictates a multilevel approach to increasing intent to pursue a biomedical career, persistence in STEM fields, and productivity (e.g. publications, presentations, and grants) by implementing transformative activities at the institutional, faculty, and student levels. These activities (1) increase knowledge of the stereotype threat phenomenon; (2) affirm communal and altruistic goals of students and faculty to "give back" to their communities in classrooms and research activities; and (3) establish communities of students, faculty and administrators as "agents of change." Agents of change are persons committed to establishing and maintaining SAFE environments. In this way, SF BUILD advances the national capacity to address biomedical questions relevant to communities of color by enabling full representation in science. IMPLICATIONS: This chapter describes the theoretical and historical context that drive the activities, research and evaluation of the SF BUILD project, and highlights attributes that other institutions can use for institutional change. While this paper is grounded in psychosocial theory, it also provides practical solutions for broadening participation.

Boyfriends, girlfriends and teenagers' risk of sexual involvement.

CONTEXT: Having a boyfriend or girlfriend, especially an older one, is associated with increased sexual risk in early adolescence. The mechanisms underlying this association are unclear. METHODS: Middle school students in Northern California were surveyed annually from 1997 to 2000. For a sample of 1,214 males and 1,308 females who were sexually inexperienced in seventh grade, logistic and linear regression were used to explore associations between relationship status in seventh grade and sexual activity in ninth grade, controlling for sixth-grade and eighth-grade characteristics. RESULTS: Males who had had a girlfriend their age by seventh grade were more likely than those who had had no relationship to report sexual activity in ninth grade (odds ratio, 2.1). Similarly, for females, the odds of being sexually active in ninth grade were elevated among those who had had a boyfriend their age (2.9); however, they also were higher among those who had had an older boyfriend than among those who had had one their age (2.1). With sixth-grade risk factors controlled, relationship status in seventh grade remained significant only for females; the association was explained by early menarche and by participation in situations that could lead to sex and riskier peer norms in eighth grade. For males, eighth-grade situations that could lead to sex, Hispanic ethnicity and sixth-grade peer norms explained ninth-grade sexual behavior. CONCLUSIONS: To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships.

Is HIV/AIDS stigma dividing the gay community? Perceptions of HIV-positive men who have sex with men.

Stigma surrounding HIV/AIDS has existed since the beginning of the epidemic, but little is known about HIV/AIDS stigma within the gay community and how it affects men who have sex with men (MSM) living with HIV. A better understanding of the effects of stigma on this population is needed to reduce it and its harmful effects. Our study used quantitative data from 206 HIV-positive MSM and qualitative data from 250 to document beliefs about HIV/AIDS stigma within the gay community and to measure its effects on sexual risk behaviors, substance use behaviors, serostatus disclosure, and mental health. Stigma was associated with increased levels of anxiety, loneliness, depressive symptoms, engaging in avoidant coping strategies, and history of suicidal ideation. HIV/AIDS stigma exists within the gay community and has a negative effect on the mental health of people living with HIV. HIV/AIDS stigma should be monitored closely so that we may better understand how to address it.

Effects of a peer-led behavioral intervention to reduce HIV transmission and promote serostatus disclosure among HIV-seropositive gay and bisexual men.

OBJECTIVES: To evaluate the effects of an enhanced peer-led intervention on transmission risk behavior and serostatus disclosure of HIV-seropositive gay and bisexual men. DESIGN: A randomized intervention trial. METHODS: HIV-seropositive gay and bisexual men were recruited from New York City and San Francisco and were randomly assigned to either a standard or an enhanced intervention. The standard intervention consisted of one session that provided safer sex information. The enhanced intervention consisted of six sessions and included safer sex information, interactive learning activities, and discussion groups that were facilitated by HIV-seropositive peers. Participants completed audio computer-assisted self interview (A-CASI) assessments at baseline and 3 and 6-month follow-ups. Optional testing for sexually transmitted infections was offered at baseline and the 6-month follow-up. RESULTS: A total of 811 participants met the inclusion criteria for outcome analyses. Of these, 85 and 90% were retained for the 3 and 6-month follow-ups, respectively. Compared with the standard intervention, fewer men assigned to the enhanced intervention reported unprotected receptive anal intercourse with a negative or unknown-serostatus partner at 3 months (21 versus 26%, P < 0.05). However, there were no other significant differences in transmission risk or serostatus disclosure at 3 or 6 months. CONCLUSION: The enhanced intervention was associated with only a limited reduction in transmission risk at 3 months relative to the standard intervention. The characteristics of the intervention that may have reduced its efficacy are identified and directions for future research are suggested.

Sexual risk, substance use, and psychological distress in HIV-positive gay and bisexual men who also inject drugs.

OBJECTIVES: Gay and bisexual men and injection drug users (IDU) are the two main groups at risk of HIV exposure in the United States, but few studies have focused on the intersection of these two groups. Little is known about HIV-positive gay and bisexual IDU. The aim of this study is to identify and compare differences in HIV transmission risk behaviors and psychological distress in HIV-positive gay and bisexual men by injection versus non-injection drug use. METHODS: Data were from the baseline assessment of a randomized controlled trial of an HIV prevention intervention for HIV-positive gay and bisexual men. RESULTS: Of the 1168 men, 236 (20%) reported injection drug use, 500 (43%) reported only non-injection drug use, and 422 (36%) reported no drug use. More of the IDU reported having sex with women, and identified themselves as "barebackers" (i.e. men who intentionally have unprotected anal intercourse). IDU reported more unprotected sexual behaviors than men who did not use drugs, but their sexual risk behaviors were similar to those of men who used non-injection drugs. IDU, compared with other drug users, reported more use of non-injected methamphetamine, amphetamine, barbiturates, and gamma hydroxybutyrate. More IDU, compared with the other two groups, reported sexual abuse, anxiety, and hostility. CONCLUSION: HIV-positive gay and bisexual IDU are a distinct group from other HIV-positive gay and bisexual men. Prevention case management and interventions that help men cope with multiple health concerns and prevent HIV transmission are needed for this population.

Prevention with gay and bisexual men living with HIV: rationale and methods of the Seropositive Urban Men's Intervention Trial (SUMIT).

OBJECTIVES: To provide a public health rationale for prevention with HIV-seropositive gay and bisexual men and to describe the methods of the Seropositive Urban Men's Intervention Trial (SUMIT). DESIGN: A randomized intervention trial. METHODS: Self-identified HIV-positive gay and bisexual men were recruited from community-based venues in New York City and San Francisco. Eligible participants completed an A-CASI baseline assessment, were asked to provide samples for sexually transmitted infection (STI) testing, and were randomly assigned to either a single-session intervention or a six-session enhanced intervention designed to reduce HIV transmission risk and promote serostatus disclosure. Participants who attended the first intervention session were assessed 3 and 6 months post-intervention. STI testing was offered at the 6-month assessment. RESULTS: A total of 1168 self-identified HIV-seropositive gay and bisexual men completed the baseline assessment, and 1110 of these (95%) opted for STI testing. A total of 811 attended the first intervention session, of which 85% were assessed at 3 months and 90% were assessed at 6 months. Of those assessed at 6 months, 92% (670/729) provided a blood or urine sample for STI testing. CONCLUSION: SUMIT demonstrates the feasibility and acceptability of prevention research with HIV-seropositive gay and bisexual men. The study provides new information about the sexual behavior, serostatus disclosure practices, and the efficacy of an intervention to reduce HIV transmission risk.

What happened in the SUMIT trial? Mediation and behavior change.

OBJECTIVES: We wished to identify which potential mediators of the Seropositive Urban Men's Intervention Trial (SUMIT) intervention were in fact changed by the intervention, and further to identify which among these factors distinguished men who decreased their risk behavior relative to those who increased it, irrespective of the intervention arm. METHODS: We examined social cognitive theory and other psychosocial variables that the intervention was designed to affect (potential mediators) in both sets of analyses. These were assessed at baseline, 3-month follow-up, and 6-month follow-up. We tested which potential mediators were changed by the intervention relative to the comparison arm, and which of these factors distinguished men discontinuing risk behavior [unprotected insertive anal intercourse (UIAI) or UIAI with HIV-negative or status-unknown partners] compared with those initiating it. RESULTS: Factors changed by the intervention included partner serostatus assumption making, hedonistic condom outcome expectancies, anxiety and depression. Factors associated with behavioral risk reduction included personal responsibility to protect others from infection and self-evaluative outcome expectancies regarding transmission risk behavior. These constructs are similar and involve the engagement of moral processes and altruism in sexual behavior with others. DISCUSSION: The present results suggest that, although we designed the intervention to enhance personal responsibility to protect others from HIV, we were not successful in this goal. However, changes in this factor did prove to be an important correlate of behavior change. Possible ways to design and deliver more successful interventions are discussed.

Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation.

OBJECTIVE: This study assessed unprotected anal and oral sex behaviors of HIV-positive gay and bisexual men in New York City and San Francisco with their main and non-main sexual partners. Here we focus on the use of three harm reduction strategies (serosorting, strategic positioning, and withdrawal before ejaculation) in order to decrease transmission risk. METHOD: The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising and other techniques. RESULTS: City differences were identified, with more men in San Francisco reporting sexual risk behaviors across all partner types compared with men in New York City. Serosorting was identified, with men reporting significantly more oral and anal sex acts with other HIV-positive partners than with HIV-negative partners. However, men also reported more unprotected sex with partners of unknown status compared with their other partners. Some evidence of strategic positioning was identified, although differences were noted across cities and across different types of partners. Men in both cities reported more acts of oral sex without ejaculation than with ejaculation, but the use of withdrawal as a harm reduction strategy for anal sex was more common among men from San Francisco. CONCLUSION: Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.

Consistent, inconsistent, and non-disclosure to casual sexual partners among HIV-seropositive gay and bisexual men.

OBJECTIVE: This study examined the disclosure of HIV status to casual sex partners, factors related to disclosure, and the relationship between disclosure and HIV sexual risk behaviors among a sample of HIV-positive gay and bisexual men in New York City and San Francisco. Comparisons were made particularly among men who reported consistent disclosure, inconsistent disclosure, and non-disclosure. METHOD: The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising, and other techniques. RESULTS: Consistent disclosers reported greater self-efficacy for disclosing and more intentions to disclose than other men. They also reported less drug use, lower incomes, and more perceived viral consequences resulting from unsafe sex than did inconsistent disclosers. Overall, sexual risk behaviors were greater among inconsistent disclosers, followed by non-disclosers, with consistent disclosers reporting the fewest HIV sexual risk behaviors. CONCLUSION: Disclosure is not an all-or-nothing process, as evidenced by the 38% of men in the sample who reported disclosing to some, but not all, of their casual sexual partners. These inconsistent disclosers, who reported the most sexual risk practices, seem to lack strategies to deal with disclosure and risky sex. Some men who never disclose appear to have been able to adopt strategies by which they do not engage in sexual risk with casual partners. Interventions to improve self-efficacy for disclosure and help HIV-positive gay and bisexual men to identify and adopt specific strategies to address disclosure and safe sex are needed.

Sexual risk taking among HIV-positive injection drug users: contexts, characteristics, and implications for prevention.

HIV-positive injection drug users (IDUs) ( N = 161) were recruited to complete a qualitative interview and a quantitative survey about sexual behavior and transmission risk. We identified two contexts in which exposure encounters occurred most commonly for HIV-positive IDUs: in intimate serodiscordant relationships and in the drug/sex economy. Salient characteristics in both contexts included the role of intimacy, drug use and sexual decision making, disclosure of HIV status, and perceived responsibility. Although these characteristics emerged in both risk contexts, they operated differently within each context. The preservation of intimacy was paramount among those in serodiscordant relationships, and agreements to take risks were common. In the drug/sex economy, serostatus disclosure was uncommon and drug acquisition and use played a significant role in sexual risk taking. Our data emphasize a need to address the specific transmission risk contexts occurring among HIV-positive IDUs and to prioritize social and interpersonal factors when promoting safer sexual norms among HIV-positive IDUs.

Do community planning groups (CPGs) influence HIV prevention policy? An analysis of California CPGs.

Since 1994, the Centers for Disease Control and Prevention has required its 65 public health department grantees to develop and implement a collaborative planning process with their state and local communities as a condition of continued HIV prevention funding. The HIV prevention community planning process offers an unprecedented opportunity for important changes in HIV prevention policy and governmental systems change through local citizen action. We examined the perceptions and experiences of members of community planning groups (CPGs) with respect to systems change and policy making in HIV prevention and identified a series of factors that either promote or inhibit systems and policy change by CPGs. Although there is reportedly substantial support from public health departments for policy making by CPGs, no official guidance supports these activities. CPGs in California have made profound changes in government systems and these experiences position them for policy making in HIV prevention.

Positive and negative consequences of HIV disclosure among seropositive injection drug users.

This study examines HIV status disclosure in an ethnically diverse sample of HIV-seropositive injection drug users (IDUs) from New York City and San Francisco. Qualitative interviews were conducted with 158 participants. Analyses revealed a number of negative and positive consequences of disclosing serostatus to sexual partners. Negative consequences included stigma, rejection by sexual partners and others, loss of intimacy, and threats to personal well-being. Positive rewards resulting from disclosure included increased social support and intimacy with partners, reaffirmation of one's sense of self, and the opportunity to share personal experiences and feelings with sexual partners. The role of responsibility in impacting disclosure and nondisclosure revealed varied patterns in terms of how this construct impacts disclosure and resulting behaviors with sexual partners. Some participants used particular strategies, such as getting involved in seroconcordant relationships or minimizing intimacy in relationships, in order to combat potential negative outcomes of disclosure. For others, positive rewards were viewed as important enough to risk negative consequences. Interventions for HIV-positive IDUs are discussed.