From Epidemiology to Action: The Case for Addressing Social Determinants of Health to End HIV in the Southern United States

Abstract

In response to cholera outbreaks in London during 1853-1854, John Snow conducted an historic investigation that launched the field of modern epidemiology [1]. Snow hypothesized that unsanitary conditions caused by sewage dumped into city cesspools contaminated local drinking water, resulting in the rapid spread of Cholera. To test his hypothesis, he collected data from Londoners who acquired and did not acquire cholera, paying close attention to where individuals who contracted cholera lived and acquired their water. Almost all individuals who acquired cholera drank from wells that were near cesspools in or near the Soho district of London. One well in particular, "the Broad Street pump," was a primary water source for hundreds of cholera victims in Soho. To intervene, Snow persuaded London city officials to remove the handle from the Broad Street pump to prevent townspeople from consuming the contaminated water. After doing so, the cholera epidemic ceased. Snow's investigation provides a good starting point for understanding the epidemiology of HIV in the southern United States ("the South"). Epidemiology is the study of the distribution and determinants of disease, and it is the "core science of public health." [2] Like Snow did with cholera in the 1850s, the HIV prevention workforce uses epidemiology to identify persons who are at greatest risk for acquiring and transmitting HIV (distribution) and the reasons why (determinants). Epidemiologic data tell us, for example, that persons most at risk for HIV infection are gay, bisexual, and other men who have sex with men (MSM); African Americans; Latinos; transgender women; and, as evidenced by the articles in this special issue, persons in the South [3]. To inform intervention approaches, our workforce uses epidemiology in attempts to prevent behaviors that most commonly result in HIV infection: condomless sex, injection drug use, and nonadherence to HIV antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP) [4].

Understanding the Risk of Human Immunodeficiency Virus (HIV) Virologic Failure in the Era of Undetectable Equals Untransmittable

“…Studies that capture the impact of social determinants of health on viral suppression indicate that factors such as racism, stigma, lack of or poor quality health insurance, and poverty contribute to lower rates of viral suppression [ 22 , 29 , 30 ]. The specific impact of health insurance status on viral suppression is mixed; some studies demonstrate increases in viral suppression rates [ 31 – 33 ] while others have found no association [ 34 ]. Among persons with a history of IDU social determinants of health have been associated with increased rates of virologic failure [ 35 ].…”

The Relationship of Alcohol to ART Adherence Among Black MSM in the U.S.: Is it Any Different Among Black MSM in the South?

“…HIV infection is particularly common in the southern U.S., commonly referred to as the South. The South includes Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Washington, District of Columbia (D.C.) [10][11][12][13][14][15][16][17][18]. In 2017, the South was home to only 38% of the U.S. population [10,16] but had in excess of 50% of the new HIV diagnoses in the country [14,15].…”

“…The South includes Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Washington, District of Columbia (D.C.) [10][11][12][13][14][15][16][17][18]. In 2017, the South was home to only 38% of the U.S. population [10,16] but had in excess of 50% of the new HIV diagnoses in the country [14,15]. The nine states commonly and collectively known as the Deep South (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas) were disproportionately impacted by HIV disease [14,17].…”

“…Unfortunately, these prevention strategies have been less effective in eliminating HIV-related disparities in the South [15]. The South continues to account for 50% of all diagnoses of HIV infection among MSM [10,16,17]. Regarding tailored interventions for Black MSM, the CDC compendium lists six interventions proposed by four studies [42][43][44][45].…”

Evolving Trends and Research Hotspots in Disaster Epidemiology From 1985 to 2020: A Bibliometric Analysis

“…Epidemiology is the study of the distribution and determinants of disease and other health-related outcomes within populations (4). The application of epidemiology was applied in a disaster setting can produce estimates of the size of affected populations, quantify disaster-related morbidity, mortality and health outcomes (particularly the long-term effects), and provide evidence to demonstrate a causal relationship between exposures and health outcomes (5,6).…”