Letters from the Director: Director’s Scientific Briefings: HIV, COVID-19 and Health Disparities

The COVID-19 pandemic has exposed and exacerbated underlying disparities in health outcomes that exist in the United States – health disparities that undoubtedly have a significant effect on HIV prevention and treatment. The longstanding health inequities that underly and connect these pandemics are serious and warrant our full attention.

To address this matter, the National Institutes of Health (NIH) Office of AIDS Research (OAR) hosted a Director’s Scientific Briefing on HIV, COVID-19 and Health Disparities on September 22nd to a broad audience of more than 150 people. NIH attendees accounted for almost two thirds of the audience, while approximately 20 percent was from academic institutions from across the country and Canada, 15 percent was from other government agencies, as well as health advocacy, policy and research organizations, and others with no identifiable affiliation. Three invited guest speakers shared their perspectives on the historical legacy and significance of racism and discrimination in the U.S. and their impact on the public health of our nation. On behalf of the OAR, I was honored to provide opening remarks to the session hosted by OAR Senior Science Advisor Dr. Meryl Sufian who introduced these distinguished speakers:

• Eliseo J. Pérez-Stable, MD: Director, National Institute on Minority Health and Health Disparities
• Lawrence Brown, PhD, MPA: Visiting Associate Professor, School of Medicine and Public Health, University of Wisconsin Population Health Institute
• Nancy Krieger, PhD: Professor of Social Epidemiology, Harvard T.H. Chan School of Public Health

Looking through the lens of their expertise and an historical framework, the speakers shared research findings and insights during their presentations:

• Spotlight on Health Disparities: COVID-19 and Racism Pandemics (Dr. Pérez-Stable)
• HIV, COVID-19, and the Spatial Legacies of Colonization and American Apartheid (Dr. Brown)
• Pulling the Thread: COVID-19, Structural Racism, and the Stories Bodies Tell (Dr. Krieger)

Dr. Pérez-Stable noted that there is a disproportionate burden of COVID-19 on racial and ethnic minority populations, with more than 50% of cases and 45% of mortality in Latinos, American Indians/Alaska Natives, and African Americans.

This finding echoes what OAR has highlighted in the NIH FY 2021-2025 Strategic Plan for HIV and HIV-Related Research (Strategic Plan) which acknowledges that Blacks/African Americans and Hispanics/Latinos are disproportionately affected by HIV compared to other races and ethnicities, and account for approximately 43 percent and 26 percent of new HIV diagnoses, respectively.

The similarity between these pandemics grows more apparent when you look at the national maps of HIV and COVID-19. As noted by Dr. Brown, COVID-19 is very heavily impacting the Deep South and the Southwest, though early in the pandemic, the Northeast was a hotspot. For HIV, 48 counties, Washington, D.C., and San Juan, Puerto Rico together account for more than 50% of new HIV diagnoses, and the Southern states bear the highest burden. Seven states have a disproportionate occurrence of HIV in rural areas¹. For both HIV and COVID-19, geographic/spatial segregation appears to be an underlying contributor of health disparities and can be traced back to the history of slavery, internal migration patterns, and segregation and related practices (e.g., restrictive covenants) in the U.S.

Deadly viruses will have a greater impact on people who are confined to communities where living conditions, and access to resources such as transportation and healthcare, are substandard. To fully comprehend the interface of COVID-19 and the HIV pandemic, and people who live in these spaces, one must look at the impact of both pandemics within the context of social determinants of health (SDOH). SDOH are conditions in the places where people live, work, learn and play that affect a broad range of health and quality-of-life risks and outcomes².

As Dr. Krieger noted, when one considers these factors for COVID-19, there are inequities that reflect structural racism and societal injustice with respect to who is exposed to the virus, such as who has the option to work from home, space to self-isolate if infected, and paid sick leave.

Social determinants play an important role for persons living with HIV. Socioeconomic status and access to transportation and health care are crucial factors in determining who can access antiretroviral drugs to reduce their risk of getting HIV (called pre-exposure prophylaxis or PrEP) and who can get tested for HIV.

The presenters emphasized that the type of data needed to understand and address systemic inequities is frequently overlooked, making it difficult to see and resolve them. For example, in clinical medicine and clinical research, we frequently do not measure or ascertain an individual’s socioeconomic status; and taken out of context, health disparity data can be misinterpreted, leading to additional stigma and discrimination and impeding scientific progress.

Systemic health disparities cut across historical generations and require systemic health solutions. To mitigate these inequities, steps must be taken to evaluate and improve processes of data collection; focus on cultural humility and patient-centered care; and address the power and structure of institutions and policies.

NIH leads many efforts to address health disparities and the impact of COVID-19. To learn more, I encourage you to review the PhenX Social Determinants of Health Assessments Collection, the Notice of Special Interest: Competitive and Administrative Supplements for Community Interventions to Reduce the Impact of COVID-19 on Health Disparity and Other Vulnerable Populations, the Rapid Acceleration of Diagnostics-Underserved Populations (RADxUP) initiative, and The Community Engagement Alliance Against COVID-19 Disparities (CEAL).

To learn more about NIH efforts to address COVID-19, HIV, and health disparities, see the Interim Guidance for COVID-19 and Persons with HIV and the OAR Director’s blog on this Guidance, and visit HIVinfo.NIH.gov on OAR’s website, to find Resources for the public, researchers, and health professionals.

Maureen M. Goodenow, Ph.D.
Associate Director for AIDS Research and
Director, Office of AIDS Research
National Institutes of Health

¹ About Ending the HIV Epidemic: Plan for America – Priority Jurisdictions: Phase I

² Social Determinants of Health: Know What Affects Health