Category: Men’s Health

A Multi-Level Analysis of Barriers to Care: Macro Level (Structural)

I argued in a previous post that public health should look at factors impacting health using a multi-level approach. In this post, I attempt to outline the various multi-level barriers to medical care (specifically access to PrEP, HIV prevention, and AIDS care) for black queer men (or black men who have sex with men). This post focuses on structural barriers, but the micro and meso level analyses are also available.

At the structural level, queer men, especially those who are men of color, poor, disabled, or uneducated,  face stigma, low health literacy, discrimination, incarceration, poverty, and a general lack of access to healthcare all of which impact their ability to gain access to PrEP and other prevention measures and to continue their treatment and care (Levy et al., 2014; Philbin et al., 2016; Rucker et al., 2017; Thomann et al., 2017). Stigma continues to stand out as a huge structural barrier, especially with respect to access to PrEP or anything related to HIV or sexual health. HIV can often still be considered a “gay men’s disease” or something that only slut and whores have to worry about; these notions continue even from the medical institution, which also continues to emphasize the idea of “Truvada Whores”—the idea that queer men take PrEP in order to participate in riskier sexual behaviors rather than to decrease their risk of contracting HIV (Calabrese et al., 2017; Calabrese & Underhill, 2015). Some providers and researchers have gone so far as to recommend PrEP for everyone; however, we must remember to target PrEP to individuals who are at risk of contracting the disease rather than encouraging everyone to take it even if they are incredibly unlikely to contact HIV (Calabrese, Underhill, et al., 2016). Of course, there are heterosexual individuals who are at risk of contracting HIV, who should likely be taking PrEP, though it has primarily been targeted towards gay men (in sometimes insensitive advertisements that increase stigma for the queer community), but there are also people who don’t have enough risk factors to warrant the medication.

Calabrese, S. K., Magnus, M., Mayer, K. H., Krakower, D. S., Eldahan, A. I., Hawkins, L. A. G., . . . Dovidio, J. F. (2017). “Support Your Client at the Space That They’re in”: HIV Pre-Exposure Prophylaxis (PrEP) Prescribers’ Perspectives on PrEP-Related Risk Compensation. AIDS Patient Care STDS, 31(4), 196-204. doi:10.1089/apc.2017.0002

Calabrese, S. K., & Underhill, K. (2015). How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores”. Am J Public Health, 105(10), 1960-1964. doi:10.2105/ajph.2015.302816

Calabrese, S. K., Underhill, K., Earnshaw, V. A., Hansen, N. B., Kershaw, T. S., Magnus, M., . . . Dovidio, J. F. (2016). Framing HIV Pre-Exposure Prophylaxis (PrEP) for the General Public: How Inclusive Messaging May Prevent Prejudice from Diminishing Public Support. AIDS Behav, 20(7), 1499-1513. doi:10.1007/s10461-016-1318-9

Levy, M. E., Wilton, L., Phillips, G., Glick, S. N., Kuo, I., Brewer, R. A., . . . Magnus, M. (2014). Understanding Structural Barriers to Accessing HIV Testing and Prevention Services Among Black Men Who Have Sex with Men (BMSM) in the United States. AIDS Behav, 18(5), 972-996. doi:10.1007/s10461-014-0719-x

Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers. AIDS Patient Care and STDs, 30(6), 282-290. doi:10.1089/apc.2016.0037

Rucker, A. J., Murray, A., Gaul, Z., Sutton, M. Y., & Wilson, P. A. (2017). The role of patient-provider sexual health communication in understanding the uptake of HIV prevention services among Black men who have sex with men. Cult Health Sex, 1-11. doi:10.1080/13691058.2017.1375156

Thomann, M., Grosso, A., Zapata, R., & Chiasson, M. A. (2017). ‘WTF is PrEP?’: attitudes towards pre-exposure prophylaxis among men who have sex with men and transgender women in New York City. Cult Health Sex, 1-15. doi:10.1080/13691058.2017.1380230

A Multi-Level Analysis of Barriers to Care: Meso Level (Interactional & Community)

I argued in a previous post that public health should look at factors impacting health using a multi-level approach. In this post, I attempt to outline the various multi-level barriers to medical care (specifically access to PrEP, HIV prevention, and AIDS care) for black queer men (or black men who have sex with men). This post focuses on the meso or mid-range level of analysis, and an analysis of the micro level is available from last week.

Black queer men especially lack trust in the pharmaceutical industry as well as in providers and the medical institution themselves (Philbin et al., 2016; Rucker et al., 2017; Thomann et al., 2017). This moves into a community level and interactional level issue where the community has many reasons not to trust providers or drug companies. We can think back to previous studies like the Tuskegee experiments, but we can also think about the lack of adequate care for black patients currently, including limited pain management and less patient-centeredness to name a few examples (Hoffman, Trawalter, Axt, & Oliver, 2016). This is a considerable barrier for providers to overcome in order to provide better treatment to black queer men. Similarly, queer men generally face implicit and explicit bias from providers and receive worse care, and this lack of care is exacerbated by other marginalized social positions (Phelan et al, 2014).

These could also be seen as macro level issues at the institutional level because the medical institution and pharmaceutical industry have constructed a practice that is ineffective for many marginalized individuals. Further, this stems from structural issues in our country such as racism, incarceration, and stigma that limit access to health care and impact our institutions.

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A, 113(16), 4296-4301. doi:10.1073/pnas.1516047113

Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers. AIDS Patient Care and STDs, 30(6), 282-290. doi:10.1089/apc.2016.0037

Rucker, A. J., Murray, A., Gaul, Z., Sutton, M. Y., & Wilson, P. A. (2017). The role of patient-provider sexual health communication in understanding the uptake of HIV prevention services among Black men who have sex with men. Cult Health Sex, 1-11. doi:10.1080/13691058.2017.1375156

Thomann, M., Grosso, A., Zapata, R., & Chiasson, M. A. (2017). ‘WTF is PrEP?’: attitudes towards pre-exposure prophylaxis among men who have sex with men and transgender women in New York City. Cult Health Sex, 1-15. doi:10.1080/13691058.2017.1380230

 

A Multi-Level Analysis of Barriers to Care: Micro Level (Individual)

I argued in a previous post that public health should look at factors impacting health using a multi-level approach. In this post, I attempt to outline the various multi-level barriers to medical care (specifically access to PrEP, HIV prevention, and AIDS care) for black queer men (or black men who have sex with men).

At the individual level (the micro level), queer men are skeptical of medication for healthy individuals and wary of the potential side effects caused by these medications (Philbin et al., 2016). These ideas seem to go hand-in-hand. If you don’t want to take medication as a healthy person, you’d be worried about the potential side effects that would ultimately make a health person sick in order to prevent something that you might or might not contract. In this sense, it might be important to make people recognize the real possibility of contract the disease. We’re treating risk here, but preventing the disease is important. Further, the side effects of PrEP are fairly uncommon.

Queer men might think that this medication would be useful for others but not for them. Here, we have to think about assessing the individual patient to decide whether or not PrEP is right for them (Philbin et al., 2016). We’re not treating someone because they’re black and queer, and black queer men have the highest rates of HIV. It’s obviously possible for black queer men to have low associated risk of HIV. Treating high risk means treating patients with high risk factors not treating everyone from a population that has high rates of the disease. However, this presents an added barrier for providers to convince patients with high risks that this is the right drug for them.

Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The Promise of Pre-Exposure Prophylaxis for Black Men Who Have Sex with Men: An Ecological Approach to Attitudes, Beliefs, and Barriers. AIDS Patient Care and STDs, 30(6), 282-290. doi:10.1089/apc.2016.0037

 

 

Multi-level Models of Health Behavior for HIV

In a post about public health and epistemologies of ignorance, I argued that public health interventions have focused solely on the individual rather than looking at other factors impacting health. Moving forward, we need to develop multi-level models of health behavior, so here are a few examples of a multi-level analysis and multi-level models related to HIV prevention and AIDS care. Kaufman et al (2014) present a multi-level analysis of factors impacting HIV-related behavior and behavior change and review a few recent models for looking at HIV-related health behavior from multiple levels. The transtheoretical and health belief models and the theories of reasoned action and planed behavior have been used repeatedly in public health literature about HIV-related health behaviors, but all of these models and theories focus on the individual rather than looking at the individual as part of a larger system.

Kaufman et al (2014) looked at four multi-level models that expand on the individual models of health behavior to look at a more holistic picture:

  1. The Multiple Domain Model: Zimmerman, R. S., Noar, S. M., Feist-Price, S., Dekthar, O., Cupp, P. K., Anderman, E., & Lock, S. (2007). Longitudinal test of a multiple domain model of adolescent condom use. Journal of Sex Research44(4), 380-394.
  2. The Network-Individual-Resource Model: Johnson, B. T., Redding, C. A., DiClemente, R. J., Mustanski, B. S., Dodge, B., Sheeran, P., … & Carey, M. P. (2010). A network-individual-resource model for HIV prevention. AIDS and Behavior14(2), 204-221.
  3. The Dynamic Social Systems Model: Latkin, C., Weeks, M. R., Glasman, L., Galletly, C., & Albarracin, D. (2010). A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS and Behavior14(2), 222-238.
  4. The Transmission Reduction Intervention Project: Friedman, S. R., Downing, M. J., Smyrnov, P., Nikolopoulos, G., Schneider, J. A., Livak, B., … & Psichogiou, M. (2014). Socially-integrated transdisciplinary HIV prevention. AIDS and Behavior18(10), 1821-1834.

These are just a few examples of models that look at factors on multiple levels, specifically for HIV. More work should be done to expand and perfect these models, though the move towards multi-level models is certainly a move in the right direction. We should attempt to use a social-ecological framework with thinking about other public health interventions as well.

Kaufman, M. R., Cornish, F., Zimmerman, R. S., & Johnson, B. T. (2014). Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach. Journal of Acquired Immune Deficiency Syndromes (1999)66(Suppl 3), S250–S258. http://doi.org/10.1097/QAI.0000000000000236

Implicit Bias in Prescription of PrEP

African American men who have sex with men (MSM) are disproportionately affected by HIV; however, recent research suggests that medical providers are less likely to prescribe Pre-Exposure Prophylaxis (PrEP), a preventative treatment for HIV, to black MSM (Calebrese et al, 2014). This is a direct result of implicit racial bias, prejudice, and a lack of institutional knowledge on the part of medical providers. Current stereotypes about gay men exist among many medical practitioners, specifically with regard to “Truvada Whores.” It is assumed that MSM who take PrEP will participate in more risky behaviors and thus be at greater risk of HIV, though PrEP is an important measure for reducing risk of HIV. This is further exacerbated by implicit racial bias which corroborates beliefs by providers that black MSM are even more likely than white MSM to partake in risky sexual behaviors if they are prescribed PrEP. As such, medical providers are less likely to prescribe PrEP to black MSM, barring them from access to an important and potentially life-saving measure to prevent HIV, a disease that they are disproportionately affected by.

This research suggests that public health interventions that focus on black MSM might be misplacing their efforts by focusing on changing the behaviors of the individuals or encouraging use of PrEP if they don’t have the necessary support from their doctors. Perhaps, public health interventions should focus on developing additional institutional knowledge to prepare medical providers for caring for black MSM and providing adequate sexual health care.

Calabrese, S. K., Earnshaw, V. A., Underhill, K., Hansen, N. B., & Dovidio, J. F. (2014). The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav, 18(2), 226-240. doi:10.1007/s10461-013-0675-x

Coffee… Good or Bad for Health?

I recently read an article that was published a few days ago in The BMJ regarding coffee consumption and health. I was curious to learn what the findings were, considering that I have heard mixed reviews over the years about the health benefits of coffee.

After conducting an umbrella review of over 200 meta-analyses regarding coffee consumption and health outcomes, Poole et al. (2017) found that drinking three to four cups of coffee a day was associated with lower risk of a variety of health outcomes. According to the article, researchers found that drinking three cups of coffee a day lowered risk for death and cardiovascular disease, compared to non-coffee drinkers. Coffee consumption was also found to lower risk of various cancers, as well as neurological, liver, and metabolic diseases. In women who are pregnant, however, high levels of coffee consumption were associated with higher risk of low birth weight, pregnancy loss, as well as preterm births. Additionally, coffee consumption was found to be associated with an increased risk of fracture in women.

A note that this study mentions is that current evidence on the topic of coffee consumption and health is mainly observational and of lower quality in nature. That said, researchers recommend that randomized controlled trials be used in future research to better understand causal associations between coffee consumption and various health outcomes.

Eliseo Guallar, professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health published an editorial in response to Poole et al. (2017). Dr. Guallar comments that while coffee drinking is generally safe, people should not start drinking coffee for health reasons. Dr. Guallar continues in stating that “some population subgroups may be at higher risk of adverse effects” of coffee consumption. Additionally, Dr. Guallar expressed the importance of the amount of coffee consumption, asserting that there remains uncertainty regarding the effects of higher levels of coffee consumption. However, Dr. Guallar expressed that moderate coffee consumption is safe and can be a part of a healthy diet.

References:

Poole, R., Kennedy, O.J., Roderick, P., Fallowfield, J.A., Hayes, P.C., & Parkes, J. (2017). Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ 2017; 359:j5024. doi: https://doi.org/10.1136/bmj.j5356 

Guallar, E. (2017). Coffee gets a clean bill of health. BMJ 2017; 359:j5356. doi: https://doi.org/10.1136/bmj.j5356 

Recent Data on Obesity Prevalence in the U.S.

The National Center for Health Statistics (NCHS) recently released a data brief on recent estimates for obesity prevalence in the United States. These estimates are from the most recent National Health and Nutrition Examination Survey for 2015-2016. Some key survey findings showed that in 2015-2016, obesity prevalence was 39.8% among adults and 18.5% among youth in the U.S. Additionally, obesity prevalence was found to be 13.9% for children aged 2-5 years, 18.4% for children aged 6-11 years, and 20.6% for children aged 12-19 years.

While there was not a significant change in obesity prevalence among U.S. adults and youth between 2013-2014 and 2015-2016, obesity continues to remain an important public health concern.

Obesity prevalence rates in the U.S. do not currently meet national weight status objectives set forth in Healthy People 2020, a 10-year national agenda for improving public health in the U.S. These objectives are to reduce the proportion of U.S. adults that are obese to 30.5%, as well as reduce the proportion of U.S. children aged 2-5 years, 6-11 years, and 12-19 years that are obese to 9.4%, 15.7%, and 16.1%, respectively, by the year 2020.

Obesity can lead to serious health effects, such as: high blood pressure, heart disease, and even type 2 diabetes. However, maintaining a healthy weight through eating right and staying physically active can prevent these negative health outcomes.

References

Prevalence of Obesity among Adults and Youth: United States, 2015-2016. (2017, October). Retrieved from https://www.cdc.gov/nchs/data/databriefs/db288.pdf

Nutrition and Weight Status. (2017, October 13). Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives

Eat Right. (N.d.). Retrieved from https://www.nhlbi.nih.gov/health/educational/lose_wt/eat/index.htm

Be Physically Active. (N.d.) Retrieved from https://www.nhlbi.nih.gov/health/educational/lose_wt/physical.htm

Football and Concussions: Where do we go from here?

October may be my favorite month of the year: sweater weather, changing leaves, and most importantly college football is at its peak. I am a University of Michigan Wolverine fan and every Saturday I look forward to watching the game. Even though I live and breath for college football, as a public health student I still have many concerns about the health implications of this game on players.

CTE (chronic traumatic encephalopathy) is a degenerative brain disease caused by multiple blows/hits to the head. This disease is seen in many former football players; however, the catch is that it is only diagnosable after a person has died through an autopsy. Symptoms of this disease include impulsive behavior, depression, memory loss, substance abuse, emotional instability and suicidal thoughts or behaviors.

CTE has affected many former NFL players such as Mike Webster, Ken Stabler, Kevin Turner, Bubba Smith and Dave Duerson. A study published in JAMA this past July found that out of the 202 deceased football players 177 had CTE (87%) while of the 111 former NFL players 110 of them had CTE (99%). The high prevalence of this disease is a call for action on better treatment and care for these players by these franchises especially since these franchises are not running low on cash.

To learn more about CTE check out the Concussion Legacy Foundation’s website: https://concussionfoundation.org/CTE-resources/what-is-CTE

Lady Gaga Reveals Battle with Fibromyalgia

This past week, music sensation Lady Gaga revealed on her Twitter account that she has been battling fibromyalgia, and was recently taken to the hospital for severe pain, leading her to cancel one of her performances. While it may not have been easy to do, Lady Gaga’s decision to open up about her condition sheds an important light on the debilitating condition that is fibromyalgia.

According to the Centers for Disease Control, fibromyalgia affects about 4 million US adults. It is a chronic condition characterized by widespread pain and can include symptoms of fatigue, depression, and headaches that can negatively affect quality of life. While it is unclear what causes fibromyalgia,  some possible risk factors include age, stressful or traumatic experiences, family history, and sex. According to the Centers for Disease Control, women are twice as likely to have fibromyalgia as men.

Treatment for fibromyalgia often involves a team of different health professionals, and can be effectively managed with a combination of medication, exercise, and stress management techniques.

Check out the following resources for more information about fibromyalgia and how you can get involved in raising awareness of this condition:

The National Fibromyalgia Association

The American Fibromyalgia Syndrome Association, Inc.

Fibromyalgia | Centers for Disease Control and Prevention

Questions and Answers about Fibromyalgia | National Institute of Arthritis and Musculoskeletal and Skin Diseases  

Note: Lady Gaga has been working on a documentary entitled “Lady Gaga: Five Foot Two,” in which she discusses her battle with fibromyalgia. This film will be available on Netflix on September 22.  

References:

Fibromyalgia. (2017, September 6). Retrieved from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm

Park, Andrea. (2017, September 13). Lady Gaga opens up about having fibromyalgia. https://www.cbsnews.com/news/lady-gaga-opens-up-on-fibromyalgia-on-twitter/

Questions and Answers about Fibromyalgia. (2014, July). Retrieved from https://www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp#c

PrEP for HIV Prevention? Here’s what you need to know

Pre-Exposure Prophylaxis, or PrEP, has changed the way in which we talk about HIV Prevention. After being approved for preventive use by the FDA in 2012, there has been a sharp increase in PrEP prescriptions in the U.S. over the past several years. Currently, the only prescription available for PrEP is Truvada, which also serves as a treatment drug for those who are HIV positive.

Truvada is a nucleoside reverse transcriptase inhibitor, or an NRTI. When exposed to HIV, a NRTI works by masking itself as a building block of the virus’s genetic structure. While our own cells are able to recognize and correct for this coding mistake, HIV cannot, and as a result is unable to replicate and mount a widespread infection.

A quick distinction: Truvada as a drug is a form of PrEP, PrEP is a general class of preventive measures. Birth control can be thought of as a form of PrEP, preventing a pregnancy before it occurs. Even sunscreen is a form for PrEP. You apply lotion to prevent sunburn before it occurs.

But PrEP only works if you take it. According to recent findings from the Centers for Disease Control and Prevention, the majority of uptake of PrEP in the United States has been among middle-aged, white, gay men. But the HIV epidemic has shifted, with the CDC noting continuous inequalities in the southern states and among young African Americans.

More concentrated efforts need to happen to ensure that those who can benefit from PrEP are able to access and receive it. Gilead, the company that produces Truvada, has a copay card available, where they pay up to $3600 a year in copays for those living under 500% of the national poverty level. For more information on PrEP, UNC campus health also serves as a great resource on campus, and students can get more information by making a free appointment with Student Wellness by emailing LetsTalkAboutIt@unc.edu or by calling (919) 962-WELL(9355).

For additional Resources on what to know about PrEP, and how to have a conversation with your provider, please see the resources below for information from the CDC. For those looking for a PrEP friendly provider, here is a list of providers in the State of North Carolina who actively prescribe PrEP.

Sources –

Gilead Copay Card: https://www.gileadadvancingaccess.com/copay-coupon-card

Centers for Disease Control and Prevention PrEP Resources: https://www.cdc.gov/hiv/risk/prep/index.html

Centers for Disease Control and Prevention PrEP Information: https://www.cdc.gov/hiv/basics/prep.html

List of PrEP Providers: https://www.med.unc.edu/ncaidstraining/files/PrEPProvidersforDownload.pdf/view