Health care disparities

Greg Millett, MPH, on the Similarities Between COVID-19 and HIV Disparities


In this podcast, Greg Millett, MPH, talks about the health disparities seen among patients with COVID-19 and HIV, how the 2 pandemics are similar, and the missed opportunities for preventing the spread of COVID-19 among communities of color. 

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Greg Millett, MPH, is the vice president and director of public policy at amfAR, The Foundation for AIDS Research in New York, New York.



Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

The HIV epidemic and COVID-19 pandemic are similar in multiple ways, including the demographics affected by each condition. This was the topic of discussion during an expert speaker session at the ANAC 2020 annual meeting.

Today I’m joined by the speaker of that session, Dr Greg Millett, who is the vice president and director of public policy at amfAR, The Foundation for AIDS Research in New York, New York.

Thank you for joining me today, Dr. To start, can you give us a brief overview of your session?

Greg Millett: First, thank you for the opportunity to speak today and to be a part of the podcast and very happy to be returning to ANAC for the session where we're talking about COVID-19 communities of color and social determinants of health.

Really briefly, I give an overview of what has been taking place domestically with COVID-19 and the disparities that we're seeing by race and ethnicity.

My colleagues at amfAR, Johns Hopkins, University of Mississippi, Georgetown University, as well as Emory—we published a series of papers early in the COVID-19 pandemic to really look at the magnitude of the disparities in Black, as well as Latino communities. And the reason that we did this is because, you might recall several months ago in April, that CDC did not have really good desegregated data by race to characterize what's taking place with COVID-19 by race or ethnicity.

What we did is we took a look at county-level demographic data across the nation to see in those counties that were disproportionately African American or Latino if we see differences in COVID-19 cases. And we did see that. We released those data, made a lot of national news.

But the other things that we have done since then—and that's part of my presentation—was to really try and take a look at why. In my presentation, I go through some of the data that we released over the summer, and then I talk a little bit about the H1N1 pandemic and the fact that CDC data were showing that communities of color were disproportionately impacted by that respiratory illness, as well. That really should have been a cautionary tale for us that COVID-19 was going to be an issue that was going to also affect these communities.

From there, I talk about the social determinants of health and how they affect COVID-19 disparities. I then talk about some really the implications that we see for HIV, particularly the plan to end HIV that President Trump released over a year ago, and what that means in this era was COVID-19—the fact that we have more than a plurality of people living with HIV, who are over the age of 50. These are the same groups that are also disproportionately impacted by COVID-19 as well as communities of color.

Looking at some of the specific issues of the COVID-19 recession and how that's impacting communities that are affected by HIV and what that might mean in terms of access to medication or able to adhere to medication.

And then I also talk about the Affordable Care Act and its role in expanding access to health care for people living with HIV over the past 10 years, and the fact that that access may be jeopardized within a pandemic of COVID-19 and also make note of the fact that states that have not expanded Medicaid are now looking to expand Medicaid, simply because they've depleted their resources for COVID-19.

We’re just in an era where we're actually seeing expansion of ACA. There’s politics afoot that might take ACA away, which means that we will never be able to get to the end of HIV, at least in the short term. So that's the brief overview of the presentation.

Amanda Balbi: You mentioned before that populations of color have higher risk of COVID-19, and we know from previous research that that's also similar among patients with HIV. Can you talk a little bit more about the specific patient characteristics that you recently found with COVID-19?

Greg Millett: Sure. There's a lot of similarities that we see between the COVID-19 and the HIV pandemics in terms of who's affected and even our reaction to it.

For instance, with COVID-19, we see that some communities of color are more likely to get COVID despite the fact that you see in data points over and over again that they are more likely to wear masks, they're more likely to social distance.

Some of that is because communities of color are more likely to have jobs that are essential workers. They really can't stay at home and work, and it also exposes them to COVID-19 at a greater proportion than compared to White households.

There was actually a study from Health Affairs that looked at households in the US that were where there are essential workers or not. They found that about 47% of White households had at least 1 person who had to work outside of the home, whereas that compares to 56% of Black households and 65% in Latino households. So, communities of color during the COVID-19 pandemic are unfortunately in positions where they have to travel, where they have to be away from home, which exposes them to COVID-19.

With HIV, you find something else that's also the same—that people living with HIV, particularly among Black and Latinos, we see greater rates of HIV. People used to assume that people were engaging in greater rates of risk behaviors, sexual risk behavior, or drug use, etc.

But while I was the CDC, I published several studies and other colleagues have also subsequently published several studies showing that that's not true that we see higher rates of HIV in Black and Latino communities, despite the fact that they're engaging in less risk behaviors. Some of that is due to greater community prevalence. It's already in the communities that if you have sex with just one person who's—unprotected sex—in the Black community, that's very different in terms of the risk as compared to in the White community somebody having unprotected sex with, say, 10 partners and still not coming into contact with someone who has HIV. So, it's a very different scenario.

The other thing that's similar between both diseases is the role that health care plays and the degree to which access to health care can reduce some of the outcomes that we see.

The other thing that we see is that's similar between them is access to technology. We know that when antiretroviral therapy therapies became available that we saw this immediate increase in mortality disparities between Blacks and Whites living with HIV because Blacks were less likely to have access to ART.

Then we saw, unfortunately, the same thing play out again with pre-exposure prophylaxis in the mid-2000s, when that became available—2010 or so. And you see again that Blacks and Latinos were less likely to have access to PrEP, despite the fact they are more likely to contract HIV.

Unfortunately, we're seeing the same thing with COVID-19 when it comes to new technologies as well. COVID-19 testing all across the nation—Philadelphia, across the South, Chicago, New York City, all through Texas, and other places—the tests were primarily placed in White neighborhoods compared to Black or Latino neighborhoods where you are more likely to see more positives.

And having access to that new innovation was part of the reason why we see these greater disparities, because people were not receiving the tests, they didn't know that they were COVID-19 positive, they weren't able to take any preventive behaviors.

There's a lot of similarities that we see between both of the diseases in these social determinants of health that really magnify these disparities. You see the same thing when it comes to housing segregation, residential segregation, where if you look at those census tracts that are primarily White as compared to more-diverse, you have fewer HIV cases. It's the same thing with COVID-19.

We published a paper showing the same thing that you have you COVID-19 diagnoses and those census tracts that are primarily White as compared to those with greater communities of color. You have the same thing with housing characteristics, where substandard housing or homelessness is associated with worse outcomes for HIV.

It's also associated with greater likelihood of COVID-19 transmission if people are working in crowded housing, so you have that similarity as well.

And then you just have the perennial thing that we always see across data and across different diseases, which is income. People who have low income have higher rates of mortality in the United States as compared to people who have high income. We see the same thing operating as well for HIV as well as COVID-19 with people with lower income are more likely to have HIV or COVID-19.

One more thing that we see that is similar between the two, and that's immigrant populations for HIV. We know that non-English-speaking Latino populations are more likely to be diagnosed late with HIV and also more likely to have opportunistic infections soon after diagnosis.

With COVID-19, we're seeing some of the same issues cropping up. There was recently a paper that was published that found that non-English-speakers, generally, were at higher rates of COVID-19 diagnosis as compared to people who spoke English.

And even one of the papers that we published looking at those counties that were disproportionately Latino, we found that monolingual Spanish speaking was associated with greater rates of COVID-19 in specific counties. So that's another thing that we see that similar.

It's a bit of a shame that we have past this prologue here we could learn from the HIV pandemic to make sure that we didn't have the same disparities for COVID-19, but unfortunately it seems that history is going to repeat itself and that we're going to continue to have these magnified racial and ethnic disparities, because of the social determinants of health.

Amanda Balbi: Yes, absolutely. And so now that all of this research has become more available, how do you think these data will affect clinical practice?

Greg Millett: I definitely couldn't see myself providing advice to many the ANAC members who are already on the frontline, who are seeing these disparities in terms of HIV as well as COVID-19, with firsthand experience, as compared to what I do is an epidemiologist.

I really think that many of the people who are listening to the podcast, who are clinicians, definitely have far more experience on what the ramifications are for clinical practice than I do. But I do think that there are certain things that we are doing that we know work.

We know that the Ryan White program works that we can reduce disparities markedly through what's taking place through the Ryan White program. Dome of the things that are done that are part of the program, such as providing transportation services for people living with HIV, offering child services, having health navigators, all of those really help to blunt the social determinants of health and to reduce some of the disparities that we see by race and ethnicity.

We have a lot to contribute to the work that we do in COVID-19 around providing wraparound services for many of these communities to make sure that we can reduce some of the disparities that we see there, as well. There's also quite a bit of work in terms of health equity that we have seen that also seems to blunt some of these disparities.

For instance, in the military, there's been a concerted effort for well over 50 years to try and stamp out racism and to promote equality and that's down to health care. You see it in the VA system. You see it in the active military members as well. And there have been several studies that have been published that have looked at various diseases where they see those systems of equity in delivery of health care actually reduces disparities for various diseases that are much smaller the disparity as compared to the general population between Blacks and Whites.

There's something that we can learn from the VA system, as well as from the active military system, on how we try and stamp out some of these disparities.

I think the last thing that is probably going to be very important for clinicians, who right now we're dealing with the dual pandemic of COVID-19 as well as HIV, not to mention the opioid epidemic and other epidemics that clinicians are dealing with, is this is an unprecedented moment to really have your voices heard. We see that we're at a dangerous period right now in the United States where science is devalued, where expert medical opinion is devalued.

And I think it's more important now more than ever for clinicians to make their voices heard, to talk about the experiences that they see.

In person around COVID-19 as well as HIV and to make sure that people really understand the consequences of both of these diseases and the things that we can do to help prevent any new infections for COVID-19 as well as HIV. I think at this point that there's a unique platform that's available for clinicians to really share their stories online, on Twitter, quite a few that have gone viral which really brings a human element to what people are facing, what they're seeing on a day-to-day basis in their practices, as compared to what most Americans see who are just living our lives.

Amanda Balbi: Absolutely. Is there anything else you’d like to add as take-home points?

Greg Millett: Nothing else to add, except to really give my heartfelt thanks and gratitude for all of the clinicians who, over the past 8 months, have been dealing with the COVID-19 pandemic, as well as dealing with really making sure that the needs of their patients living with HIV are met.

On behalf of many of the community members, on behalf of many of us who are involved in HIV policy work, I really am eternally grateful for all of the work that all of you do.

Amanda Balbi: Great, thank you again for speaking with me today and answering all my questions.