For EtE plans to succeed, they must centrally address social and structural barriers to care, treatment, and prevention. Here are some basics on social and structural determinants of health (SSDHs) from the Centers for Disease Control and Prevention (CDC):
“The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.”
While many interventions for HIV care or prevention focus on individual knowledge and behaviors, SSDHs look at the broader context. An individual facing significant barriers to services is less likely to be successful at preventing new infections or reaching viral suppression, no matter how empowered or knowledgeable that person is. For example, unstable housing is frequently tied to increased vulnerability to HIV. Having stable housing—renting or owning a home—has been shown to increase the odds that a participant would achieve protective levels of PrEP in their system during one study by more than double.[i]
City- and state-integrated care, treatment, and prevention plans typically do not address these critical factors. EtE plans, by contrast, tend to place social and structural barriers front and center. Houston’s Roadmap is divided into five areas of recommendations; one area is entirely devoted to social determinants of health, another looks entirely at criminal justice barriers. The Fulton County plan discusses social determinants of health at length and establishes objectives for improving outcomes related to housing, transportation, food insecurity, childcare, incarceration, violent trauma, education, job training, stigma, and sex work.
Holistically addressing the contextual issues facing people living with or vulnerable to HIV makes these plans far more strategic by more accurately reflecting the real-life experiences of affected communities.
[i] Riddell J, Cohn JA. Reaching High-Risk Patients for HIV Preexposure Prophylaxis. JAMA. 2016;316(2):211-212. doi:10.1001/ jama.2016.9128.