Addressing Social Determinants of Health in the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections, and Tuberculosis

This special issue of Public Health Reports (PHR) focuses on innovations and advances in incorporating a social-determinants-of-health (SDH) framework for addressing the interrelated epidemics of human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB) in the United States and globally. This focus is particularly timely given the evidence of increasing burden and worsening health disparities for these conditions, the evolution in our understanding of the social and structural influences on disease epidemiology, and the far-reaching implications of the global economic downturn. The global trends and adverse health impact of HIV, viral hepatitis, STIs, and TB remain among the major and urgent public health challenges of our time.1 These conditions account for substantial morbidity and mortality, with devastating fiscal and emotional costs to individuals, families, and societies. Despite decades of investment and support, the U.S. still experiences a disproportionate burden of these conditions compared with other Western industrialized nations, with substantial health disparities being observed across population subgroups and geographic regions.2 The reasons for these inequities are multifaceted and complex. It is true that individual-level determinants, including high-risk behaviors such as unsafe sexual and drug-injecting practices, are major drivers of disease transmission and acquisition risk. However, it is also clear that the patterns and distribution of these infectious diseases in the population are further influenced by a dynamic interplay among the prevalence of the infectious agent, the effectiveness of preventive and control interventions, and a range of social and structural environmental factors.3,4 Many of these conditions arise because of the circumstances in which people grow, live, work, socialize, and form relationships, and because of the systems put in place to deal with illness, all of which are, in turn, shaped by political, social, and economic forces. Understanding the multilevel and overlapping nature of these epidemics, and their social and structural determinants, is key to designing and implementing more effective prevention programs.5 Individual risk behaviors influence the probability of contact with other infected or infectious individuals. However, these behaviors do not occur in a vacuum. With respect to STIs, an individual's sexual risk behavior occurs within the context of a sexual partnership or partnerships, which are, in turn, located within a wider sexual network. For other infectious diseases, including TB, the built or physical environment can influence patterns and opportunities for interpersonal contact, social mixing, and probability of onward transmission of the infectious agent.6 These more proximal determinants of transmission risk also occur within the context of wider social and structural determinants.7,8 Structural factors include those physical, social, cultural, organizational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid disease transmission. Social factors include the economic and social conditions that influence the health of people and communities as a whole, and include conditions for early childhood development, education, employment, income and job security, food security, health services, and access to services, housing, social exclusion, and stigma. Our understanding of the connections between these determinants, and their relative importance to each other, has evolved over time. Earlier models for infectious disease transmission highlighted the primacy of the interactions among the individual, the infectious agent, and the environment, with infectious disease prevention and control programs being focused predominantly on targeting interventions toward the individual—e.g., individual-level counseling, testing, screening, and treatment interventions. Thus, HIV prevention has been dominated by individual-level behavioral interventions that seek to influence knowledge, attitudes, and behaviors, such as promotion of condom use, education about sexual health, and education of injecting drug users about the dangers of sharing equipment.4 While there has been some success with this approach, public health programs have failed to achieve sustained reductions in incidence or achieve elimination of these conditions and their associated inequities. There is also a growing appreciation that although some individually oriented interventions have shown results in reducing risk behavior, their success is substantially improved when HIV prevention addresses the broader structural factors that shape or constrain individual behavior, such as poverty and wealth, gender, age, policy, and power.9 The growing recognition of the social and structural barriers to prevention and control efforts for HIV, viral hepatitis, STIs, and TB have allowed prevention experts to employ more comprehensive approaches to their interventions. Such structural approaches include actions implemented as single policies or programs that aim to change the conditions in which people live, multiple structural actions of this type implemented simultaneously, or community processes that catalyze social and political change (e.g., social mobilization to oppose a harmful traditional practice). They also include policy or legal interventions (e.g., legal actions to combat or reform a discriminatory practice), interventions to influence the way services are delivered through promoting collaboration and integration,10 contingent funding, and economic and educational interventions.11 These approaches can be applied in combination with behavioral or medical interventions targeted at individuals, and aim to address factors affecting individual behavior, rather than targeting the behavior itself. It is within this context that this special issue of PHR has been brought together to reflect upon the influences, opportunities, and impact of SDH on the transmission of HIV, viral hepatitis, STIs, and TB. Major strategic priorities for the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC)12 are promoting health equity and reducing health disparities through adopting a social-determinants approach to our prevention activities. NCHHSTP also intends to place more emphasis on structural and contextual determinants of health, particularly health policy and legislation, economic and social interventions, and cross-sectoral collaboration.