Iniquities and Inequities in HIV Care

By Jessica Bishai November 2, 2017

This summer, I served as an intern with NASTAD’s Health Care Access program. I am a sophomore at Harvard College studying statistics and global health and health policy, and I was beyond excited to combine those fields by working at NASTAD. I assisted with the development of fact sheets and presentations, but the majority of my summer was spent working on the National Ryan White HIV/AIDS Program (RWHAP) Part B and ADAP Monitoring Project.

My favorite sentence from the 2017 National RWHAP Part B and ADAP Monitoring Project: Annual Report: “[People living with HIV (PLWH)] should be enrolled in insurance or provided other access to health care and the services associated with addressing the whole health of the individual.” The thing about health, though, is that it is not just physical, and it extends far past disease.

The causes of disease extend past a virus entering the body; this is especially true for HIV. Social determinants of health are well exemplified in the demographics of the clients AIDS Drug Assistance Programs (ADAPs) serve. HIV does not impact people proportionally; instead, it affects the populations most vulnerable to social and structural barriers. People who inject drugs (PWID), incarcerated individuals, and racial minorities are among the more heavily impacted groups: 


The ADAP clients served in Calendar Year 2015 were 38% African American and 23% were Hispanic. Forty-six percent were below the federal poverty level and the vast majority (about 91%) of clients were below 300% of the Federal Poverty Level.

The impacts of disease are not just physical. Living with a chronic disease like HIV presents a heavy emotional burden on both PLWH and those close to them. Further, disease can create stigma and exclusion. PLWH are particularly susceptible to such rejection from society, because of false notions that PLWH did something wrong and deserve HIV. Because of this, conditions like HIV are often accompanied by significant mental health conditions, including depression. These can be exacerbated by the socioeconomic challenges faced by PLWH. Without support from systems like ADAP, obtaining treatment for HIV and other related conditions can be financially devastating or impossible. Subjecting already disempowered communities to these deleterious complications creates a vicious cycle; since HIV weakens them both internally and externally, they are less able to manage HIV.

That is why it is so important for Ryan White HIV/AIDS Program (RWHAP) Part B programs and ADAPs to provide holistic care. We are making progress. In CY2015, Part B Program clients received mental health services in 36 jurisdictions, substance use services in 18 jurisdictions, food services in 28 jurisdictions, housing services in 22 jurisdictions, and medical transportation services in 35 jurisdictions. Furthermore, 22 jurisdictions served individuals recently released from incarceration with RWHAP Part B and/or ADAP services, and 17 jurisdictions served individuals currently incarcerated as they prepare to exit the correctional system as part of effective discharge planning or when they are in the correctional system for a brief period. 

By  providing services beyond just subsidizing medication, we have made huge advances in increasing viral suppression rates. ADAPs provide insurance for PLWH (i.e., paying for premiums, co-payments/cost-sharing, and/or deductibles), which in turn covers many of the core services PLWH need. This maximization of insurance access helps increase viral suppression rates among ADAP clients (see below), leading to better overall health outcomes, as is demonstrated by the viral suppression rates recorded in The Report.

Despite our advances, there is still room for improvement. We must continue to consider and fight against the social determinants and societal outcomes of HIV. The 2017 National ADAP Monitoring Project Annual Report documents what measures are in placeto help enable you to increase health equity in your jurisdiction.