Examining COVID-19 and HIV: The impact of intersectional stigma on short- and long-term health outcomes among African Americans

Abstract

The COVID-19 pandemic has exacerbated the health disparities and structural racism among African Americans. We examined overlaps between the COVID-19 pandemic and HIV epidemic using an intersectional stigma framework through the lens of Critical Race Theory. Intersectional stigma, medical mistrust, and decreased likelihood of referral for HIV and COVID-19 testing leads to decreased engagement in the healthcare system. Social inequities increase health disparities and lead to increased rates of chronic diseases, which increases the risk and severity of COVID-19. Solutions to mitigate impact among African Americans include increasing engagement regarding African American health, funding, and providers of color.

The unprecedented COVID-19 pandemic has exacerbated the marginalization, stigma, health disparities, and structural racism that was already crippling African American communities. Race is often misunderstood as a risk factor but actually operates as a social construct due to marginalization and stigmatization resulting in structural racism (Ford and Airhihenbuwa, 2010). African Americans experience worse health outcomes, decreased access to healthcare, and lower quality healthcare across various diseases and conditions than other races (Ford, 2017). Clear overlaps exist between the COVID-19 pandemic and the HIV epidemic. Across the United States, the number of COVID-19 cases, hospitalizations, and deaths among African Americans are considerably overrepresented compared to population density (Artiga et al., 2020; Garg et al., 2020). Similarly, as HIV rates decline overall nationally, rates in the South remain alarming because vulnerable communities, particularly those of color, endure a disproportionate burden of HIV (Centers for Disease Control and Prevention, 2005; Fleming et al., 2006; Hill et al., 2020). This essay identifies the parallels between COVID-19 and the HIV epidemic among African American communities using intersectional stigma through the Critical Race Theory lens.

Intersectional stigma

The intersectionality framework considers multiple, compounding social, economic, political, and structural factors that further affect already marginalized groups rather than focusing on single, social identities (e.g. race/ethnicity, gender, class; Bowleg, 2012; Rao et al., 2018; Rice et al., 2018). Intersectional stigma explains co-occurring, mutually enhancing social identities and related inequities from multiple influences and sources. Stigma and existing power structures enhance structural racism and discrimination, which are inextricably linked with community- and social-level structures (Rice et al., 2018). Racializing a disease by attributing it to specific cultures or racial/ethnic minority populations as with COVID-19 and other diseases/infections has occurred throughout history (e.g. HIV/AIDS; Bailey et al., 2020).

Barriers to healthcare

Stigma and discrimination

Low perceived risk, stigma, and decreased likelihood of referral for HIV and COVID-19 testing leads to decreased engagement in the healthcare system (Rao et al., 2018; Rice et al., 2018; Stangl et al., 2019). Already stigmatized groups, such as African Americans, may avoid testing or hide symptoms of COVID-19, enhancing community risk and increase the likelihood of transmitting the disease (American Psychological Association, 2020). HIV stigma serves as a barrier for individuals engaging in prevention and treatment, thus overall affecting the well-being of those at risk for or are living with HIV (Rice et al., 2018; Stangl et al., 2019). The intersecting stigma of social identities or behaviors with HIV further stigmatizes individuals of social groups, such as racial/ethnic minorities (Stangl et al., 2019). Intersectional stigma and discrimination lead African Americans to avoid engaging in the HIV continuum of care; they may be less likely to get tested for HIV, adopt pre-exposure prophylaxis, attend appointments, and/or adhere to medication (Eaton et al., 2017; Murray and Oraka, 2014; Nydegger et al., 2020; Rao et al., 2018; Rice et al., 2018; Stangl et al., 2019). Social inequities increase health disparities and lead to increased rates of chronic diseases, including HIV/AIDS, which increases the risk and severity of COVID-19.

Structural and environmental factors

Structural factors and stigma in healthcare and the built environment – including residential segregation and concentrated poverty – disproportionately affect African American communities and increase risk for both HIV and COVID-19. Historical, structural, and individual discrimination based on race can lead to medical mistrust and mistrust of testing, prevention, and treatment messages (Bogart and Thorburn, 2005; El-Bassel et al., 2009; Rice et al., 2018). This gives rise to medical mistrust and societal norms whereby gross misinformation has fueled increases in HIV and COVID-19 rates among African Americans. Individuals who live in higher socioeconomic status (SES) neighborhoods have better access to COVID-19 testing (Austin, 2020; Bailey et al., 2020) and receive overall better medical treatment (Bailey et al., 2020; Williams, 2020) leading to racial disparities among COVID-19 testing.

Individuals with higher incomes and private insurance have increased access to HIV and COVID-19 testing and treatment. African Americans are overrepresented among those un- and underemployed and are less likely to have access to insurance or Medicaid compared to other racial groups (Bailey et al., 2020). Perceived and systemic racism manifests as implicit bias in clinical decision making for African Americans by the healthcare system (Bailey et al., 2020; Eligon et al., 2020). African Americans are frequently overlooked and have long experienced intersecting structural stigmas in the allocation of HIV prevention resources, public attention, and activism (Rice et al., 2018). They are less likely to receive HIV-related treatment. When treatment is provided, the quality is poor – controlling for other demographics – and they receive fewer diagnostic procedures and medications, further elevating their risk of morbidity or mortality (El-Bassel et al., 2009; Nydegger et al., 2020; Rice et al., 2018) and transmitting HIV to others. Medical mistrust among African Americans due to historical mistreatment (e.g. the HIV epidemic) may impact seeking medical care if it is available for COVID-19 (Williams, 2020).

Proposed solutions

Plausible solutions to mitigate the compounding impact on African American populations include (a) increased community engagement among stakeholders on the health of African Americans, (b) increased population and public health funding to build health equity among African Americans, and (c) increasing the number of African American social workers and healthcare providers. COVID-19 presents an opportunity to repair the systemic damage leading to health disparities among African American and White communities by providing relief efforts for improving healthcare. States that did not expand Medicaid after the Affordable Care Act was implemented should do so now to increase healthcare access and prevent the spread of COVID-19 among marginalized and stigmatized groups (Williams, 2020). Due to the institutional mistrust among many in the African American community, non-Black institutions must train trusted Black institutions, medical personnel and social workers of color, church communities, and community organizations to increase equitable treatment of individuals of color. Globally, social workers have an opportunity to enhance how they prioritize and consider race as a structural and social construct. Increasing attention to the many ways in which stigmatizing race poses a threat to African Americans and other races/ethnicities can influence social workers’ attention and efforts individually and collectively to ultimately diminish the negative impact of race at the individual and structural level. (Cornelius et al., 2018; Nyblade et al., 2019). By leveraging two established theoretical models, the Critical Race Theory and Intersectionality, we have addressed many social injustices secondary to structural racism. This framework provides insight into considerations needed to effectively and adequately examine the effects on marginalized groups, especially African Americans, to mitigate the current effects of the COVID-19 pandemic and prevent future negative effects on these groups.

Biographies

Author biographies

Liesl A Nydegger, PhD, MPH is an assistant professor in Health Behavior and Health Education at the University of Texas at Austin and Director of the Gender Health Equity Lab.

Mandy J Hill, DrPH, MPH is an associate professor and Director of Population Health in Emergency Medicine in the Department of Emergency Medicine at the University of Texas Health Science Center at Houston.