Importance of Addressing Social Determinants Underscored by HIV Epidemic, Says Fryer Award Winner

HIV/AIDS, like COVID-19, has revealed health inequities and the influence of social determinants of health on disease, said Kenneth Bryan Ashley, M.D., who delivered this year’s John Fryer Award Lecture.

He is an assistant professor of clinical psychiatry at the Icahn School of Medicine at Mount Sinai and director of mental health services in the Peter Kruger Clinic at Mount Sinai Beth Israel Medical Center, a division of the Institute for Advanced Medicine.

Ashley provided an overview of the history of the HIV/AIDS epidemic and its changing demographics and regional incidence. “The HIV epidemic epicenter in the U.S. began in coastal major metropolitan areas,” he said. “The current HIV epidemic in the U.S. is focused in the South.”

Ashley said the South (Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Washington, D.C.) accounted for 53% of all new HIV cases in 2019. Within that region, Black people, who represent 19% of the population, accounted for 50% of all new HIV cases in 2019. Hispanic people accounted for 24% of all new cases. White people and others accounted for 26%.

Citing statistics from AIDSVu, an interactive online mapping tool that visualizes the impact of the HIV epidemic on communities across the United States, Ashley said that the South is home to the highest percentage of gay and bisexual men (44%) living with HIV and that they are more likely to experience discrimination. Moreover, negative social determinants of health—poverty, lack of health insurance, lack of education, low household income, food insecurity, and unemployment—are more pronounced in the South, and all of them affect the health of people living with HIV. For instance, 14.3% of people in the South lack health insurance compared with 10.4% of people nationwide.

Ashley also discussed “Ending the Epidemic: A Plan for America (ETE),” initiated in 2019 by the Department of Health and Human Services. The multiyear program will infuse 48 counties; Washington, D.C.; San Juan, Puerto Rico; and seven states that have a substantial rural HIV burden with the additional expertise, technology, and resources needed to end the HIV epidemic in the United States. The goal is a 75% reduction in new HIV cases in five years and a 90% reduction in 10 years.

“ETE can reduce rates of new HIV infections in targeted groups, but will not resolve inequities,” Ashley said. “Structural racism and social determinants of health must be addressed as part of the ETE to hope to address health inequities. Engagement with community-based HIV and health organizations will be vital to addressing health inequities.”

Ashley has been active in APA at both the local and the national levels. He is the former president of the Association of Gay and Lesbian Psychiatrists and the Society for Liaison Psychiatry, the New York metro area component of the Academy of Psychosomatic Medicine. He is a senior fellow of the Group for the Advancement of Psychiatry (GAP) and a member of its LGBT Committee, as well as a member of the Executive Council of the World Psychiatric Association Section on HIV/AIDS.

The John Fryer Award is given to individuals whose work has contributed to the improvement of mental health of sexual minority communities. It is named in honor of the psychiatrist who was part of the protest by gay psychiatrists at APA’s 1972 Annual Meeting that led to the removal of homosexuality from DSM the following year. John Fryer, M.D., appeared at the meeting in a mask as Dr. Henry Anonymous and testified about the barriers confronting gay psychiatrists. ■

The John Fryer Award is cosponsored by APA and the Association of LGBTQ+ Psychiatrists.