An intersectionality-based policy analysis of social determinants of HIV in Puerto Rico

Carlos Rodriguez Diaz
September 14, 2021

Carlos and study collaboratorsCarlos Rodriguez-Diaz, PhD, MPHE, MCHES (GW) has received an NIH CFAR Administrative Supplement entitled, “An intersectionality-based policy analysis of social determinants of HIV in Puerto Rico”. This project will be implemented in collaboration with elTEAM Network at the University of Puerto Rico (UPR). This research project is grounded in the collaborations initiated among these institutions since 2019 and the establishment of the Government-Community-Academic Partnership (GCAP) to end the HIV epidemic in Puerto Rico.

Understanding the social determinants of HIV within a specific geographical context is essential for identifying the steps needed to reduce rates of HIV infection and HIV disparities in the U.S. San Juan, PR is a Phase 1 Priority Jurisdiction identified in the EHE Initiative. Latinxs in PR have an estimated lifetime risk for HIV infection of 2.08% (1 in 48), higher than the lifetime risk for HIV diagnosis among Latinos in the continental US. (1.92%;1 in 52). In PR, the estimated HIV prevalence in the general adult population is nearly 1.1% and 7.3% among sexual minority men (SMM). Further, PR has one of the highest levels of HIV status unawareness among SMM in the U.S. (23% in 2011) and the lowest PrEP uptake reported in the US. Ending the HIV epidemic in PR requires local culturally appropriate interventions, but there are very few interventions or research projects being conducted in PR or those integrating a community-based and intersectional approaches. The goal of this study is to identify the social determinants of health (SDoH) influencing primary (reduction of acquisition risk) and secondary (reduction of transmission risk) HIV prevention. To achieve this goal, we will conduct an intersectionality-based policy analysis using a convergent parallel mixed method design, a community-based participatory (CBPR) approach, the Consolidated Framework for Implementation Research (CFIR) and through the following aims: 1) To identify how SDoH are associated with primary and secondary HIV prevention outcomes in PR. We will conduct a secondary statistical analysis using data from the PR HIV Surveillance System and from the Ryan White-Part B Program to identify how selected SDoH impact HIV primary and secondary prevention outcomes, and 2) To describe how stakeholders identify and understand the social determinants of health in PR and explore their recommendations to reduce HIV inequalities at the social and structural levels. We will conduct semi-structured qualitative interviews with n=24 stakeholders in PR triangulate these perspectives. Achieving the proposed aims will inform structural interventions and policy shifts to improve HIV outcomes considering the intersectional experiences of populations with high HIV incidence and prevalence, and suboptimal care continuum outcomes. Results for this study can also inform future research activities to develop and scale-up culturally relevant interventions.