In 2019, the U.S. Department of Health and Human Services (DHHS) launched the Ending the HIV Epidemic Initiative in the United States (CDC, 7 Sept 2021) with the goal of reducing new infections by 90% by 2030. A hallmark component of this initiative is to address the racial, ethnic, and geographic inequities that have been an unjust outcome of HIV prevention, care, and treatment activities for far too long.
For just a moment, let us pause and reflect on the overwhelming epidemiologic evidence that highlights the social injustices associated with the HIV epidemic. But let us start with some good news first. Between 2015 and 2019, the number of new infections among Black/African American people in the United States declined from 15,400 to 14,300 new infections per year (CDC, 4 Feb 2022). However, and here is the social injustice, these 14,300 new infections represent 41% of all new HIV infections, which does not equate to the demographics of the United States. Compounding this injustice, only 8% of Black/African American people who could benefit from PrEP to prevent HIV infection were prescribed it in 2019.
When we examine the HIV epidemiologic evidence among Hispanic/Latino People in the United States, we see a similar trend. Like Black/African American people, Hispanic/Latino people also saw a decline in the number of new infections between 2015 and 2019, although the decline was only a difference of 400 cases—10,600 in 2015 compared with 10,200 in 2019 (CDC, 28 June 2022). These 10,200 new cases of HIV equate to 29% of all new infections. Again, like Black/African American people, this percentage does not equate to the stratified racial and ethnic demographics of the United States. Regarding PrEP, only 14% of Hispanic/Latino people who could benefit from PrEP were prescribed this biomedical prevention intervention in 2019.
The Indian Health Service documents that during the period of 2012 and 2016, there was a 34% increase in HIV diagnoses among the American Indian and Alaskan Native people (IHS, n.d.). In 2019, there were 230 new HIV infections among this population.
The social determinants of health, as defined by the World Health Organization (WHO, 2022), are the conditions in which people are born, grow, live, work, and age. These nonmedical factors profoundly affect health outcomes and shape many aspects of daily life for the 8 billion people inhabiting the planet. In 2019, in the United States, 12.3% of all persons lived in poverty, with the lowest rates being among White people (9.0%) and Asian, Native Hawaiian, and Pacific Islander people (9.7%). Like HIV, Black/African American (21.2%), Hispanic/Latino (17.2%), and American Indian and Alaskan Native people (24.2%) and people who self-identify with multiple races (14.9%) have higher rates of poverty. Further evidence of the inequities, so common in the United States.
Exactly 20 years ago, in the November/December 2002 issue of JANAC, I coauthored a guest editorial entitled, The Social Injustice of the HIV/AIDS Epidemic (Jerez & Relf, 2002). In that editorial, we stated, “at the beginning of the 21st century, the principles of market justice rather than social justice are the basis for U.S. health care policy” (Jerez & Relf, 2002, p. 14). At that point in time, we stated,
The current health care delivery system embraces market justice principles based on the individualistic view, where the fundamental concern is the protection of the individual freedom of choice. The implication is that ‘society does not recognize a general obligation to protect the individual against disease and injury’ because ‘the primary duty to avert disease and injury still rests with the individual’ (Beauchamp & Steinbock, 1999, p. 103).
Essentially, this viewpoint asserted that access to health care and equitable health outcomes was not a fundamental human right. Instead, it was the individual's responsibility.
With the passage of the Patient Protection and Affordable Care Act in 2010, millions of Americans who were either uninsured or underinsured were able to access health care insurance—moving us toward a more equitable health care system. This landmark legislation removed a major barrier to health care services for many, but not all. However, in the decade since this momentous legislation was signed into law, there have been numerous legal and legislative attempts to overturn the Affordable Care Act. Unfortunately, I anticipate there will be continued legal and legislative attacks intended to overturn or dismantle the tenets of the Affordable Care Act in the future.
As the epidemiologic data presented earlier clearly documents, “the vicious cycle of social injustice must be addressed” if we are to achieve the laudable goals of the Ending the Epidemic Initiative (Jerez & Relf, 2002, p. 15). Simultaneously, we must also confront and dismantle the issues of racism, stigma, homophobia, transphobia, and other forms of oppression and marginalization contributing to the HIV and other health inequities and injustices that remain so problematic.
The ethical principle of justice is generally defined as the fair, equitable, and appropriate treatment of persons (Varkey, 2021). Related to the principle of justice is social justice. Although viewed as a political statement by some, social justice is “based on the Christian doctrine of helping less fortunate people” (Ornstein, 2017, p. 545). Ultimately, social justice occurs when “there is an equitable bearing of burdens and reaping of benefits in society” (Kneipp & Snider, 2001, p. 113). To understand the historical context and contemporary attributes of social justice, I would encourage you to read Allan C. Ornstein's article—Social Justice: History, Purpose and Meaning—published in Society (2017).
As Braverman et al., 2011 stated, “It is time to be explicit that the heart of a commitment to addressing health disparities is a commitment to achieving a more just society” (p. S154). Collectively, everyone must strive to break the cycles of social injustice, ultimately bringing an end to the inequities affecting the world in which we live—including the ongoing HIV inequities in the U. S.
Now, more than ever, nurses, as moral agents, must assert their “influence on social and public policy to promote social justice” (p. 9) and work diligently to maintain and strengthen the “social contract that exists between nursing and society, upon which the authority to practice nursing is based” (p. 6; American Nurses Association, 2010). As individuals, as nurses, as a profession, if the time to achieve social justice is not now, when will the time be?
The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.
Michael V. Relf was involved with the conceptualization, writing the original draft, and review and editing.
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Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC). (28 June 2022a). HIV and Hispanic/Latino People. https://www.cdc.gov/hiv/group/racialethnic/hispanic-latino/index.html
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