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Social Inequality

‘Scoping’ location: the role of ‘place’/’space’ as an influence on HIV outcomes amongst young MSM

14 Mar, 17 | by Leslie Goode, Blogmaster

Bauermeister & Stephenson (B&S) is a scoping review addressing the impact of location – ‘space’ and ‘place’ – on HIV prevention and care outcomes for young MSM (YMSM).  It owes much to Diaz & Ayala and their concern to view human behaviour in terms of ‘social location’ ‘within a context of social oppressive factors’ rather than in terms of ‘individual identity’.  It focuses on 17 studies, selected for inclusion much as in a systematic review, but analyzed according to scoping methodology (i.e. with a view to mapping out the investigative territory rather than addressing a specific question).  Social location is translated by this study into concepts of ‘space’ and ‘place’.  Space here refers to the physical and geographical aspects of location such as proximity to services and transportation, and place to more socially constructed aspects – ‘the interpersonal exchanges and dynamics that result in physical and social resources in space’.

It is perhaps on account of the breadth of these goals and the methodology of scoping that no very conclusive findings emerge.  Where location assumes the more geographically defined characteristics of ‘space’, the findings underscore the importance of geographic information system (GIS) approaches (see also: Simms & Petersen (STIs editorial); Petersen & Simms (STIs)).  But elsewhere – especially where the concept of location shades into less physical definitions of context (i.e. ‘place’) – the evidence is more contradictory and sometimes appears counter-intuitive.   For example, there are studies that find a positive correlation between social disadvantage and higher levels of adherence to HIV prevention and care recommendations.  Apparently, however, income inequality (as measured by Gini ratio or male-to-female ratio of earnings) stands out across studies as an indicator of poorer YMSM outcomes.

In discussing the limitations of their study, the authors make the interesting point that in a field of investigation as hard to define and as open to fresh hypotheses as this, the tendency for studies reporting an insignificant or null finding not to make their way into the literature could contribute to a serious distortion of our understanding (i.e. ‘publication bias’).  As is evident from their discussion of the review findings, well-conducted studies reporting non-significant findings on the influence of location can make a valuable contribution to the debate (such as, for example,  Haley & Cooper (STIs), a paper published online on the related issue of influence of location on STIs).

A second intriguing question is raised by this review, even if it is perhaps not adequately discussed in it: whether social context is always translatable in terms of ‘geospatial’ location.  Does the concept of ‘place’, for example, really extend to the case of ‘virtual space’ – or does virtual space effectively break free of any geospatial definition?  The question is, of course, very pertinent, given the importance for this population in particular, of dating apps.  Interestingly, Yu & Shang (STIs), in a paper published online, make a case for characterizing an important category of YMSM (occupying a specific ‘place’ in contemporary China society) in terms of extreme geospatial mobility.  One would like to know how B&S would accommodate the paradoxical existence of social ‘places’ defined by the loss of geospatial definition.  Are we still really talking about place?

Shared needles for Viagra injection fuel STIs among the Korean elderly

1 May, 14 | by Leslie Goode, Blogmaster

UK BBC radio’s 4’s Korean correspondent, Lucy Williamson refers in last Tuesday’s Crossing Continents to a category of STI transmission through IVDU, which is unlikely to be familiar to our readers.  A recent article in the Korea Times  gives further details.  The individuals at risk are the 16% of South Korean seniors (65+) in Seoul who pay for sex (Korea Herald).  The means of transmission are the syringes used by elderly prostitutes carrying on trade in soft drinks (Korean-style Bacchus) to inject their elderly patients with Viagra, and then “recycled” – according to the interview, “ten or twenty times, or until the needle breaks”.  No surprise, levels of STIs among these elderly partners were found by a recent survey to be as high as 40%.

The proportion of seniors in Seoul who pay for sex (16%) (half of these five times over the last two years) seems high. The percentage of individuals who use sex workers varies enormously between countries, as does the age profile of the typical user (Prostitution: the Johns Chart).  By comparison, rates of use in the US and a number of European countries stand at around 20%, in Spain and Italy nearer 40%, though the typical user is likely to be in his 30s or 40s – not his 60s and 70s.  (For the situation in the UK, see STIs/Ward & Mercer).

Prostitution is illegal in Korea, and most safe-sex counselling is aimed at young people.  “There is a great lack of instructors for sex education for senior citizens”, says a welfare professor at Baekseok University.  “We also need to create quality programs, through which senior citizens can meet friends of the opposite sex and form wholesome relationships” (Korea Herald) .

This problem may currently be local to Seoul.  Commentators  attribute it, however, to rising levels of poverty among seniors – a consequence, they argue, of a fast ageing population in a culture that once placed a high value on Confucian values of filial duty, but has now ceased do so.  If these commentators are right, one can well imagine these conditions being replicated in other Asian countries, as they follow the trajectory of Korea.  In which case, Jong-myo Park may be the shape of things to come (Korea Times).

HIV impact of ObamaCare reduced by US Supreme Court decision

5 Mar, 14 | by Leslie Goode, Blogmaster

What impact will the roll-out of the US Affordable Care Act (ACA) – ObamaCare – have on health insurance coverage of people with HIV?  A recently published “issue brief” on behalf of the US Centers for Disease Control and Prevention (CDC) offers a first estimate (Kates & Garfield (K&G)).

The ACA includes a provision to expand Medicaid 1. by extending it to non-disabled childless adults (a group at present excluded), and 2. by raising the threshold of eligibility from the present 100% of the Federal Poverty Level (FPL) to 138%.  This would have considerable impact on uninsured HIV infected-people, as a large proportion of them are non-disabled childless adults, and relatively poor.  Thanks to a recent Supreme Court decision, responsibility for the implementation of this ACA provision rests ultimately with state legislatures.  Thus far, only 26 of the 51 states have plans to go ahead with it.  The authors of the brief give estimates, firstly for the impact that the ACA would have had but for the Supreme Court ruling, and, secondly, for the impact it will have, assuming implementation by just the 26 states that of stated their intention to go ahead with it.

In the case of full implementation of Medicaid expansion, say K&G, c.47,000 of the c.70,000 uninsured adults retained in HIV care would immediately be brought under Medicaid, while a further c.20,000 could benefit from the second major ACA provision relevant to the HIV-infected – namely, the subsidized insurance coverage which will be supplied by Health Insurance Marketplaces (HIM).

But, with just 26 states planning to expand Medicaid provision, only c.26,500 additional people will be brought under Medicaid.  Of the c.20,000 who ought to have qualified, but will now fail to do so, some 5,000 may be able to gain subsidized cover with HIM (those at between 100% and 138% of FPL), while the remaining c.15,000 (those under the 100% bar for subsidized coverage by HIM) will remain entirely uninsured.  Many people in this situation will seek coverage under the Ryan White HIV/AIDS program, as they have done in the past.

So the beneficiaries of ACA among the HIV-infected will, according to this brief, be considerably reduced by the Supreme Court ruling.  But does it really matter whether the HIV-infected of the US are treated through an expansion of Medicaid, or through the Ryan White program?

The authors of the brief seem to be in no doubt that ACA would represent an improvement on the present arrangements – and principally for two reasons.  The first has to do the 700,000 HIV-infected (63%) who are undiagnosed, or not linked to – or else not retained in – HIV care.  A proportion of these (the authors reckon as many as 124,000), newly eligible for Medicaid under ACA, could have been brought into regular medical care through the program.  This is the first opportunity missed.  The second has to do with the possibility of addressing the unmet needs of a particularly needy population (i.e. the c.200,000 HIV-infected who are currently uninsured but eligible for cover under ACA) on a more general and ongoing basis than is possible through the Ryan White program.  These, according to K&G, are the benefits which will be largely foregone in states that do not to ratify the expansion of Medicaid.

How does neighbourhood impact on STI (Chlamydia) risk?

19 Jun, 13 | by Leslie Goode, Blogmaster

The influence of neighbourhood on STI (and more particularly Chlamydia) acquisition is widely recognized fact.  Biello & Nikkolai argue for UK urban populations that neighbourhood socio-economic status (SES) is more closely correlated with Chlamydia risk than individual SES (  In another UK study (Birmingham), Shahmanesh & Ross find residence in neighbourhoods having certain SES characteristics to be  strongly predictive of both Chlamydia and Gonorrhoea (

But what is it exactly about these neighbourhoods that places their residents at far greater risk of STI acquisition than other neighbourhoods?  Is it, as some sociologists have proposed, the general level of social disorganization that heightens the risk, or is it poverty itself, or maybe the degree of residential instability?  Ford & Browning, in a recent study using data on a sample of 11,460 young adults from the US National Longitudinal Study of Adolescent Health, waves 1 and 3 (1994-2002), attempt to establish the pathway whereby neighbourhood influences the risk of acquiring Chlamydia (

The nature of the data allows the researchers to capture the association of Chlamydia acquisition amongst young people in their twenties, not only to various characteristics of their current neighbourhoods (i.e. at wave 3 of the study), but also the characteristics of those neighbourhoods in which they accomplished their transition into adulthood some years before (i.e. at wave 1).  The main finding of Ford & Browning is that characteristics of the current neighbourhood show no statistically significant correlation with Chlamydia acquisition, but characteristics of neighbourhoods at the time of adolescence – especially  “poverty” (on different models OR 1.23 & 1.25 respectively) – do show a correlation.  The obvious explanation is that these associations are mediated through individual variables such as sexual behaviour or psychological factors (e.g. depression).  Yet multi-variate findingsdid not confirm this mediation.

So what potential mechanisms are there for the influence of neighbourhood on STI acquisition?  While stressing the need for further research, the authors point principally to two.  The first of these is a “network” explanation.  Maybe neighbourhood of residence during adolescence could influence opportunities for future partner selection;  young adults who lived in an impoverished neighbourhood during adolescence may have a pool of higher risk sexual partners to choose from compared to their peers from more advantaged neighbourhoods.  The other interesting possibility is the influence of chronic stress associated with adverse neighbourhood conditions resulting in impaired immune system function and increased infectious disease risk through increased inflammation and cortisol secretion.

Either way, structural factors that are largely refractory even to the most ambitious public health interventions.  I am reminded of Wilkinson and Picket’s argument in The Spirit Level ( the determinants of health outcomes are effectively located at a level that is presumably beyond of the reach of any but the most radical (indeed revolutionary) political interventions.  “The poor you will always with you.”  At the same time, sociological explanations of this kind provide justification for careful targeting of public health resources on needy populations and help us counter the “inverse care” law.


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