MIRIAM GARFINKEL: Hi, my name is Miriam Garfinkel and I’m the eLearning manager here at the California Prevention Training Center. We’re recording this podcast in July 2012 just as the International AIDS Conference is happening in Washington D.C. It seems like it’s the most hopeful time we’ve had in the history of the epidemic in the United States and around the world. The idea of treatment as prevention and the ensuing emphasis on combination prevention has also created more discussion than I can ever remember about social determinants of health. So, I’m here with Alice Gandelman, Director of the California Prevention Training Center and she’s going to give us an introduction to the topic of social determinants of health. So, Alice, can we begin by having you tell us a bit more about exactly why we’re even talking about social determinants of health so much these days?

ALICE GANDELMAN: Sure. Thanks Miriam, and yes I definitely agree it is now a very important and exciting time in HIV prevention. The primary significance now, at least from my perspective, is that people are actually talking about social determinants of health and recognize that these are very important factors that influence health and wellbeing. In fact, the importance of this issue has been formally addressed by several federal partners at various centers and divisions at the Centers for Disease Control including the Division of HIV/AIDS Prevention as well as in many other federal programs. We’re all familiar with the National HIV/AIDS Strategy and Goal Three of the Strategy is to reduce HIV-related health disparities, and more importantly to help reduce stigma, racism, and homophobia. Social determinants of health is now addressed in the 2020 Healthy People Objectives and I’m not sure how familiar people may be with these objectives but they’re Healthy People Objectives that are developed by CDC and I believe they came out the year 2000, again in 2010 and now they’re developed for the 2020 Objectives. I thought this was very significant. This objective acknowledges that family and social, economic and physical environmental factors are primary interrelated determinants of health. And not only that, I think these objectives and some of the other content acknowledges that this encompasses both individual level and population level risk factors and disease-specific information and approaches, and I’ll talk a little bit more about this later but I think the fact that we’re talking about not only individual but population large issues is significant. Finally, many of our viewers and listeners are familiar with the recent Health Department Funding Opportunity announcement for HIV prevention which has definitely broadened its scope. So, in addition to the new emphasis on bio-medical approaches the Division of HIV/AIDS Prevention is now also funding health departments to develop policy initiatives and structural level interventions. I think this is also very importance because CDC has also acknowledged that in addition to lack of access to health care that stigma, homophobia, and racism are significant barriers to HIV prevention and treatment services. This is really providing a form that we’re seeing these words in print, we’re talking about them and I think it’s very important that this is happening right now.

MIRIAM GARFINKEL: It seems like it’s a really good example of how discussing things at an institutional level and at a larger level really not only gives permission but encourages people to talk about it in a more widespread way and in a more ultimately effective way. Before we go any further it seems like it would make sense for us to talk a little bit about exactly what we mean by social determinants of health, to give some clear definitions.

ALICE GANDELMAN: That makes perfect sense. I think I’ll start with the World Health Organization’s definition, and they define social determinants of health as “…conditions in which people are born, grow, live, work and age, including the health system, these things are shaped by the distribution of money, power and resources, at global, national, and local levels which are themselves influenced by policy choices.” The social determinants of health are mostly responsible for health inequities which they define as “the unfair and avoidable differences in health status seen within and between communities.” I know that’s a mouthful, but it’s a powerful mouthful.

MIRIAM GARFINKEL: It is and it also raises the question for me about what the differences are between health disparities which we often hear talked about and health inequities which you just mentioned.

ALICE GANDELMAN: Yes, that’s a really important question Miriam. Thanks for asking about it. Health disparity as National Institutes of Health have defined it, and I’m sure several other entities have defined it in a similar way, are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States, basically in any geographic area. I think they were using that as an example. Basically it’s an epidemiologic term. There’s not necessarily value judgment implied in that definition and we often see health disparities illustrated in rates of diseases or health conditions among different population groups in different geographic areas. Health inequities, on the other hand, are inequalities in health that are deemed to be unfair or stemming from some form of injustice. So this definition actually requires some value judgment that determines that differences are caused by an inequity. I recently heard a webinar in which Camara Jones, who is a research director on social determinants of health and equity at CDC’s National Center for Chronic Disease and Health Promotion, and she defines inequalities or inequities or even “isms,” for example “racism,” as structuring opportunities and assigning values, in this example, based on race which unfairly presents disadvantages for some and unfairly presents advantages for others. Of course you can refer to any “ism,” but I thought that was a very important and clear definition of how inequities were defined.

MIRIAM GARFINKEL: Thanks for those definitions, Alice, that helps to get us all on the same page, and it also now raises the question for me of what do social determinants, in particular, have to do with the current emphasis on bio-medical approaches and treatment as prevention?

ALICE GANDELMAN: I think that’s a really important question and what many of us are discussing and talking about right now, and I think I’d like to answer that question with kind of beginning with where we were and where we’re moving towards. Many of us are very familiar with DEBI, that’s the Diffusion of Effective Behavioral Intervention, and this has been a primary approach that we have been utilizing for HIV prevention for the last decade, and as many of us know DEBIs aim is to identify and modify behavioral determinants that can contribute to HIV risk. So, the focus is on behavioral approaches. High impact prevention aims to identify persons with HIV, link them and keep them in care and treatment, and the focus is on bio-medical approaches, for example testing, treatment adherence issues; that’s kind of where we are right now. Both are extremely important strategies. However, neither approach explicitly addresses the larger social, environmental, and structural factors that we know also impact risk for acquisition and transmission of HIV, such as for example laws that may prevent risk reduction

practices or rights among certain individuals; economic conditions, such as poverty, that prevent persons from accessing health care services or staying in care or navigating the health care system; societal attitudes or beliefs including racism and homophobia. So these are just a few examples but the point is that these same issues are going to present the same challenges in high impact prevention priorities in our new bio-medical initiatives and they must also be addresses if we want to be successful. So, really, when we’re talking about successful HIV prevention it requires a shared responsibility, balancing personal responsibility, things like identification of sound behavioral and bio-medical approaches to maximize health, in this case HIV prevention with social responsibility, that is the recognition of external factors such as social, economic, or political factors that in many cases are beyond the control of an individual and that we know directly impact health conditions.

MIRIAM GARFINKEL: Well, that is a great lead in to my next question, which is what can we do about it? What can we do to address social determinants of health in our HIV prevention work today?

ALICE GANDELMAN: Yes, that’s a big question and a big strategy that we really need to be thinking about. I guess what I want to say is I’d like to talk a little bit about combination prevention approaches because I think combination approaches really provide a great mechanism to address the social determinants of health. So, in addition to the behavioral interventions that have been implemented as well as the bio-medical strategies that are now being emphasized, I think if we include social and or structural level interventions that can address these broader issues, we’re much more likely to bring about more sustained changes. I also think that these are critical components of a comprehensive program. So, just one or two quick examples, and I’m sure our listeners have many many more that they have actually implemented, but for example a social marketing campaign that would be focused on anti-stigma or anti-homophobia, that discourages negative attitudes and beliefs about persons at risk or living with HIV. This is one social marketing approach that comes to mind that could be used in conjunction with other behavioral or bio-medical approaches. Other things like changing policies, regulations, or laws that support HIV risk reduction, for example syringe exchange, condom distribution, same-sex marriage laws, etc., these are examples of structural level interventions that can also go a long way in reducing the overall HIV infection rates. Of course these structural level interventions we know take longer periods of time to enact and they really require partnerships with many difference entities but I think some of these approaches in combination with what we’re doing now can actually result in much more sustained change.

MIRIAM GARFINKEL: So, Alice, maybe you can tell us a little bit more about where our listeners out there can go if they want to learn more about social determinants of health and the issues that are related to them.

ALICE GANDELMAN: Sure. I guess where I’ll start is with our two courses that are being offered. The California Prevention Training Center’s Behavioral PTC in partnership with other behavioral prevention training centers throughout the country will soon be offering a course on social determinants of health. We have delivered that several times. We also have another course that has not been formalized in this country but can be very shortly, and that’s a combination prevention approach which really encompasses some of the things we talked about earlier, Miriam, utilizing bio-medical, behavioral, social

marketing, and structural approaches together. People can certainly come to our website if they have more questions and contact us if you’re interested in those courses. I would also recommend people go to the variety of CDC and other websites because there is more and more information on this topic as well as own, and maybe I’ll turn that over to you because you may have some additional recommendations around references.

MIRIAM GARFINKEL: Well just to let people know, our website where we do have a lot of resources available is , and then the CDC website that also has a ton of information is . I want to thank everybody out there for listening and for continuing the conversation.