Speaking at the HIV Endgame conference in November, 2016, LaRon Nelson, a current OHTN research chair from the University of Rochester, explains the impact of chronic stress and the need for structural interventions to address health disparities.
The HIV Endgame conference logo appears on screen. Text reads: LaRon Nelson, How does chornic stress affect us? LaRon Nelson stands alone on the Endgame stage. An on-screen graphic identifies him as a current OHTN Research Chair. Unless otherwise noted, the slides Nelson references contain the same information he speaks about in bulleted form.
LaRon Nelson: Right, it’s the way that syndemics that could be happening in a city like Toronto might impact one group differently and another group differently in this particular space. But, it might look differently in Ottawa, or it might look differently in Los Angeles, or different in New York City. So, this is based on things like legal status, economic status, gender and gender conformity or gender nonconformity status, and race. And, what this actually does is has the effect of producing hardships. And hardships is defined at the bottom of the screen as “inequitable impacts of policies on marginalized communities that may lead to poor health outcomes.”
So, this is to think about, why is political ecology of health relevant when we talk about synemics and HIV risk? So, because political ecology actually situates hardships within a frame for understanding how syndemics and their impacts are shaped by larger social forces and political forces. So, Dr. Mimiaga talked a bit about psychosocial issues that people might have, there was a range of those things. So, those could be happening, but those happen in the context where other things are happening, that are actually shaping the degree to which those impact on different populations who experience different levels of marginalization.
So, it raises the question if individual level behavioral characteristics are the same, if they’re equal, why then, was something like HIV incidence be different from place to place? And it’s — so, it’s probably not one one answer to that question, I think you’ll see from what I’ll present in a few minutes. There are different ways to think about what the answer might be.
So, I’ve been thinking about about this for a while, and the question comes up, but how? So, HIV is transmitted through a finite number of ways. So, why does geography politics matter, because geography doesn’t transmit HIV, people do? Well, the answer is that this fill-in-the-blank is stressful.
Nelson displays a slide titled “This s**t is stressful!” The slide includes a flowchart mapping psychological stress onto immune dysfunction in humans and rodents. Immune dysfunction maps onto Innate, Cell Mediated and Adaptive functions. These functions map onto potential complications. The fine details of the flowchart are difficult to discern from the audience, but Nelson highlights the main points as he speaks. Text in the footer identifies this chart as coming from a paper by JP Godbout and R Glaser in 2006, called Stress-inducted immune dysregulation: Implications for wound healing, infectious disease and cancer. Published in the Journal of Neuroimmune Pharmacology.
The things that are happening in the environment, be it things like criminalization of culture, criminalization of health status, actually exert stress on people. And so, stress is — that stress is not just — or discrimination and these factors don’t just, sort of, hurt people’s feelings — like, they actually trigger responses in the body.
So, we know from literature, when you look particularly at folks who have certain illnesses, that those — that what it triggers actually can impact the clinical outcomes. But, it might also have an effect on how people are vulnerable to HIV infection, even if they don’t have a particular illness.
So, we know that chronic stressors are just as traumatic as traumatic stressors. Much of the work you see around traumatic stress is about catastrophic events. You were in a war zone, or you were sexually assaulted. So, those are things that are catastrophic. And very — you can point to the event that happened. But some people experience traumatic stress that is not attributable to one catastrophic event, but a long, chronic continuum of exposure to events over time that still can produce those same type of stress symptoms in people, and these processes in the body.
Nelson displays a slide containing a diagram that depicts neurotransmitters leaving the human brain and flowing toward tumors, infections, arthritis, multiple sclerosis, and skin diseases. The footer text identifies the source of this image as a paper by ME Kemeny and M Schedlowski, published in 2007, called Understanding the interaction betweeok psychosocial stressors and immune related diseases: A stepwise progression. It was published in Brain, Behaviour, and Immunity.
So, this is just another figure that talks about stress and immunity. So, this is showing how a acute and sustained psychological stress can actually affect the circulation of immunocompetent cells and their release of particular hormones that can impact body systems. So, it could be norepinephrine, cortisol, acetylcholine. So, all this — so, you don’t see this. So, all this stuff is happening up here, and I think the primary explanation is that when people are stressful, when things are bad, when you don’t have a house, when you don’t have a job, that it leads you to behave in particular ways. And, that may be true. But that’s not the only effect of it. Like, it actually does cause processes in the body that can be harmful to human systems.
Nelson displays a slide containing two graphs. The top graph, labelled “repeated hits,” shows stress levels spiking and returing to a normal level repeatedly over time. The bottomd graph, labelled “Prolonged response,” Shows stress levels gradually increase and remain high over time.
This is just another figure to show — so, in normal times, right, you’re exposed to a stressor and your body reacts. So, you might react and do something behaviorally. You might run away if there was… somebody was attacking you. Then, after a while, the threat goes away and then the body resets back to the normal point. The challenge is that — and, when we think about political ecology, and when there are marked — there oppressive social forces at play — you never actually reset. So, you have this response, which could be a behavioral response, psychological response, and a physiological response, but the actual stressor is still there.
Like, you live in an environment where there’s racism. You live in environment being discriminated against. So, the body never — that response never resets and that actually exerts what’s called “load.” Some folks — in the literature, it’s called “allostatic load” onto the body’s system. So, that has a real impact, right? So it’s not just that these things cause people to do things, but it does cause people to do things, but that’s not the only impact that it has. So, environment and biology intersect.
Research reports that stress impacts human physiology. We’ve heard that this morning. Chronic exposure to stress might trigger countermeasures to mitigate that stress, but nonetheless increase one’s risk for HIV, which could be unprotected sex, be it because you’re not using — decide not to use condoms, or not treatment as prevention, or not PrEP, as the person just mentioned a few minutes ago, or it could lead to substance abuse, which could be a way to mitigate the stress but also has other consequences.
So, when I talk about environment and biology or political ecology, it does not remove the role of the individual as an actor in this process. But it acknowledges that there are other factors — possible environmental factors. So, the other thing is that it does create or it structures pathways.
Nelson’s slide contains an image of a maze that appears to have been taken from a children’s activity book. The image shows four cartoonish pilgrim characters entering a circular maze from different sides, attempting to reach a turkey who stands at the centre. The maze is drawn in such a way that only one of the pilgrims has a clear path to the turkey from his start position. The other three do not have access to any paths that will reach the centre of the maze.
So, I use this little graphic, which is problematic in a lot of ways. But it’s, sort of, just — it’s meant to just illustrate a simple point. So that social, cultural, economic and political processes structure opportunities that either support or thwart healthy decisions. So, imagine it’s a maze. If you’ve seen a maze before. Some doors that are systematically closed to some people. Like there — so, regardless of your intention, regardless of your motivation, regardless of how much you really want to get into it, there’s only certain — you’re only going to come out at a very limited number of places, because that’s how the maze is structured. And certain people, depending on where they’re positioned to start, are only going to end a certain way. So, in a way, that doesn’t really depend on behavior. So, it won’t matter what you do. You end up in particular ways.
So, this is just a study, it’s called This Place is Killing Me. It was a comparison of four US counties with the highest incidence of HIV — of AIDS cases between ‘81 and ‘90 and 1995 and 1999. So, what they found is that counties with the highest increases in AIDS also had higher levels of other poor health indicators like suicide or homicide, lung cancer, infant mortality. And the counties also had — those counties had the lowest levels of annual earnings, literacy, and educational attainment. This is a study that was done in Mexico. It compared, actually, injection drug users in two cities, Juarez and Tijuana. So, what they did from it was that there was differences in terms of social and economic environmental influences between those two cities that act as either risk or protective factors. So, people who are injecting drugs living in Tijuana we’re 12 times more likely to have been deported compared to those in Juarez. So, additionally, folks in Tijuana were more likely to report being homeless, being arrested for carrying syringes, sharing syringes, and other equipment, having sex with men — 46 percent in Tijuana compared to Juarez — and having sex for money, drugs, or resources.
We’ll pass this one.
So, this is some work that was done by Greg Millett, which was a meta-analysis comparing data from studies on Black MSM in countries around the world. So, US, Canada, and the United Kingdom, and some folks here are part of that work, too. So, what they found is that Black MSM were more likely to be HIV-positive than non-Black MSM, both in the US and UK. And that Black versus non-Black MSM had structural disparities. So, it wasn’t just disparities in HIV but lower income, higher incarceration histories, and current unemployment were greater in the US than in other locations.
Then the last I’ll talk about, Sex and the Cities. So, Sex in the Cities was a six city study in the US, Atlanta, Boston, Los Angeles, Washington DC, and two other cities. So, it looked at data on 1,500 men. The outcomes that we looked at in this study were unprotected sex and the number of sexual partners. So, we wanted to understand whether they were differences associated with legal, economic, or social hardships that these men may have experienced. So, we did find in these six cities that, in cities where the samples of Black MSM reported the highest HIV risk indicators, also reported the highest number of legal indicators, so, arrest and conviction histories, number of incarcerations, economic, which are recent job loss, not working currently, unemployed, having a financial crisis, as well as social, so unstable housing, religious non acceptance — meaning your church or faith environment did not affirm you, and no health insurance.
And so, we did find that conviction history was associated with condomless anal intercourse among the guys. Recent job loss was associated with having an increased number of sex partners, two or more sex partners in the past six months. Financial crisis was associated with having an STI at six months, and unstable housing was associated with having an STI at twelve months. So these are not psychosocial stuff — things, right? These are structural issues that are impacting risk.
So, I’ll close with trying to address the question, if geopolitical contexts are implicated in HIV risk then what do we do next? How do we address these issues? So, future research can address a few things. One is to more precisely and conclusively identify mechanisms by which municipal contexts influence risk and infection. To incorporate individual measures that can be linked to city, county, province, region, state-level data to support more multi-level analysis. Because most of our analyses are focused on the individual. So, the answer that we’ll always get will be individual. It will never implicate the systems that actually have a larger role in influencing risk. Identifying test variables that elucidate the pathways by which contexts are associated with HIV risk-related behaviors. And exploring if differences between locations and HIV infections totally explain the differences by HIV risk behaviors. We already know that it doesn’t.
The relevant interventions then if places is implicated, are structural interventions to improve living conditions, and then thinking about social justice as HIV prevention. The work that I do in Ghana, people are very clear that HIV prevention cannot exist without human rights interventions as well. So, I think we have to think about this in this context, too, that it’s not just what you do at the individual level. But, we have to figure how we change environments within which people have to figure out how to live their lives. All right, thank you.
applause followed by piano chords as the OHTN media logo appears.
Note on video accessibility: For a fully keyboard-accessible alternative to this video, view it in Chrome or on any Android or iOS device, view it in Firefox with the YouTube ALL HTML5 add-on installed, or disable Flash in Internet Explorer.