Socio-Ecological Model – Case study
- Apply the socioecological model to persons with HIV/AIDS.
- Discuss issues of cultural bias with marginalized patient populations (e.g. LGBT).
- Identify approaches at the clinical, community, and policy levels that clinicians can use to help care and advocate for their patients.
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Setting the scene
Since the recognition of the human immunodeficiency virus (HIV) as the cause of acquired immunodeficiency syndrome (AIDS) in the early 1980’s there have been many medical advances in the ability to diagnosis and treat those infected with HIV. However, despite these medical advances, 4500 Brits each year continue to be infected with this virus. In addition, since more infected individuals have access to effective treatment, they are living longer, and the increasing number of persons with chronic HIV infection requires effective long-term coordinated chronic disease prevention and management. Continued work is needed on individual, community, and public policy levels to address the continued epidemic of HIV and chronic management of the complex psychosocial and medical needs of this vulnerable population. A socio-ecological model can help guide our thinking about how to address a formidable challenge of our time.
In today’s case study, we turn our attention to a complex public health challenge that is no less a part of the current medical landscape: HIV/AIDS. How do we care for patients who may be marginalized or stigmatized, and who may receive fragmented care in our health system? How do race, ethnicity, income, and sexual orientation affect access to care? What are the barriers to HIV prevention, and why do they pose such an intractable challenge? What can we do as physicians to mitigate the effects of the virus in our communities?
Suggested Learning Resources:
- The HIV/AIDS Epidemic in the United States – The Kaiser Family Foundation: http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states/
- Speak Out is a campaign from Greater Than AIDS to engage the gay community in response to the silence and stigma surrounding HIV/AIDS. Speak Out: For Our Community: https://www.youtube.com/watch?v=ZK-ayJKkhvA
- LGBT Older Adults – MAP Project: http://www.lgbtmap.org/lgbt-older-adults
- https://www.avert.org/professionals/hiv-around-world/western-central-europe-north-america/uk
- https://www.aidsmap.com/news/jan-2020/could-uk-hiv-transmissions-really-go-down-near-zero-2030-latest-report-suggests-so
*Bonus!: A recently unearthed video of comedian Dave Chappelle rapping about the stigma of HIV/AIDS in the late ‘80s: http://www.vibe.com/2015/08/dave-chappelle-hiv-aids-psa/
CASE PRESENTATION
John: 59 yo HIV positive black male who presents to the clinic after recent evaluation in the emergency department (ED) for a scrotal abscess. In the ED, the abscess was drained and patient was given an antibiotic and told to follow-up with his PCP. He feels that the abscess is improving, but he also wanted to discuss today a concern about rectal bleeding that has been present for 6 months. He has seen other providers during the past six months but did not feel comfortable discussing this issue until today.
For 6 months he has noted some intermittent bright red blood per rectum. His stools have been firm and hard to pass with the need to strain often during bowel movements. He notes blood on the tissue paper as well as in the water, but not mixed in the stool. He had a normal colonoscopy 9 years ago and recently performed a digital rectal self-exam at home and felt some “fullness” there. He feels like there is something blocking the passage of his stool.
He had some prostate enlargement in the past, for which he saw a urologist without need for intervention. He has never had any colorectal problems in the past. He typically has a bowel movement every day or two, and it has been firm. He has not been using any laxatives nor fiber supplements, but he has been trying to eat more fruits and vegetables.
John is HIV positive, initially diagnosed in 1988. His mother passed away at the age of 66, she had colon cancer. Sister had breast cancer.
John lives with unmarried male partner of >20 years. He smokes a quarter to a half packet of cigarettes a day. No alcohol nor drugs. Lives in a two story house. Not had sex for years.
John was referred for further evaluation of the rectal mass and the biopsy shows squamous cell carcinoma of the rectum, stage IV.
The patient is interested in treatment and proceeds to receive multiple courses of local radiation and chemotherapy with the understanding at the end of the course of treatment that his cancer has been cured.
Unfortunately, at the end of treatment, the patient is very weak, deconditioned, and poorly nourished. Prior to treatment, he was able to walk with a cane due to chronic hip pain but now is unable to leave the house and has trouble getting around his two story house. In-home nursing care is not covered by his insurance, and in-home care is not otherwise financially possible for this patient. He does not wish to consider staying in an extended care facility, since he does not want to leave his partner alone. He is estranged from his immediate family, who has never been supportive of his sexual orientation, and he serves as the primary caregiver for his partner who has advanced HIV-related dementia. The patient reports several unfortunate experiences with medical care in the past and expresses concern about new care providers and how they will treat him.
QUESTION – How do age, race, ethnicity, income, and sexual orientation affect access to care in the context of this case? What barriers did this patient face on individual, community, and public levels within the context of the socio-ecological model?