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WHERE WE LIVE MATTERS:
SOCIAL DETERMINANTS OF HIV RISK
Presented by
DEMOGRAPHICS
INCOME
ENVIRONMENT
SOCIAL/
POLITICAL /
ECONOMIC
OUR PLACE DETERMINES OUR HEALTH
But all of
these factors
determine our
place
WHAT FACTORS IMPACT HEALTH?
• Genetics
• Access to medical care
• Health literacy
• Social networks
• Stress levels/coping mechanisms
• Income
• Social Stigma (racism, sexism, ageism, etc.)
• Education
• Safety/Violence
• Water, air, and soil quality
• Access to healthy foods
• Working conditions
• Transportation
Where We Live Matters: January 2013 Update
Socioeconomic
Status
Environment Health
Social
Disadvantage
Risky coping
behaviors
HIV risk
SOCIAL NETWORKS
WHO’S IN OUR SOCIAL NETWORK MATTERS
Individual risk is not determined by personal risk
behavior alone, but also the “pool” of disease in
their sexual/drug using networks
SOCIAL NETWORK DENSITY
 Density – how many people in a network have had sexual
contact with each other
SORTING IN SOCIAL NETWORKS
 Sorting – tendency of people with similar
characteristics (race, age, neighborhood) to
associate with one another and not others outside
the community
MIXING IN SOCIAL NETWORKS
 Mixing – when someone has sexual contact with someone
outside their primary network
 Concurrent partnerships – having more than one sexual
partner at a time
CONCURRENT PARTNERSHIPS
SEX RATIO IMBALANCE
More
women
than men
Infant
mortality
Incarceration
Death by
accident and
homicide
PHILADELPHIA FACTORS - CONCURRENCY
 Philly has the 4th highest incarceration rate in the
U.S. – 5.7 per 100 residents
 Nearly 45% of African Americans have never been
married
 Fewer than 10% of individuals living below the
poverty line are married
 Philly has sex ratio of .82 for African Americans
(Nunn, Dickman, Cornwall, et. al 2011)
SOCIOECONOMIC FACTORS
Segregation, poverty and social factors
RACIAL/ETHNIC COMPOSITION
 Philadelphia population: 1,526,006
 White: 626,221 or 41.0 %,
 46,893 Male & 66,239 Female below the poverty
level (2009)
 Black: 661,839 or 43.4 %
 79,976 Male & 111,335 Female below the poverty
level (2009)
 Hispanic: 172,483 or 11.3%
 31,600 Male & 37,799 Female below the poverty
level (2009)
 Asian: 96,405 or 6.3%
 Male 9,877 & 9,835 Female below the poverty
level (2009)
(US Census Data)
Fairmont
Park
Cobbs
Creek
Park
Phila Int.
Airport
Clark Park
Pennypack
Park
Northeast
Airport
nm
nm
1915319153
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1914019140
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1914119141
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1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
tracts
BLACK POP %
0.07% - 4.44%
4.45% - 12.75%
12.76% - 32.4%
32.41% - 69.17%
69.18% - 94.44%
94.45% - 98.65%
Zip Code Boundaries
0 0.8 1.60.4 Miles
BLACK POPULATION
HISPANIC POPULATION
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
tracts
HISPANIC POP %
0.26% - 1.24%
1.25% - 1.88%
1.89% - 2.75%
2.76% - 4.22%
4.23% - 10.01%
10.02% - 88.49%
Zip Code Boundaries
0 0.8 1.60.4 Miles
WHITE POPULATION
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
tracts
WHITE / POP2000
0.28% - 2.41%
2.42% - 16.5%
16.51% - 45.3%
45.31% - 73.6%
73.61% - 90.16%
90.17% - 100%
Zip Code Boundaries
0 0.8 1.60.4 Miles
RACIAL/ETHNIC DISPARITIES
Compared with Whites, Black and Hispanics:
Generally
 Earn less income and have less schooling
 At the same educational level, have lower
incomes
 At the same educational/income level, are more
likely to have grown up in disadvantaged
circumstances
 At a given income level
 Have less wealth (all earnings, properties, investments)
 Live in unstable neighborhoods
(RWJF 2011)
RACIAL SEGREGATION AND SOCIAL FACTORS
 Race may help determine place, but people of
different ethnic/racial groups experience similar
health outcomes in severely disadvantaged
neighborhoods
 Segregation is the primary cause of racial
differences in socio-economic status (SES)
 The worst urban context in which Whites live is
better than the average context for Black
communities.
EDUCATIONAL ATTAINMENT
 Educational attainment affects health through:
 Health knowledge
 Employment and income
 Sense of control
 Social networks
 People with more education are more likely to:
 Live longer
 Experience better health outcomes
 Practice health-promoting behaviors
 Have close friends on whom they can rely
 Have greater family stability and supportive marriages
LESS THAN HIGH SCHOOL, MALES > 25, 2010
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Zip Code Boundaries
Rivers and Streams
tracts
M12THGNL / POP2010
0%
0.01% - 5.85%
5.86% - 8.1%
8.11% - 10.73%
10.74% - 13.17%
13.18% - 56.79%
0 0.8 1.60.4 Miles
LESS THAN HIGH SCHOOL, FEMALES >25, 2010
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Zip Code Boundaries
Rivers and Streams
tracts
F12THGNL / POP2010
0%
0.01% - 6.54%
6.55% - 10.07%
10.08% - 13.21%
13.22% - 16.73%
16.74% - 37.5%
0 0.8 1.60.4 Miles
POVERTY AND CHRONIC STRESS
 Poverty/near poverty is often
stressful because so much
time/energy devoted to daily
tasks and securing
necessities
 Stress can lead to harmful
coping mechanisms like
smoking, drug use and risky
sex
THE GAP WIDENS
Whites
• Fell by 16%
• From $134,992 to $113,149
Blacks
• Fell by 53%
• From $12,124 to $5,677
Hispanics
• Fell by 66%
• From $18,359 to $6,325
Between 2005 and 2009 the average net worth
of households decreased considerably:
(Woolf & Braverman, 2011)
LIVING BELOW POVERTY, 2010
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Zip Code Boundaries
Rivers and Streams
tracts
TPOPBELP / POP2010
1.19% - 8.34%
8.35% - 13.04%
13.05% - 19.97%
19.98% - 29.04%
29.05% - 38.28%
38.29% - 83.13%
0 0.8 1.60.4 Miles
FEMALE-HEADED HOUSEHOLDS WITH
CHILDREN, 2010
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
nm La Salle, City Hall
Zip Code Boundaries
Airport
Runway
FCC
Parks
Rivers and Streams
tracts
FHH_CHILD / HOUSEHOLDS
0.34% - 3.99%
4% - 6.93%
6.94% - 11.34%
11.35% - 16.44%
16.45% - 20.32%
20.33% - 50%
0 0.8 1.60.4 Miles
LINKS BETWEEN VIOLENCE AND HEALTH
 Violence can affect health-related behaviors
 Violence-related stress may lead to poorer health
 Violence can influence health through its impact on
social and economic conditions
(RWJ, 2011)
Health
Violence
ASSAULTS – DOMESTIC, 2011
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
Assault-Domestic
nm La Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
Zip Code Boundaries
0 0.8 1.60.4 Miles
ASSAULTS, 2011
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
Assaults
nm La Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
Zip Code Boundaries
0 0.8 1.60.4 Miles
HOMICIDES, 2011
nm
nm
1915319153
1912819128
1915419154
1911419114
1911119111
1913619136
1913119131
1911619116
1914519145
1912419124
1914819148
1911519115
1913419134
1914419144
1911819118
1911919119
1914319143
1912019120
1910419104
1915219152
1914019140
1913519135
1912119121
1913719137
1914919149
1913219132
1915119151
1912919129
1913919139
1911219112
1914119141
1914619146
1913819138
1914219142
1912519125
1914719147
1915019150
1912319123
1912219122
1913019130
1913319133
1912619126
1910619106
1912719127
1910319103 1910719107
1911319113
1910219102
Legend
Homicide 2011
nmLa Salle, City Hall
Airport
Runway
FCC
Parks
Rivers and Streams
Zip Code Boundaries
0 0.8 1.60.4 Miles
Unemployment
Incarceration
Low income
High
STI
rates
1915319153
1912819128
1915419154
1911419114
1911119111
1911619116
1914519145
1912419124
1913119131
1913619136
1914819148
1911519115
1914419144
1913419134
1910419104
1911819118
1911919119
1914319143
1912019120
1915219152
1914019140
1912119121
1913519135
1914919149
1913219132
1915119151
1912919129
1913919139
1914119141
1911219112
1914619146
1913819138
1914219142
1915019150
1914719147
19125191251912219122
1913019130
1913319133
1912319123
1913719137
1912619126
1912719127
19106191061910319103
1910719107
1911319113
Legend
Airport
Runway
FCC
Rivers and Streams
FCC
Parks
Zip Code Boundaries
1 Dot = 30
Export_Output.chlamydiarates
Export_Output.syphillisrate
Export_Output.gonorrhearate
$
0 3 61.5
Miles
STD RATES, 2008
STIS AND HIV
 CDC identified higher HIV prevalence among
heterosexual individuals who had previously
received an STI diagnosis (4.0%) vs. those who did
not (1.7%)
 Transmission and acquisition of HIV may be
increased up to 10 times by the presence of other
sexually transmitted infections
HIV/AIDS
National and Local Epidemiological Contexts
HIV IN PHILADELPHIA
 25,563 people are living with HIV/AIDS in the
Philadelphia 9 county region, almost 75% of those
live in Philly
 Estimated another 5,000 HIV+ people are not
aware of HIV+ status
 Philly’s HIV incidence rates are 4 times national
average
 It is estimated that 2% of African Americans in Philly
are HIV+
2009 ESTIMATE OF HIV INCIDENCE -
PHILADELPHIA
 Local estimate of 941 new HIV infections in 2009 in
adults and adolescents (95% CI, 659 – 1,222)
 Case rate of 76.8 new HIV infections per 100,000
population
 4 times the national rate
 90% increase in incidence among youth, 13-24
between 2006 to 2009
 Driven by increases in young, black, MSM
Mistrust of
Health
Care
System
Unsafe/
Unstable
Neighborhoods
Unprotected
Sex
Drug
and
Alcoho
l
Abuse
Incarceration
Social
Inequality
Historic and Modern
Inequality
Increased
Risk of HIV
and STD
Concurrent
Partnerships
(Advocates for Youth, 2008)
NEIGHBORHOOD CHARACTERISTICS AND HIV
 Philadelphia neighborhoods with high rates of HIV
(GENERALLY) have these characteristics:
 Low socio-economic status
 High concentration of Black/African American
residents
 High death rates due to homicide, AIDS,
septicemia or other illness
 High birth risk
 High neighborhood instability
 High crime rates of multiple types
INCOME AND HIV
 Poverty is associated with an increase in risk
behaviors
 CDC found HIV prevalence associated with
socioeconomic status:
 Prevalence higher among those :
With less than high school education* (2.8%)
Incomes at or below poverty* (2.3%)
Unemployed *(2.6%)
Homeless (3.1%)
*statistically significant differences
Where We Live Matters: January 2013 Update
1915319153
1912819128
1915419154
1911419114
1911119111
1911619116
1914519145
1912419124
1913119131
1913619136
1914819148
1911519115
1914419144
1913419134
1910419104
1911819118
1911919119
1914319143
1912019120
1915219152
1914019140
1912119121
1913519135
1914919149
1913219132
1915119151
1912919129
1913919139
1914119141
1911219112
1914619146
1914219142
1915019150
1914719147
1912219122
1913019130
1913319133
1912319123
1913719137
1913819138
1912519125
1912619126
1912719127
19106191061910319103
1911319113
Legend
Airport
Runway
Rivers and Streams
FCC
Parks
Zip Code Boundaries
tracts
PLWHA / POP2008
0.000
0.001 - 0.006
0.007 - 0.011
0.012 - 0.016
0.017 - 0.024
0.025 - 3.222
0 1 20.5 Miles
$
PERCENT PLWHA PER CENSUS TRACT,
2008
ADDITIONAL RESOURCES
 Office of HIV Planning – Epidemiological profile and
Geographic Risk Analysis
 http://www.hivphilly.org/documents.html
 CDC:
 http://www.cdc.gov/socialdeterminants/
 World Health Organization:
 http://www.who.int/social_determinants/en/
 Robert Wood Johnson Foundation
 Vulnerable Populations Portfolio
 www.rwjf.org/vulnerablepopulations

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