CASE

A thin 27-year-old male with no known past medical history presented to the ED for evaluation of 3 days of fever and several weeks of fatigue. Associated symptoms included nausea, diarrhea, and a 15 pound weight loss. On further questioning, the patient reported food and housing insecurity. He stated he was living at a bathhouse and had multiple male sexual partners in the past month. He smokes cigarettes and endorses occasional alcohol and drug use. He stated that he has no source of income or cell phone, and reported being estranged from many family and friends.   

Vital signs were remarkable for temperature 100.7F. He was cachectic and had a flat affect, but otherwise his exam was unremarkable.  

DIAGNOSIS

A broad lab work-up, including STI testing, was obtained. The HIV PCR was positive. 

DISCUSSION

What are the next steps? 

Confirmatory testing was obtained, and we discussed this patient’s case with our hospital medicine, infectious disease (ID), and social work colleagues. Concerns were expressed by the hospital medicine team regarding the efficacy of admitting this patient and initiating antiretroviral therapy (ARVT), since this patient’s housing insecurity and lack of a support system, transportation, and cell phone represent multiple barriers to long-term ARVT adherence.  

HIV Risk Factors and Barriers to Treatment 

In the United States, the incidence of HIV is highest among men who have sex with men (MSM) and people who inject drugs (PWID). There are also intersecting disparities by race and ethnicity, age, and socioeconomic status. HIV infection rates are higher among young Black and Latino MSM and IDUs, and individuals with inconsistent income and a history of exchanging sex for money and/or drugs [1,2] . 

The initiation and adherence to ARVT in individuals with HIV is responsible for significant reductions in morbidity and mortality [3]. Effective ARVT can also slow the progression of disease and reduce the risk of transmission [4]. However, very strict adherence is necessary to suppress viral load and prevent the development of resistance [5]. As with other medications, there are factors that make consistent use of ARVT difficult or impossible, including mental illness, substance abuse, stigma, housing instability, lack of health insurance, poor social support, access to transportation, health literacy, and adverse medication side effects [4,6,7,8]. 

A complete review of the barriers to the initiation and long-term treatment of HIV/AIDS is beyond the scope of this discussion. Rather, I hope to provide a brief review of the factors that lead many of our patients to seek care in the emergency department. As emergency medicine (EM) physicians at “safety net” hospitals, we are often confronted by these complex situations and have the challenge to recognize and address health inequities.

Definitions

Health disparities are differences among specific population groups in the “attainment of full health potential” [9]. Is there a difference in rates of disease and illness between population groups? 

Health inequities refer to the systematic differences in the opportunities groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes [9]. Is the disparity in disease and illness rates due to differences in social, economic, environmental, or health care resources? 

Structural inequities and social determinants of health are the root causes of health inequities. 

Structural inequities are human-created systems that privilege certain groups and actively oppress others. Some examples include racism, sexism, classism, and xenophobia [9]. 

Social Determinants of Health (SDOH) are the conditions in which people are “born, grow, live, work, and age”. These include economic stability, education access, health care access, the neighborhood and physical environment, and the social environment [9]. SDOH play a much larger role in health outcomes (30-55%) compared to medical care (20%) [10,11].   

How does this apply to Emergency Medicine?

Studies have shown that a significant percentage of patients who seek care in the emergency department are unhoused or housing insecure, food insecure, and struggle to afford essential expenses [12]. EM physicians also care for patients with high rates of substance use disorder, mental illness, and trauma [13,14].  Additionally, racial and ethnic minorities and patients with lower socioeconomic status are more likely to utilize the ED [15,16]. 

Training in EM focuses on recognizing, stabilizing, and treating critically ill and injured patients, while there is less emphasis on identifying and addressing the SDOH that contribute to ED visits. Yet, EM is caring for the unhoused patient with return visits for recurrent cellulitis, the child with an asthma exacerbation due to a cockroach infestation at home, and the victim of domestic assault who delayed care due to her immigration status. Treating medical problems while minimizing or ignoring the role of the structural inequities and SDOH in patient health leads to poorer health outcomes, increased ED visits, and increased burnout among EM physicians [11].  

Fortunately, there is growing recognition of the importance of Social Emergency Medicine, in which EM providers aim to recognize and effectively address SDOH with support from a multidisciplinary team [17]. By expanding our focus to include both the medical diagnosis and the underlying factors that contributed to the patient’s illness, EM physicians can better meet our patients’ needs. 

CASE RESOLUTION

During the brief encounter with this patient, it was impossible to fully understand the complex factors that contributed to his illness and ability to access care. However, housing and food insecurity, high risk sexual practices, mental illness, and lack of a support system likely played a significant role. This patient was evaluated by ID while in the emergency department and provided with outpatient follow-up at the ID clinic. The social worker also provided him with a list of shelters and food pantries to address his housing and food insecurity. While this response reflects a recognition of his social situation, I worry that it was inadequate to address his complex needs. Ideally, we could have provided him with stable housing and a community health worker to help him navigate his new diagnosis and the health care system. By seeking to understand the factors that contribute to illness and engaging a multi-disciplinary emergency department team, physicians can serve as advocates for our patients and improve health and access to care. 

TAKE-AWAYS

• Consider the underlying factors that contribute to your patients’ illness and disease 

• Advocate for policy and practice changes that aim to reduce health inequities and engage social workers, community health workers, and case management colleagues to remove barriers to treatment 

AUTHOR: Nichole Michaeli is a fourth-year emergency medicine resident at Brown University/Rhode Island Hospital. 

FACULTY REVIEWER: Rebecca Karb, MD is an emergency medicine physician at Brown Emergency Medicine

Keywords:

Health equity, social emergency medicine, social determinants of health 

REFERENCES

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2. Rondinelli, A. J., Ouellet, L. J., Strathdee, S. A., Latka, M. H., Hudson, S. M., Hagan, H., & Garfein, R. S. (2009). Young adult injection drug users in the United States continue to practice HIV risk behaviors. Drug and alcohol dependence, 104(1-2), 167-174.

3. Saag, M. S., Gandhi, R. T., Hoy, J. F., Landovitz, R. J., Thompson, M. A., Sax, P. E., ... & Volberding, P. A. (2020). Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society–USA panel. Jama, 324(16), 1651-1669.

4. Bhatti, A. B., Usman, M., & Kandi, V. (2016). Current scenario of HIV/AIDS, treatment options, and major challenges with compliance to antiretroviral therapy. Cureus, 8(3).

5. B Nachega, J., C Marconi, V., U van Zyl, G., M Gardner, E., Preiser, W., Y Hong, S., ... & Gross, R. (2011). HIV treatment adherence, drug resistance, virologic failure: evolving concepts. Infectious Disorders-Drug Targets (Formerly Current Drug Targets-Infectious Disorders), 11(2), 167-174.

6. Sullivan, P. S., Campsmith, M. L., Nakamura, G. V., Begley, E. B., Schulden, J., & Nakashima, A. K. (2007). Patient and regimen characteristics associated with self-reported nonadherence to antiretroviral therapy. PloS one, 2(6), e552.

7. Mugavero, M., Ostermann, J., Whetten, K., Leserman, J., Swartz, M., Stangl, D., & Thielman, N. (2006). Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care & STDs, 20(6), 418-428.

8. Holtzman, C. W., Brady, K. A., & Yehia, B. R. (2015). Retention in care and medication adherence: current challenges to antiretroviral therapy success. Drugs, 75(5), 445-454.

9. National Academies of Sciences, Engineering, and Medicine. (2017). Communities in action: Pathways to health equity.

10. WHO. (not dated). Social determinants of health. Accessed on May 29, 2022 from https://www.who.int/health-topics/social-determinants-of-health

11. Hsieh, D. (2019). Achieving the quadruple aim: treating patients as people by screening for and addressing the social determinants of health. Annals of emergency medicine, 74(5), S19-S24.

12. Doran, K. M., Kunzler, N. M., Mijanovich, T., Lang, S. W., Rubin, A., Testa, P. A., & Shelley, D. (2016). Homelessness and other social determinants of health among emergency department patients. Journal of Social Distress and the Homeless, 25(2), 71-77.

13. Behr, J. G., & Diaz, R. (2016). Emergency department frequent utilization for non-emergent presentments: results from a regional urban trauma center study. PLoS one, 11(1), e0147116.

14. Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikkadar, N., Zwald, M., Hoots, B., ... & Houry, D. (2021). Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA psychiatry, 78(4), 372-379.

15. Tang, N., Stein, J., Hsia, R. Y., Maselli, J. H., & Gonzales, R. (2010). Trends and characteristics of US emergency department visits, 1997-2007. Jama, 304(6), 664-670.

16. Kangovi, S., Barg, F. K., Carter, T., Long, J. A., Shannon, R., & Grande, D. (2013). Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health affairs, 32(7), 1196-1203.

17. Anderson, E. S., Lippert, S., Newberry, J., Bernstein, E., Alter, H. J., & Wang, N. E. (2016). Addressing social determinants of health from the emergency department through social emergency medicine. Western Journal of Emergency Medicine, 17(4), 487.