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February 21, 2019

HIV/AIDS, Opioids, and Economic Recession in Urban Areas

By Angela Wong

Since June 1981, the HIV/AIDS epidemic has claimed hundreds of thousands of lives. Today, over 1.1 million people live with HIV throughout the United States. Studies have indicated that the epidemic has differentially impacted individuals living in urban and rural areas. According to CDC surveillance of HIV in urban and nonurban areas through 2016, of adults and adolescents diagnosed with HIV, there is a substantially larger percentage who have progressed to AIDS. Between 1985 and 2015, HIV-positive individuals who have progressed to AIDS in larger urban areas have progressively decreased while those of smaller cities (populations of 50,000 to 499,000) and metropolitan areas have increased. A secondary analysis of 2005 and 2009 Behavioral Risk Factor Surveillance System data found that individuals living in rural areas are less likely than their urban counterparts to report prior HIV testing, which may contribute to later HIV diagnosis in rural areas. Limited HIV testing is simply a symptom of a larger problem: disparities in healthcare access. 20 percent of Americans live in rural areas, yet only 9 percent of physicians practice there. A strong health infrastructure that provides essential prevention and care, therefore, is integral to reducing the impact of HIV/AIDS.

Almost ten years after the eve of the first wave of HIV/AIDS cases, the opioid epidemic began following the spike in opioid prescriptions for pain treatment. As of January 2018, more than 90 Americans die of opioid overdose each day—three people every hour. In a 2017 CDC report, rates of drug overdose deaths surpassed rates in non-metropolitan areas. As with HIV/AIDS, limited numbers of clinicians influence health outcomes. For example, only 3 percent of primary care physicians, the most common medical specialty in rural areas, received DEA Drug Addiction Treatment Act waivers to prescribe buprenorphine-naloxone, leaving over 30 million people without access to crucial treatment.

Though the HIV/AIDS and opioid epidemics have gained widespread attention, the systemic interaction between the two have received relatively less notice despite its demonstrated ramifications. In 2015, a sudden HIV outbreak was triggered by the sharing of needles among opioid users in rural Indiana. Understanding structural factors that influence vulnerability to the syndemic can inform policy and interventions that improve population health. Examples of public health interventions include promoting HIV testing, needle/syringe exchange programs, and naloxone programs.

The Great Recession caused the most dramatic nationwide employment contraction of any recession since the Great Depression, with 6.1 percent of payroll employment dropping. Unemployment was somewhat lower in New York City (4.4 percent), but not equally distributed. The lowest paid workers have not had wage increases since 2008. In 2016, African Americans continued to have the highest unemployment rate of any other racial or ethnic group in the city; similarly unemployment among this group was also the most sensitive to economic fluctuations. At the same time, death from opioid analgesics have skyrocketed—increasing 300 percent in New York City from 2000 to 2015. Concurrently, HIV has long faced an elevated HIV rate compared to the rest of the country, with HIV spread at three times the national rate with an incidence of 72 new infections for every 100,000 people. There is evidence that during economic downturns people lean on abuse of hallucinogens and prescription pain relievers, although this is linked largely to working-age while males; a different study suggests that substance abuse reduces during economic scarcity while exercise and social bonds strengthen. Little research has explored the potential syndemic interactions between financial crisis, substance use, and HIV rates in New York City neighborhoods.

Particularly during economic recessions, times of severe emotional strain, it has been found that public health programs are essential for keeping syndemics under control. In the context of a different syndemic that affected New York City—one of tuberculosis, HIV, and homicide—cuts in funding to public health, safety, medical and social service infrastructure following the city’s 1975 financial crisis compromised the city’s ability to provide preventative services. It also contributed to increases in these health conditions, particularly among vulnerable populations. Throughout history, many societies have demonstrated a propensity to cut health spending in the name of economic recovery. The Body Economic: Why Austerity Kills details cases where this counter-productive approach resulted in slower recovery and sustained increases of disease incidence and prevalence.

In contrast, during the Great Recession of 2008, educational and health services was the only industry group to add jobs in the state of New York. Information about HIV and opioid health treatment access before, during, and after the recessions is not readily available, but free and low-cost HIV testing, condoms, Ryan White services, and housing services are available for individuals living with HIV. Methadone and buprenorphine treatment is offered at health-department funded primary care sites. There does not appear to be evidence of any substantial cuts in public health infrastructure.

 Further research should explore the relationship between the availability of public health services and the resiliency in New York City's health during periods of economic stress, particularly the recession's differing effects on affluent and impoverished areas due to an unequal distribution of resources. Such research might bolster the case for maintaining a robust public health infrastructure within cities like New York City. Regardless of the current economic state, implementing similar services in rural or mid-sized metropolitan areas and illuminating health disparities within city boundaries would be useful for policymakers when tailoring public health interventions. To successfully promote population health collectively, they must consider the unique characteristics and needs of sub-populations.

Angela Wong (C’19) is a senior majoring in biology of global health and a student fellow with the Global Health Initiative.