College of Medicine, Drexel University, Philadelphia, PA, USA.
Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
AIDS Behav. 2024 Sep;28(9):3001-3037. doi: 10.1007/s10461-024-04387-y. Epub 2024 Jun 8.
Structural racism and discrimination (SRD) is deeply embedded across U.S. healthcare institutions, but its impact on health outcomes is challenging to assess. The purpose of this systematic literature review is to understand the impact of SRD on pre-exposure prophylaxis (PrEP) care continuum outcomes across U.S. populations who could benefit from HIV prevention. Guided by PRISMA guidelines, we conducted a systematic review of the published literature up to September 2023 using PubMed and PsycInfo and included peer-reviewed articles meeting inclusion criteria. At least two authors independently screened studies, performed quality assessments, and abstracted data relevant to the topic. Exposure variables included race/ethnicity and any level of SRD (interpersonal, intra- and extra-organizational SRD). Outcomes consisted of any steps of the PrEP care continuum. A total of 66 studies met inclusion criteria and demonstrated the negative impact of SRD on the PrEP care continuum. At the interpersonal level, medical mistrust (i.e., lack of trust in medical organizations and professionals rooted from current or historical practices of discrimination) was negatively associated with almost all the steps across the PrEP care continuum: individuals with medical mistrust were less likely to have PrEP knowledge, adhere to PrEP care, and be retained in care. At the intra-organizational level, PrEP prescription was lower for Black patients due to healthcare provider perception of higher sex-risk behaviors. At the extra-organizational level, factors such as homelessness, low socioeconomic status, and incarceration were associated with decreased PrEP uptake. On the other hand, healthcare provider trust, higher patient education, and access to health insurance were associated with increased PrEP use and retention in care. In addition, analyses using race/ethnicity as an exposure did not consistently show associations with PrEP continuum outcomes. We found that SRD has a negative impact at all steps of the PrEP care continuum. Our results suggest that when assessing the effects of race/ethnicity without the context of SRD, certain relationships and associations are missed. Addressing multi-level barriers related to SRD are needed to reduce HIV transmission and promote health equity.
结构性种族主义和歧视（SRD）在美国医疗保健机构中根深蒂固，但评估其对健康结果的影响具有挑战性。本系统文献综述的目的是了解 SRD 对可能受益于 HIV 预防的美国人群的暴露前预防（PrEP）护理连续体结果的影响。本研究遵循 PRISMA 指南，使用 PubMed 和 PsycInfo 对截至 2023 年 9 月的已发表文献进行了系统综述，并纳入符合纳入标准的同行评议文章。至少两名作者独立筛选研究、进行质量评估并提取与主题相关的数据。暴露变量包括种族/民族和任何级别的 SRD（人际、组织内和组织外 SRD）。结果包括 PrEP 护理连续体的任何步骤。共有 66 项研究符合纳入标准，证明了 SRD 对 PrEP 护理连续体的负面影响。在人际层面上，医疗不信任（即，由于当前或历史上的歧视行为，对医疗组织和专业人员缺乏信任）与 PrEP 护理连续体的几乎所有步骤都呈负相关：不信任医疗的个体更不可能了解 PrEP、坚持 PrEP 护理、并保持在护理中。在组织内层面上，由于医疗服务提供者认为黑人患者的性行为风险更高，因此黑人患者接受 PrEP 处方的可能性较低。在组织外层面上，无家可归、社会经济地位低和监禁等因素与 PrEP 使用率降低有关。另一方面，医疗服务提供者的信任、更高的患者教育和获得医疗保险与 PrEP 的使用和护理保留增加有关。此外，使用种族/民族作为暴露因素的分析并不总是显示与 PrEP 连续体结果的关联。我们发现 SRD 对 PrEP 护理连续体的所有步骤都有负面影响。我们的结果表明，在没有 SRD 背景的情况下评估种族/民族的影响时，会遗漏某些关系和关联。需要解决与 SRD 相关的多层次障碍，以减少 HIV 传播并促进健康公平。
