DR Nicola Skyers, senior medical officer in the HIV/Sexually Transmitted Infection/Tuberculosis unit of the health promotion and protection branch at the Ministry of Health and Wellness (MOHW), says in order to meet the 90-90-90 global targets set by UNAIDS in 2014 to end the AIDS epidemic by 2020, it is critical to address the social determinants of health (SDH).

“How do you get around the social issues that persons face, some persons are in the lower socio-economic status so they are more concerned about their basic needs. They have to get to work, they have to feed children, so coming in for health care and getting medication, even though it’s free, is filled with barriers,” Dr Skyers told the Jamaica Observer while speaking about the social enablers and barriers to care for HIV patients.

She added: “There are lots of issues people face coming in for care even though healtcare is free. If you’re a security guard and you work from 7:00 am to 7:00 pm, sometimes the hours are not good for you. If you don’t go to work you lose a day’s pay, so there are lots of issues that impact how persons who are socially vulnerable access care and that’s a significant part of the population we serve.”

The 90-90-90 targets specify what has been described as ambitious goals of having 90 per cent of all people living with HIV knowing their status, 90 per cent of all people with diagnosed HIV infection receiving sustained antiretroviral therapy and 90 per cent of all people receiving antiretroviral therapy having viral suppression by 2020.

According to the World Health Organization (WHO), SDH are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These conditions affect a wide range of health, functioning, and quality-of-life outcomes and risks.

Theorists Göran Dahlgren and Margaret Whitehead in 1991 put forward the layers of influence on health, describing a social ecological theory to health in which the relationship between the individual, their environment and disease is demonstrated. The layers look at individual lifestyle factors, social and community networks and the wider determinants of health general socio-economic, cultural and environmental conditions.

Further, the model places the individuals at the centre with a fixed set of characteristics such as age, sex and constitutional factors that cannot be changed and surrounding the individual are influences on health such as social ills, community networks, education work environment, policy, environment working conditions, housing, sanitation, food production, culture, unemployment and health care services. These wider determinants can be modified to get the best outcome for the individual. Best practices recommended that health care initiatives be developed from a psychosocial model which accounts for these issues and not solely from a biomedical model of care, which focuses on treatment.

Subsequently, Dr Skyers posits that the greatest and most meaningful impact is at the family level and urged those involved in the fight against HIV/AIDS to tailor interventions at the family and community levels.

“Where we can have impact is at the family level. Because of the stigma, discrimination and perceived issues, sometimes persons don’t disclose to their family members and a lot of the support and care is needed at that level. That is critical. People living with HIV come to the facilities for treatment every two to three weeks but they are living with their families every single day. As I keep saying to persons, those living with HIV or any critical condition come to the facilities two or three times per year but you live with your family everyday. So, if you don’t have that network to support you then your intermittent interface with the network is certainly not sufficient to provide you with what you need in terms of support. The most important part for me is family and support network and ensuring persons have that and are comfortable to disclose and know persons will support them,” she said.

In addition, Dr Skyers said intervention at the community level to change stigmatising behaviours is a complex issue as discrimination is caused by multiple factors, hence making it difficult to target interventions.

“When we talk about complaints it’s not the health care system that is number one in terms of discrimination, it’s the community. We have the systems in place. Testing is free, drugs are free, there is psychosocial support, social workers, case managers, but how do we reduce stigma and discrimination to a point where patients can feel comfortable telling their mom and dad they have HIV and not anticipate that backlash,” Skyers said.

Moreover, Dr Kevin Harvey, Caribbean regional director at AIDS Healthcare Foundation, said social issues impact across all areas of the 90-90-90 targets and they must be addressed in order to win the fight against HIV.

“If you have to hide to take medication, can’t negotiate condom use in marriage and relationships, there alone we have issues. When you ask patients to come to clinics once every month to collect their pills, they don’t want to go every month. You’re at work and have to leave jobs and spend entire day at clinics, medications have side effects, some doctors are not properly trained with how to optimise the education regimes with patients. Some do the same thing that is failing or they just start with one standard thing despite the patient’s reaction. There is a lot more training that needs to happen and I am very disappointed I must tell you that after 35 years the doctors coming out of UWI are not properly trained to manage HIV,” Dr Harvey said.

He added: “We are still hypocrites. We don’t want to talk about sex but we are having a lot of sex. There are still lots of issues — young girls and old men — and we don’t talk about it. In order to win the fight we have to address social issues.”