Faith is a Social Determinant of Health

My career in HIV began 15 years ago, by accident. Year three of my formal medical training was planned to be a one-year clinical fellowship caring for people with cancer in Buenos Aires, Argentina, but as the old Yiddish proverb goes, “When we plan, God laughs.” I’d spent my entire life planning and preparing for a career dedicated to curing cancer, and until 2008, things were going as planned.

Then God laughed.

My plans to care for people with cancer quickly fell apart, and I was left scrambling to salvage a year abroad at a critical point in my training with no time to waste. An alternative opportunity to train with Argentina’s principal HIV foundation, the Fundación Huésped, was presented to me, and although I’d only studied cancer up until this point in my education, I accepted. Little did I know that decision would change not only the trajectory of my career, but my faith formation, and my life. My time in Argentina introduced to me the social determinants of health in a way I had not experienced before. Everyone I cared for presented with an HIV diagnosis that was deeply rooted in complex social circumstances and conditions.

One such person was a woman of trans experience with a history of sex work. She talked openly about life as a trans woman in Latin America. She lamented over the friends she’d lost along the way, mostly from HIV/AIDS but some from violence rooted in transphobia. But what stuck with me the most was her relationship - or lack thereof - with her faith. She talked about being raised Roman Catholic, as more than 90% of Latin America was and continues to be – and I could tell that she had great passion for Christ just from the emotion that she spoke with. So, you could imagine my dismay when she shared that she no longer identified with the Church, because the church didn’t identify with her. The Church condemned her identity as a transgender person living with HIV because the only way she could survive was by putting herself at risk for HIV exposure when selling the sole thing she could offer at the time - her body.

I left Argentina that year really struggling with her story and how Church and society had rejected her in a way that ultimately made her more vulnerable to HIV. I realized that no matter what we did for people seeking care in a clinical setting, we would always have to send them back into a world that makes them sick, and faith was a part of the story, for better or worse. I returned to the United States conflicted about my own professional path, but also emboldened to learn how the social determinants of health, and particularly faith, play a role in the HIV epidemic in the U.S., because faith is a social determinant of health.

This is especially true for Black Americans who shoulder the greatest burden of HIV in the U.S. According to Pew Research, Black people are the most religious ethnic group in the country, with almost eight-in-ten Black Americans being affiliated with some religion, and nearly all Black Americans (97%) indicating that they believe in God or a higher power, regardless of their religious affiliation. Likewise, most Black adults say they rely on prayer to help make major decisions, including about health. When considering this in the context of the demographic landscape of the HIV epidemic in the U.S., where the southern region of the country accounts for the largest population of Black people, people who identify as LGBTQIA+, people living with HIV, and people of faith – it’s impossible to ignore faith as a social determinant of health overall, and of HIV specifically.

Rightfully, research is beginning to support the case for more consideration of faith when assessing health outcomes in Black Americans. In the Jackson Heart Study conducted by the Mayo Clinic, religion and spirituality were associated with improved heart health in over 5,000 Black men and women in the Jackson, Mississippi area[1]. The findings suggest that spiritual perspectives or religious beliefs could play an important role in heart-health interventions among Black Americans.  Another study by the Center for HIV/AIDS Educational Studies and Training (CHEST) at City University of New York reviewed 9 studies with 13 statistical analyses, examining the relationships between individual HIV syndemic-related health conditions, religion, and spirituality in men who have sex with men (MSM)[2]. This systematic review identified 5 negative associations and 2 positive associations between religion/spirituality and HIV-related health conditions in MSM, concluding that the need for the inclusion of faith in HIV and health disparities research with MSM is clearly supported, and that scientists and public health policymakers should critically examine how faith can promote positive health outcomes among MSM.

The HVTN Faith Initiative is a prime example of the ways in which institutions committed to biomedical discovery can effectively integrate faith into their research priorities, but you don’t have to be a scientist or clinician to understand the impact faith has on the wellness of communities. Just drive through any urban epicenter in America and note the number of houses of worship present compared to the number of healthcare facilities, grocery stores, or fitness centers. For many people, faith isn’t merely an ideal, but rather a support system that fills the gaps in access to the things that are supposed to keep us healthy.

In the 15 years since I started this journey, I’ve grown into a more complete healthcare provider; not solely because I refined my clinical skills, but mostly because I honed my people skills. Treating people versus treating disease means considering everything that people bring with them when assessing their well-being, including their faith, because faith is a social determinant of health. For better or worse, faith has to be a part of the conversation when addressing health disparities like HIV/AIDS if we expect to make our worst better, and our better, best. Without faith, we’ll still be having conversations around health inequity well into the fifth decade of the HIV epidemic and beyond.

Although the struggle continues…remember to keep the faith!


References:

[1] Brewer LC, Bowie J, Slusser JP, Scott CG, Cooper LA, Hayes SN, Patten CA, Sims M. Religiosity/Spirituality and Cardiovascular Health: The American Heart Association Life's Simple 7 in African Americans of the Jackson Heart Study. J Am Heart Assoc. 2022 Sep 6;11(17):e024974. doi: 10.1161/JAHA.121.024974. Epub 2022 Aug 24. PMID: 36000432; PMCID: PMC9496409.

[2] Lassiter JM, Parsons JT. Religion and Spirituality's Influences on HIV Syndemics Among MSM: A Systematic Review and Conceptual Model. AIDS Behav. 2016 Feb;20(2):461-72. doi: 10.1007/s10461-015-1173-0. PMID: 26319130; PMCID: PMC4755900.


Dr. Ulysses Burley is the founder of UBtheCURE LLC and Project Director of the HVTN Faith Initiative.