Fryer Lecture Awardee: HIV Epidemic Revealed Inequities That Persist Today

HIV/AIDS, like COVID-19, has revealed health inequities and the influence of social determinants of health on disease, said Kenneth Bryan Ashley, M.D., who delivered this year’s John Fryer Award Lecture at APA’s Annual Meeting in New Orleans.

He is an associate professor of psychiatry at the Icahn School of Medicine at Mount Sinai, an attending psychiatrist in the Division of Consultation-Liaison Psychiatry at Mount Sinai Beth Israel, and director of Outpatient C-L Psychiatry at Mount Sinai Beth Israel. He is also the psychiatric liaison to the Mount Sinai Center for Transgender Medicine and Surgery Post-Surgical Gender Affirmation Surgery Service.

Ashley provided an overview of the history of the HIV/AIDS epidemic and its changing demographics and regional incidence. “The HIV epidemic epicenter in the U.S. began in coastal major metropolitan areas,” he said. “The current HIV epidemic in the U.S. is focused in the South.”

Ashley said the South (Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Washington, D.C.) accounted for 53% of all new HIV cases in 2019. Within that region, Black people, who represent 19% of the population, accounted for 50% of all new HIV cases in 2019. Hispanic people accounted for 24% of all new cases. White people and others accounted for 26%.

Citing statistics from AIDSVu, an interactive online mapping tool that visualizes the impact of the HIV epidemic on communities across the United States, Ashley said that the South is home to the highest percentage of gay and bisexual men (44%) living with HIV and that they are more likely to experience discrimination. Moreover, negative social determinants of health—poverty, lack of health insurance, lack of education, low household income, and food insecurity—are more pronounced in the South, and all of them affect the health of people living with HIV. For instance, 14.3% of people in the South lack health insurance compared with 10.4% of people nationwide.

Ashley also discussed “Ending the Epidemic: A Plan for America (ETE),” initiated in 2019 by the Department of Health and Human Services. The multi-year program will infuse 48 counties; Washington, D.C.; San Juan, Puerto Rico; and seven states that have a substantial rural HIV burden with the additional expertise, technology, and resources needed to end the HIV epidemic in the United States. The goal is a 75% reduction in new HIV cases in five years and a 90% reduction in 10 years.

“ETE can reduce rates of new HIV infections in targeted groups, but it will not resolve inequities,” Ashley said. “Structural racism and social determinants of health must be addressed as part of the ETE to hope to address health inequities. Engagement with community-based HIV and health organizations will be vital to addressing health inequities.”

Ashley has been active in APA at both the district branch and the national levels. He is an Assembly representative of the New York County Psychiatric Society and former president. He is also co-chair of the New York State Psychiatric Association Committee on Structural Racism. He is active in the APA mentors program, as well as a member of APA’s National Minority Mentor Network, and serves on APA’s Council on Consultation-Liaison Psychiatry.

He is the former president of the Association of LGBTQ+ Psychiatrists and the Society for Liaison Psychiatry, the New York regional organization of the Academy of Consultation-Liaison Psychiatry. He is a senior fellow of the Group for the Advancement of Psychiatry (GAP) and a member of the LGBTQ Committee.

The John Fryer Award, sponsored by APA and the Association of LGBTQ+ Psychiatrists, is given to individuals whose work has contributed to the improvement of mental health of sexual minority communities. It is named in honor of the psychiatrist who was part of the protest by gay psychiatrists at APA’s 1972 Annual Meeting that led to the removal of homosexuality from DSM the following year. John Fryer, M.D., appeared at the meeting in a mask as Dr. Henry Anonymous and testified about the barriers confronting gay psychiatrists. ■