Running

head: HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

Joshua Jenkins
University of South Florida
College of Nursing

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

According to estimates by the University of Floridas Bureau of Economic and Business

Research, the population of Hillsborough County as of April 1, 2015 is 1,325,563 (University of
Florida, 2015). As one of the most populated counties in the state of Florida, its makeup is
primarily that of the city of Tampa and its suburban areas, including Brandon, Plant City,
Temple Terrace, Ruskin, and New Tampa. In 2015, the Tampa Bay Times reported that Florida
now has the highest number of new HIV diagnoses in the nation, with Hillsborough County
demonstrating the largest increase (McNeill, 2015). This paper will explore that trend and
factors related to this increase.
Hillsborough County is located in the western part of central Florida, encompassing
1,072 square miles of land east and north of Tampa Bay, south of where Interstates 75 and 275
bifurcate, east to the outskirts of Lakeland, and south to north of Lake Parrish (Hillsborough
County, 2014). According to the US Census in 2010, 96.5% of residents in Hillsborough County
lived in an urban environment, with only 3.5% living in rural (US Census Bureau, 2010).
The Tampa Bay areas large population contributes to the significant resources available
within the state. Health care systems in the Tampa Bay area are extensive, with the Florida
Hospital system, Baycare Health system, Tampa General Hospital, and several other smaller
networks working throughout the county. The Baycare Health System, Inc., is also one of the
areas largest employers, with approximately 22,900 employees as of 2015, according to the
Tampa Bay Partnership. The Tampa Bay Partnership also lists Publix and the Home Shopping
Network as major employers in the region, with approximately 13,000 and 10,550, respectively.
Further research into additional major employers in Hillsborough County and the surrounding
area detail WellCare, Tampa General Hospital, Moffitt Cancer Center, Florida Hospital, and

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

Humana (Tampa Bay Partnership, 2015). Evidently, the area under study has a significant
healthcare footprint.
Study into the demographics of Hillsborough County demonstrates in most cases, the
county is reflective of the statewide trends, with notable exceptions of being, in general terms, a
younger and more educated population. According to the US Census Bureaus 2010 data,
Hillsborough County accounts for 13.1% of residents being over 65, as opposed to the statewide
19.1%, and the national average of 13.0%. 29.8% of Hillsborough residents report having a
Bachelors degree or higher, against 26.8% of Florida residents and 29.3% of Americans. High
school diploma recipients are similar across county, state, and national levels with 87.1%,
86.5%, and 86.3% respectively. Continuing to analyze the data from the US Census, 16.8% of
Hillsborough residents are living in poverty, nearly equal to the 16.5% of Floridians, both of
which are higher than the national average of 14.8% in poverty.
English proficiency data for Hillsborough county reflects the highest two groups with
highest rates of speaking English poorly or not at all are those who identify Spanish and
Asian/Pacific Islander languages as their first language, with 26 and 19 percent respectively
(University of South Florida, 2012). Overall analysis of the data shows that children 5-17 are
proficient in English, with the highest percentage who identify as not speaking English well to be
11% of those children ages 5-17 who speak Asian and Pacific Island languages (University of
South Florida, 2012).
As described, there are substantial private healthcare opportunities available within
Hillsborough County and the surrounding areas. Publicly funded resources are also available,
and have substantial resources throughout the county to diagnose, treat, and manage care for
individuals with healthcare needs. Looking into the data, it seems that these resources are having

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

the desired impact in a number of areas. According to statistics by the Florida Department of
Health (2016), preventative care is in the first or second quartile in the categories of prenatal
care, aerobic and resistance exercise, eating enough fruits and vegetables, and avoiding smoking.
These preventative care elements show that many residents in this area take their health seriously
and understand a need for taking care of themselves. Hillsborough also fell within the first
quartile for the availability of medical and dental services. This is not an area where health
resources and facilities are not available. With 80.9% of Hillsborough residents reporting having
some type of health care insurance coverage, most residents of the area have access to the
healthcare they need (Fl. Dept. of Health, 2016). Hillsborough also falls within the first quartile
for suicide death rates, which potentially indicates that with the above described access to health
care, people are seeking out mental health help at times when it is needed (Fl. Dept. of Health,
2016).
However, there are many areas in which the Hillsborough health scene is less successful.
According to the National Conference of State Legislatures, 26.4% of Floridians self-reported
being obese in 2013 (2014). Other chronic illnesses related to obesity, specifically diabetes and
heart disease, to be areas which need improvement (Fl. Dept. of Health, 2016). While early
prenatal care is a 89%--significantly higher than the Healthy People 2020 goal of 77.9%,
Hillsborough ranks poorly in terms of neonatal death rate, repeat births to mothers under 20,
infant and fetal death, and premature births (Fl. Dept. of Health, 2016). Most troubling though,
is how poorly Hillsborough performs in infectious disease cases. Hillsborough is in the lowest
quartile for tuberculosis, sexually transmitted infections, vaccine preventable diseases, HIV, and
AIDS cases (Fl. Dept. of Health, 2016). Outbreaks of these diseases have substantial
consequences for those infected and those they are in contact with.

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

Given the prevalence of HIV infection in Hillsborough County, the remainder of this
essay will focus on its impact in Hillsborough County, particularly with men who have sex with
men (MSM). The Florida Health Department reports that infections of HIV in the age group of
20-39 to encompass 56% of all HIV cases, with MSM accounting for 68% of cases. Given that
Florida has been identified as the state with the highest number of new diagnoses in the United
States, rising use of Pre-Exposture Prophylaxis (PrEP) treatment in mainstream usage, the
continued evolution of both medical treatment of the disease and viral mutations of resistance
against such treatments, it is critical that this disease not be downplayed in its importance. New
infections in Hillsborough County in 2014, according to the Florida Health Department report,
placed the county (330 cases) only behind Miami-Dade (1,217), Broward (716), and Orange
(384) counties (Fl. Dept. of Health, 2015). Attitudes today often regard HIV as such a
manageable disease that its impact on the life of the affected individual is often underestimated.
This lackadaisical attitude toward prevention of the disease has placed Florida in its current
position.
According to the Office of Disease Prevention and Health Promotion, the Determinants
of Health Model is the interaction of the following categories and how they relate to one another
to determine the health of an individual and population: policymaking, social factors, health
services, individual behavior, and biology and genetics (Office of Disease Prevention and
Health Promotion, 2016). Health management by nurses is so different from the medical
management by physicians because nurses must consider the whole person, and not just the
disease process involved inside the patients body. Community health nurses, along these same
lines, have a critical job of identifying the factors in the life of the individuals they care for and
discovering trends in their communities.

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

For example, Title XXIX Florida Statute 384.24 requires anyone with any sexually
transmitted disease, including HIV, to disclose his or her infection to any sexual partners prior to
engaging in sexual activity. The community health nurse will need to explore if this disclosure is
happening with her patients, and to teach about the importance of and consequences in failing to
do so. Social factors in this age group are tremendously important in the epidemiology of this
disease. The Florida Health Department reports in 2013, only 4% of MSM HIV infections fell
into the exposure category of injecting drug users, while 68% were from homosexual sexual
contact. The further elements of hypersexualization, the hookup culture in the single gay mans
world, and the ubiquity of dating apps places sex a couple of swipes away. A nurse has a great
opportunity to intervene in the individual behaviors of a patient with the ability to discuss safe
sex practices, multiple partners, drug and alcohol use and how it pertains to sexual activity.
The community nurse can ensure that individuals are aware of the availability of health
services, including testing centers, HIV specialist doctors, support groups, case management, and
medication assistance. A complex healthcare team is necessary for the care of the HIV infected
individual because of the intricacies of the disease and the complications associated with the
care. The Tampa Bay Times discussed back in the 1980s and 1990s, the medical regimen
consisted of over 20 pills per day (McNeill, 2015). Today, there are several medications that
consist of only one pill per day, but the side effects can still be difficult to endure. The disease
process of HIVs progressive destruction of the immune system opens the patients up to a
tremendous array of opportunistic diseases. According to Aids.gov, the acute infection usually
manifests as severe flu-like symptoms, whereas the latency stage is a period of slow viral
replication and years of destruction of the immune system. Because this phase is not
characterized by significant symptoms, it is here that patients are likely to fall off of their

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

medication regimens and fall out of care. Montaner et. al. (2014) explain poor medication
regimen compliance often attributed to concerns regarding potential for incomplete adherence
leading to HIV drug resistance and the threat of spreading primary HIV drug resistance to the
population at large. It often falls on the community health nurse to properly communicate with
the patients the necessity of understanding the disease process and the complications that can
occur as a result of failure to seek proper care.
The population diagnosis in this case is increased risk of HIV infection and management
of care in HIV infected young men who have sex with men in Hillsborough County as evidenced
by increasing rates of HIV infection in the county among citizens of that age group.
Interventions for HIV infection must begin with the individual at risk, and advance
outward from there. Primary levels of intervention require the community health nurse to be
open to discussions with the patients, particularly those at increased risk such as MSM under 40
years of age. It is imperative to explain the necessity of condom usage, and be knowledgeable
about other protections such as Pre-Exposure Prophylaxis (PrEP) as a means of protecting
oneself from HIV infection. Zoblotska, Spelman, and Glulich (2015) describe how the previous
six years of research has identified the safety and efficacy of PrEP, primarily in the form of
tenofovir and emtricitabine combination marketed as Truvada, and how PrEP decreased infection
rates by 86%. A multifaceted approach to prevention is key to that risk factors are mitigated, and
health promotion is enhanced for the community members. Finding assistance can be found
through Gilead Pharmaceuticals website with a co-pay card to provide the medication free of
charge to patients. Going to Truvada.com, the patient can get signed up for their assistance
program. Condoms are available free of charge at the county health department, any HIV testing
site, Metro Wellness facilities, and most doctors offices. It is important that during all contacts

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

with patients, the community health nurse assesses the use of safe sex practices and what other
interventions the patient may be interested in to prevent infection with HIV.
Secondary levels of prevention occur at the community level, providing clinics for
patients infected with HIV to be able to see a specialist and have their care managed through
case management. This type of clinical involvement within the community encompasses case
finding, surveillance, and screening with in-clinic testing, diagnosis and reporting within the
health department and other clinics to report infections to the CDC, as well as treatment, as many
of these clinics have specialists on staff to manage the care of the patients. Nurses and
physicians in this role must assess the readiness of the patient to begin anti-retroviral therapy for
newly infected individuals and those returning to care after discontinuing their treatments. Here,
the clinics can ensure the patient is undergoing regular blood level testing every three to six
months, the patient has access to their medication, are able to pay for it or are enrolled in
payment assistance programs, as well as the emotional and mental state of the patient for
treatment. Controlling the disease through proper medication adherence is the best way to
prevent transmission to anyone else (Montaner et. al., 2014). Funding of the secondary
interventions are a combination of state, federal, and social charities funding, particularly
through the Ryan White Foundation and the Americans with Disability Act funding.
Tertiary levels of prevention also occur at the community level. The community nurse
speaks with the patients to ensure they are maintaining compliance with medications of HIV
infected patients, and maintaining compliance to safe sex practices by at risk individuals. It is
important for the nurse to follow up with patients to have them keep their appointments to
monitor for treatment effects of the medications, so the health care team and decide if it is
necessary to reconsider the treatment for a patient. The nurse must assess for noncompliance

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

with medication regimens, and be sure the patient understands the risks of medication resistance
that can develop in an HIV infected individual. The nurse must also discuss other aspects of life
with the patient, to consider the mental and emotional state of the patient with HIV, and how he
or she is handling their diagnosis, particularly at the onset of care. Addressing these issues with
the patients allow the community health nurses at health clinics to educate patients on their role
in preventing the spread of the disease to others. The other interventions at the tertiary level
involve keeping the patients healthy and within care, with services such as immunizations and
ensuring access to the medications. Providing these services in the community provide
opportunities to mitigate HIV infection spread in Hillsborough County.
Health policy in general has a substantial impact on health care, particularly for the
community. Health policies dictate guidelines for care to be managed, and within these
guidelines clinicians are able to provide safe, ethical, legal care to their patient populations.
A proper health policy to propose to battle the high rate of HIV infections is through
education. The primary preventative focus of education being put forward in schools about HIV,
how HIV works, is transmitted, what treatments are out there and information about safe sex,
PrEP, and at risk populations for HIV infection. Current educational policies of abstinence only
are not realistic and to not properly address or prevent diseases such as HIV. The goal would be
to increase knowledge and understanding about the disease and the risk factors associated with
infection. The stakeholders are universal, because it would require the legislators to change the
laws, public officials to institute the education into the school system, health care providers to be
aware of what was being taught, and community members to teach in the schools and to learn.
Funding would have to come from the state legislature, since the policy directly impacts the
state-run schools. It would require training to be provided to the instructors and materials to be

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provided to the students. Proponents of the policy would be health professionals, and anyone
who supports increased education about sexually transmitted diseases. Opponents would be
those in favor of abstinence only education. Those opposing must come to terms with the
numbers and the increasing incidence of the HIV in Florida and Hillsborough County,
understanding their policy has failed our state.
In order to adopt this policy, the legislature must pass a bill to allow the education to be
presented in our schools statewide. Once the lawmakers pass a law to allow the education, the
counties will have to incorporate it into their curriculum. It would have to begin with a letter
written to a legislator to propose the bill before anything can happen, because it requires
changing state policy. The impact will be a more educated population and able to better
understand how to protect oneself, and how to treat the disease if one is infected. Better
education and understanding will also mitigate stigma, to encourage more people to seek care.
In conclusion, HIV prevalence is still a major problem in Florida, and in Hillsborough
County, particularly within the gay community. Phenomenal advancements have been made in
the care and treatment of the disease, but as discussed, the lack of education and lack of
involvement in the community for caring for HIV infected individuals places Hillsborough
County as the fourth highest infection rate in the state. Patient must have access to the care they
need, and to be educated on the preventative options they can discuss with their physicians.
Given the significant rates of HIV infection in Florida, this topic is important to the career of any
nurse. There is a substantial lack of knowledge on the subject even from health professionals.
Hopefully furthering understanding and acknowledgement of the disease will help to curb the
current trend of its increase infection rates by reducing stigma and advancing care.

HIV INFECTIONS AMONG GAY MEN IN HILLSBOROUGH COUNTY

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References
Florida Department of Health, Division of Disease Control and Health Promotion. (2015,
December 23). Monthly surveillance report (Hepatitis, HIV/AIDS, STD, and TB).
Retrieved March 6, 2016, from http://www.floridahealth.gov/diseases-and-
conditions/aids/surveillance/_documents/msr/2016-msr/msr0116.pdf
Hillsborough County Board of County Commissioners. (2014). About the county. Retrieved
March 6, 2016, from http://www.hillsboroughcounty.org/index.aspx?nid=423
McNeill, C. (2015, July 2). Florida seeing highest number of new HIV cases in the nation.
Tampa Bay Times. Retrieved March 6, 2016, from
http://www.tampabay.com/news/health/new-hiv-infections-in-hillsborough-countyhighest-in-the-state/2236007
Montaner, J. S., Lima, V. D., Harrigan, P. R., Loureno, L., Yip, B., Nosyk, B., . . . Kendall, P.
(2014). Expansion of HAART coverage is associated with sustained decreases in
HIV/AIDS morbidity, mortality and HIV transmission: The HIV treatment as
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Office of Disease Prevention and Health Promotion. (2016). Determinants of health.
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measures/Determinants-of-Health#policymaking
Tampa Bay Partnership. (2015, April 21). Major employers. Retrieved March 6, 2016, from
http://www.tampabay.org/site-selection/major-employers

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United States, Department of Commerce, US Census Bureau. (2012, September). Florida

2010 Housing and Unit Census Counts. Retrieved March 6, 2016, from
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University of Florida, College of Liberal Arts and Sciences, Economic and Business
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demographics/data/PopulationEstimates2015.pdf
University of South Florida, School of Architecture and Community Design, Florida Center
for Community Design and Research. (2012). Hillsborough community atlas.
Retrieved March 6, 2016, from
http://www.hillsborough.communityatlas.usf.edu/demographics/default.asp?ID=1
2057
Zablotska, I. B., Spelman, T., & Grulich, A. (2015). 2015 a seminal year for HIV biomedical
prevention. Journal of the International AIDS Society, 18(1).
doi:10.7448/ias.18.1.20814