Psychology Topic 5 Assignment

AJPH ENDING THE HIV EPIDEMIC

Stigma, Implicit Bias, and Long-Lasting Prevention Interventions to End the Domestic HIV/AIDS Epidemic

See also Kapadia and Landers, p. 15; and the AJPH Ending

the HIV Epidemic section, pp. 22–68.

Ending the domestic HIV/ AIDS epidemic will require collaborative, innovative, and community-informed approaches since the factors fueling the epi- demic in the United States are largely social and structural. It is no coincidence that the communities most disproportionately affected by HIV (i.e., racial/ethnic mi- norities, sexual and gender mi- norities, and immigrants) share devalued identities and carry a legacyof violence, victimization, stigma, and discrimination.1 To successfully meet the goals of the federal End the HIV Epidemic proposal, effective interventions must be developed and imple- mented in three domains: (1) addressing stigma and discrimi- nation, (2) increasing awareness and building capacity to address implicit bias, and (3) developing an effective preventive HIV vac- cine or similar long-acting bio- medical prevention strategy.

ADDRESSING STIGMA AND DISCRIMINATION

The proposed plan to end the epidemic pays little attention to adequately addressing perva- sive stigma and decades of in- stitutional discrimination.Black and

Latino/a persons, especially men who have sex with men (MSM) and transgender individuals, dis- proportionately experience health care services that are of lower quality, are more expensive, have limited availability because of lim- ited access to Medicaid or no Medicaid expansion, lack cultural responsiveness (ability to learn from and relate respectfully with people from other cultures), and fail to provide population-focused health services (emphasizing the needs of a whole population, not individual members, to eliminate inequalities and stress prevention).2,3 The im- pact of these inequities is most ev- ident in Black and Latino/a MSM and transgender individuals, who experience markedly lower access to preexposure prophy- laxis (PrEP),delays inearlydiagnosis and treatment, and lower likeli- hood of virological suppression.4,5

Interventions aimed at elimi- nating the discriminatory policies and practices that have resulted in barriers to obtaining and main- taining health care, lower-quality care, homelessness, incarceration, and poverty are critical in our efforts to end HIV. These in- clude, but are not limited to, affordable housing, moving away from criminalization and toward effective interventions (e.g., harm reduction)6 and support

services (e.g., promoting and supporting leadership) for drug users and sex workers, decrimi- nalization of HIV transmission, decreasing intimate partner vio- lence, increased access to health care, and increased civil rights and protections for racial/ethnic mi- norities, sexual and gender mi- norities, and immigrants. We must specifically address the stigmatizing and discriminatory practices of our health care system. For example, 30 states (60%) ei- ther ban transgender health careor do not clearly state their Medicaid policy on such care, further stig- matizing transgender individuals and perpetuating mistrust of the medical community. Any HIV prevention efforts must include collaborative efforts that focus on addressing these institutional, so- cial, and structural barriers that negatively affect HIV risk, trans- mission, and infection. To ensure meaningful engagement of com- munities, these efforts must utilize community-based participatory research approaches7 and in- clude health as part of a larger program that meets other community-identified needs.

INCREASING AWARENESS TO ADDRESS BIAS

Any successful plan to end HIV must also address the implicit biases that fuel perva- sive stigma and discrimination. Biases held by health care workers and service providers influence patient–provider relationships and communica- tion; treatment recommenda- tions; quality of care; empathy; prophylactic, diagnostic, and treatment decisions; treatment adherence; and patient out- comes. For HIV populations, bias is implicated in experienc- ing delays in initiating HIV care, being denied care, chal- lenges linking to care, lower likelihood of being prescribed antiretroviral therapy (ART), lower adherence to ART, verbal harassment, and being refused treatment.

For people living with HIV (PLWH), the ultimate goal is viral suppression, and this too is af- fected by pervasive implicit biases. People of color are less likely to be virally suppressed; this is particularly true of Black people, who, even after adjusting for ART use and adherence, are less likely to be virally suppressed. Among all PLWH subgroups, Black and Latina women expe- rience higher rates of morbidity andmortality and Latino/Hispanic

ABOUT THE AUTHORS All of the authors are with the HIVVaccine Trials Network and the Fred Hutch Vaccine and Infectious Disease Division, Seattle, WA.

Correspondence should be sent to Michele Andrasik, PhD, EdM, HIV Vaccine Trials Network, 1100 Fairview Ave N, E3-300, Seattle, WA 98109 (e-mail: mandrasik@ fredhutch.org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This editorial was accepted October 12, 2019. doi: 10.2105/AJPH.2019.305454

January 2020, Vol 110, No. 1 AJPH Andrasik et al. Editorial 67

men experience shorter life expectancy.

To end HIV domestically, the plan must explicitly address providers’ implicit biases. At a minimum, health care providers, HIV prevention researchers, and service providers must receive formal education (i.e., inmedical, nursing, and graduate school) to learn how their implicit biases influence their practice of med- icine; research questions, designs, methods, and interpretation of results; and health care service provision. It is imperative that we build the capacity of these indi- viduals, providing them with the skills they need to reduce nega- tive behaviors and mitigate neg- ative outcomes associated with these biases. Institutions and or- ganizationsmust also develop and implement metrics to identify disparities and inequities in their services and practices in real time to inform effective interventions to eliminate them.

DEVELOPING AN EFFECTIVE HIV VACCINE

Ultimately, any plan to end the HIV epidemic requires an effective long-acting biomedical prevention method, such as a vaccine, that is acceptable to populations at greatest risk. His- torically, vaccines have been re- quired to prevent infectious diseases. The numerous available HIV prevention methods, in- cluding PrEP, provide individ- uals with many choices, but most are dependent on behavior changes relating to adherence and the faithful and continuous use of the prevention method selected. Only long-acting in- terventions like vaccines and other injectables can overcome these adherence issues, and are

required to reduce the acquisi- tion rates to nonepidemic levels.

Any effort will require part- nering with communities to ensure that proposed plans are acceptable and meet the needs of the community, and that implementation is feasible. This is a complex field of trust, com- mitment, expectation, and belief. Such arrangements need to start somewhere but take years to be optimally successful. The HIV Vaccine Trials Network (HVTN) started its community engagement program 20 years ago. It is in the last five years that we have seen ongoing and iter- ative HVTN community en- gagement efforts lead to increases in minority and transgender en- rollment and favorable partici- pant experiences. These efforts have included targeted commu- nity stakeholder engagement, community consultations, protocol-specific community working groups, utilization of community-based participatory research approaches, and cul- tural responsiveness training. Most of our participants join our trials for altruistic reasons, and 80% report experiencing social benefits as a result of their par- ticipation. To ensure that this translates to acceptability and uptake, a commitment to com- munity engagement needs to extend post licensure. The hu- man papilloma virus vaccine has taught us that the development of an effective vaccine does not guarantee acceptance or uptake, so continued community en- gagement is not only necessary, it is critical.

To ensure the realization of ending the HIV epidemic do- mestically, we will need to focus on community-based work to establish and maintain relation- ships that build health and sexual literacy, normalize discussions about sex, and overcome the

pervasive mistrust of medical institutions resulting from de- cades of ethical violations and abuses of marginalized pop- ulations. Traditional models of medicine and clinical trials have not supported community ac- ceptance and ownership of bio- medical HIV tools broadly, especially in populations most vulnerable to HIV. To support community acceptance and ownership, the plan must in- vite clinical trialists and the larger medical community—the entire community, not simply those most convenient and ac- cessible for our work—to join in engaging participants, pa- tients, and communities as full partners in the process. This work entails recognizing that com- munity partners have agency, assets, and contributions that extend far beyond testing inves- tigational agents and receiving products to respond to disease, and these communities must be considered as more than the recipients of a service or product. It will also require ef- forts to increase the abysmally low numbers of racial, ethnic, and gender minority health care providers and researchers work- ing in the field.

Although this work may seem daunting, it simply represents a paradigm shift in which we center social justice, trauma- informed and patient-centered care, and harm reduction in our work. Now that we have the tools necessary to see the end of HIV in the United States, we must be bold enough to tackle the underlying issues that, until they are addressed, will render these tools useless for the most vulnerable populations.

Michele Andrasik, PhD, EdM Gail Broder, MHS Linda Oseso, MPH

Stephaun Wallace, PhD

Francisco Rentas, MAT Lawrence Corey, MD

CONTRIBUTORS M. Andrasik led the writing and editing of the manuscript. All other authors con- tributed equally to the manuscript.

ACKNOWLEDGMENTS A special thank you to Mindy Miner for her editorial assistance.

CONFLICTS OF INTEREST The authors report no conflicts of interest.

REFERENCES 1. Walters KL, Mohammed SA, Evans- Campbell T, et al. Bodies don’t just tell stories, they tell histories. Du Bois Review. 2011;8(1):179–189.

2. Halkitis PN,Wolitski RJ, Millet GA. A holistic approach to addressing HIV in- fection disparities in gay, bisexual, and other men who have sex with men. Am Psychol. 2013;68(4):261–273.

3. James SE, Herman JL, Rankin S, et al. The Report of the 2015 US Transgender Survey. Washington, DC: National Cen- ter for Transgender Equality; 2016.

4. Hall HI, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among sub- populations in the United States. JAMA Intern Med. 2013;173(14):1337–1344.

5. Highleyman L. PrEP use is rising fast in the US, but large racial disparities remain. Aidsmap, 2016. Available at: http:// www.aidsmap.com/PrEP-use-is-rising- fast-in-US-but-large-racial-disparities- remain/page/3065545. Accessed August 19, 2019.

6. Collins SE, Clifasefi SL, Logan DE, Samples L, Somers J, Marlatt GA. Current status, historical highlights and basic principles of harm reduction. In: Marlatt GA, Witkiewitz K, Larimer ME, eds. Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. 2nd ed. New York, NY: Guilford; 2011:3–35.

7. Wallerstein N, Duran B, Oetzel J, Minkler M. Community-Based Participatory Research for Health. 3rd ed. San Francisco, CA: Jossey Bass; 2017.

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68 Editorial Andrasik et al. AJPH January 2020, Vol 110, No. 1

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