Black MSM and HIV: What are we Missing?

Transcription

1 Black MSM and HIV: What are we Missing? DAVID MALEBRANCHE, MD, MPH MOREHOUSE SCHOOL OF MEDICINE HIV PREVENTION SUMMIT BIRMINGHAM, AL SEPTEMBER 29, 2017

2 Agenda EPI Disparity explanations Continuum of Care What s missing? Summary/Questions/Discussion

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4 Sounding the alarm? Really? Valleroy et al., in 3 MMWR, % prevalence MMWR, 2009 Jackson, MS 93% increase MMWR, 2011 Milwaukee, WI 144% increase

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7 WHY?

8 Proposed factors HIV testing Sexual networks Access to care Mental health Condomless sex rates Masculine socialization Incarceration Poverty Racism in white gay communities Lack of insurance Sexual prejudice Substance abuse Black church/religion Non-disclosure of sexual orientation Dishonesty with providers MOST RESEARCH STILL FOCUSES ON INDIVIDUAL LEVEL BEHAVIOR

9 Why the racial disparity? STI prevalence difference Undiagnosed seropositivity Access to care and treatment services Linkage to care Retention in care Use of ART Maulsby et al., 2014

10 Continuum of care

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13 This is Us When the CDC finally acknowledges U = U

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15 Common denominator?

16 CULTURAL HUMILITY

17 HIV Testing Over-screening of Black MSM Approaches incorporating Black MSM = HIV HIV fatigue Missed opportunities Assumptions based on race, masculinity, marriage No sexual history discussion You don t need that

18 Lack of adequate area resources Linkage to Care Provider/staff fatigue Provider apathy Not following through

19 Engagement/Retention in Care Crowded facilities Stigma of the clinic itself Overworked staff Institutional/individual rules Staff/provider attitudes

20 Provider bias and assumptions Prescribed ARV therapy/viral Suppression Not listening to our patients Adherence testing phase Inadequate preparation for potential side effects Barriers to contacting us with questions

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22 Have we done a sufficient evaluation of ourselves?

23 Preexposure Prophylaxis (PrEP)

24 PrEP Black MSM unaware of PrEP reported: Lower rates of HIV testing knowledge Fewer HIV testing experiences Higher rates of transactional sex Medical students PrEP assumptions and prescribing practices Black patients rated more likely than white patients to engage in condomless sex if prescribed PrEP Reduced willingness to prescribed PrEP to Black patients compared to white patients Eaton et al., 2016; Calabrese et al., 2014

25 PrEP why the slow uptake? Insufficient PrEP knowledge Competing needs among Black MSM Insufficient access to PrEP due to cost or provider-related issues Inaccurate HIV risk perceptions Community opposition to PrEP HIV, race, and MSM stigma Provider resistance and perceived incompetence with prescribing PrEP Inconsistent criteria for identifying at-risk PrEP candidates Lack of culturally tailored messaging on uptake and adherence to PrEP California HIV/AIDS Policy Research Centers, 2016

26 My week Patient at HIV clinic Working at Fulton County Jail Friends in need

27 Human aspect of sex Trauma informed care Racial, masculine, and sexual trauma Sex not as just potential for disease Love Pleasure Release Connectedness Healing Fund love

28 What can WE do better?

29 OUTSIDE THE ACADEMIC BUBBLE The Counter Narrative: Thrive: National Alliance of State and Territorial AIDS Directors (NASTAD): HIS HEALTH: WELL VERSED: Kaiser Family Foundation: #speakouthiv #askthehivdoc series

30 Summation HIV racial disparity persists among Black MSM Asset-based approaches needed Honest conversations/approaches about race and Black MSM Different approaches to sexual health through the whole person Behavioral research/interventions should accompany the biomedicalization of HIV prevention

31 THANK YOU!!!