New Provider Training Moves Black Gay and Bisexual Men, Transgender People to the Front
A Shared Responsibility
"We're talking about black gay men having experiences along the continuum of what black men experience," Malebranche said in the module on whole health assessments. "It's about living in predominantly black neighborhoods. There's a fallacy I see of the gay ghettos, but these may not be the areas where a lot of black MSM reside. Issues of unemployment, of community violence, of perhaps drug trafficking. ... It's important to recognize that the conditions that affect African-American and black people overall are also going to be affecting black MSM."
So, that means the care can't just be focused on sexual health.
Regular mental health screenings and talking to patients about their exercise and smoking routines, about their spiritual lives and community, are all important for building trust with black MSM before a provider starts asking them if they're a top or a bottom or how often they use condoms, said Moore in the module.
"We have to think about the [medical history] as a way to build rapport," he said. "I'm saying, let's not only focus on sexual health, because that's something that a lot of black gay men are frankly tired of hearing and tired of being talked to about solely."
Indeed, there needs to be an acknowledgement on the providers' part, Malebranche said in the module, of both the "trauma of being a black man in this country and the trauma of being a gay man or a man who has sex with men in this country."
And, he emphasized, it's not just the patient's job to bring up the issues. It's a shared responsibility.
"That individual that is coming into your office has a lot of baggage he's carrying with him, a lot of issues he may not disclose to you," Malebranche said in the module. "It's not just blaming the victim. It's not just, 'Oh, you're on your own, you just have to act right.' It's realizing the importance of our role."
Optimizing Care and Highlighting Successes
But how do you do that when you've got 15-minute appointments and when the literature is rich on barriers but sparse on solutions? His Health's creators thought about that, too, NASTAD's Omoighe said.
"We were thinking, 'Gosh, if we know that this is a patient community that researchers and a number of government agencies have said, there's a fire here, a huge epidemic here, why hasn't anyone created a resource of programs that have figured out what's working?'" she said. "For us, [designing this program] was a wild, wild west."
Since no one else had done it, His Health did. NASTAD assembled an advisory panel of 12 health policy experts -- many of them, including Malebranche and Moore, who are themselves black gay men -- and combed through 45 models of care that had shown success specifically with black MSM. They narrowed it to 12 programs and finally settled on four from different regions of the country to become models for each of the four continuing education courses.
The programs they ended up highlighting -- St. Jude Children's Research Hospital in Memphis for the HIV linkage and engagement to care program, Project Silk in Pittsburgh for transgender health care, Oakland's CRUSH Clinic for PrEP and Moore's LA County PrEP Centers of Excellence for black MSM whole health care -- include some that are well known and some that have been hiding in plain sight, Omoighe said.
"We scoured publications and online research," she said. "Some were tried and true, and some were more like, 'Why don't more people know about this?' The CRUSH Clinic is one of those. The fact that it sits in a hospital program is fantastic."
The idea now is to roll out the program to as many providers as possible, from front desk staff to medical directors, to help them scale up interventions that work and improve the health of those who need it most.
"It Wasn't That Bad"
In the last of the short modules that made up the whole-health assessment course, the viewer gets to see Andre one more time -- Andre, the same patient who was scared to tell his family doctor about his anal itching on the one hand, and scared of the assumed heterosexuality and sexual judgments of medical staff on the other.
In the final video, Andre shares that he went to see a provider who studied these modules and applied these lessons.
This time, instead of furrowing his brow, he smiled into the camera.
"It wasn't that bad. It ... wasn't that bad!" he said, burying his head in his hands and laughing.
"She didn't even flinch when I told her I barely use condoms. She just like ... she was cool. She was real cool. I told her about the [anal] itching, and she said, 'Let me look back there for you.' Now that, that was a first."
He said he told her about this new guy he's seeing, a relationship he said he could see turning into something.
"We are using condoms for now, and I do want to do this right," he said. "She said she's going to run some tests for me, and I hope it's nothing. I really do."
Then he paused and added, again, "The crazy part is that it wasn't so bad."
This is one of the possible benefits of overcoming implicit bias. As noted in the module by Quintin Robinson, M.D., of the AbsoluteCARE Medical Center in Atlanta, this approach "is making [Andre] a lot more comfortable engaging in the health care system."
Heather Boerner is a health care journalist based in San Francisco and author of Positively Negative: Love, Pregnancy and Science's Surprising Victory Over HIV.
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