Bias Is Everywhere: Uncovering HIV Prejudice to Improve Service Delivery

Part One of a Two-Part Conversation With Marsha Martin, D.S.W.

Contributing Editor
Marsha Martin, D.S.W.
Marsha Martin, D.S.W.
A.S. Martin

"All disparities in HIV are connected to the biases," proclaimed HIV public health veteran Marsha Martin, D.S.W., in a workshop at September's U.S. Conference on AIDS (USCA); "and we need to figure out how we are going to take them on."

Martin, coordinator of the Global Network of Black People Working in HIV and a former director of Washington, D.C.'s HIV/AIDS programs, is dedicated to a public health approach to the HIV epidemic response. However, she said, we won't get much further in that response if we don't start addressing the biases that act as barriers to effective HIV service delivery. And we cannot do that until we openly acknowledge that such biases exist.

In the USCA workshop, Martin began by encouraging pairs of participants, strangers and colleagues alike (this writer included), to share three cultural ideas they hold about themselves. I caught up with Martin after USCA to ask more about how these kinds of conversations can have an impact on how HIV professionals do their work. Read Part Two of this two-part conversation.

Olivia Ford: In your USCA session you made, and drew out of the crowd, some very compelling points about the nature of bias in the HIV community. Why is this an important conversation to begin to have with HIV providers?

Marsha Martin: To begin with, there is bias everywhere. There is explicit and implicit bias in HIV. The response to HIV has been heavily impacted by the experience of people who are living with HIV, working in HIV, and vulnerable to HIV.

Now, some people translate those biases into acts of discrimination, prejudice. Some people say stigma results from it. I don't go that far yet. Let's all recognize our own biases. Let's see a little bit how they come into play. Let's see what our own consciousness is around our own biases. Let's start there, before we say, "Somebody's done something to me," or, "Somebody's this and that," or, "They're not this and that," or, "This is wrong." Let's just work with ourselves.

I opened up that session with: Who am I? What do I bring? How do I know I bring it?

Related: How to Reverse Implicit Bias in HIV Care: 6 Steps to Take Today

That's important for us all to know. Then I ask people to share with each other. Because we walk in the room with it. I know I'm a black female. I walk into the room and I know that means something to me.

First, let's work on ourselves. And let's work on ourselves with colleagues. Let's spend some time knowing who we are. That was the first phase of that little exercise, which was really revealing. In it there's all kinds of implicit "I think I know who you are. We don't even have to talk about that. Because I see you. I know you." And I think, "Well, maybe you don't see me. Maybe you don't know me, or what I bring that's important to the work that I do."

People said, "Wow. I never thought about myself this way," or, "I work with this person all day long, and we never even talk like this."

So that's that first part. That first part is us.

OF: What do people's individual biases have to do with HIV testing, care, prevention, and epidemic control?

Marsha Martin: In HIV there is an anti-public health bias. That anti-public health bias is there because of two things, I believe. The first is that the level of rejection and discrimination that people who were living with HIV [experienced] in the early days, and continue to experience, has resulted in individuals not wanting to jeopardize people's freedom and people's rights. I totally understand that.

The days have changed, and we are more sensitive in public health. We've had anonymous testing; voluntary counseling and testing; changes to the testing apparatus. These improvements have been made because of the pushback against public health. That is a bias.

I go to the other side and say things are better now. We should test everybody. There shouldn't be anybody in our country that doesn't know they have HIV. If we have it, we have it; if we don't, we don't. But we should know about it. And then we should accordingly do something about it. That's just a public health perspective; it's also a bias. I know it's a bias. It's a professional identity, too. It's something I walk in the room with, and I can be aware of that.

And then, someone else can walk in the room and say, "But I'm a person living with HIV. Let me tell you what happened to me, and what that public health approach did to me." And I can say, "I'm sorry."

But if I don't know, and you and I spend all our time in a struggle, and you are resisting knowing your status or encouraging others to know theirs because of your bias, and I say "Everybody should know their status" because of my bias, then we're not going anywhere.

HIV is full of bias. I'm not saying it's good or bad. [But] if you look at our approach to how we do our HIV interventions, there are people left out; that's because the approach is biased. It's very, very, very male. It's very [geared for] males who have no children. I can just stay there, without talking about any of the other nuances, cultural realities, cultural contexts, and other complexities.

Let's just talk about it, then. Let's just say: Where are we biased in HIV? Let's have a conversation about it. You know some of my biases. What are some of your biases?

I also believe people living with HIV can play a dramatic role in helping to end the epidemic. I think they should be in the forefront. That's another bias I have. There are others who don't believe that.

There are people who believe that people living with HIV are the problem in the epidemic response. And that's a bias. Doesn't mean you don't like people living with HIV. Doesn't mean that you think they're a scourge, or vectors of disease. It's your implicit bias. And implicit biases sometimes become explicit. Especially if you run an agency. Especially if you are the program coordinator.

OF: It sounds like the goal is not to run an organization that is free of bias, so much, as to run an organization that is aware of what its biases are, and is aiming to do as little harm as possible with those biases.

MM: That's right. The approach should be harm reduction, and do no harm.

We want people to really start thinking about bias. We want people to look at, "How have I, then, contributed to people being on the outside? What has happened in my agency, in my organization, among my staff, that we are misfiring? We're missing opportunities to reach and serve the people we say we want to reach and serve."

That's where I think we are reaching a plateau in the HIV response. We've kind of maxed out. We've heard repeatedly in communities: "We're finding this many people testing positive, and it's been this way for about two years. We keep going and we're only finding five or six in this community, when we used to find 30." Well, then, maybe we need to change our approach. What about if we think about it a different way?

To think about it a different way, we've got to figure out what our biases are. What's keeping us from going into a different neighborhood, having different hours, or hours at night? What's keeping us from meeting with various constituents? Because we think they're not at risk, right? We've already decided we don't need to do that.

I don't know the answers. But I believe in public venue testing -- that's another bias I have -- because it helps to market and create an environment where HIV is everybody's business.

Other people's bias is: "It's only this neighborhood. It's only this group of people that behave in this fashion." I think that we have played that out.

Some people say, "It's not everybody's business. Don't waste your time on that." But if it's everybody's business, that means you have to be included in looking at your own behavior.

I can use myself to demonstrate what my bias is. I've got some biases that people might say are not so nice to talk about in public. I will talk about them in a staff meeting, if we're going to sit and have a conversation about what our biases are. I'd say, "If it impacts our clients and our services, then let's all work together and do something about it."

This transcript has been lightly edited for clarity.

Read Part Two of this two-part conversation.