For years, researchers have been trying to figure out why gay and bisexual (men who have sex with men, or MSM) black men have such high rates of HIV -- so high, in fact, that today in some parts of the U.S., a black MSM has as much as a 50-50 chance of acquiring the virus in his lifetime.
Researchers have asked in study after study what black MSM do differently: Do they have more partners than other groups of MSM? Are they just having sex more often, but not with more partners? Maybe they use condoms less. Maybe stigma about their sexuality means they don't go to the doctor as much.
But, as it turns out, research doesn't bear out any of those theories.
Instead, what's emerging is another picture based on social and structural factors. And among factors such as social mixing patterns, income inequality and access to health insurance and providers, one particular barrier might surprise to medical professionals: black MSM's health care providers themselves.
Old Stories Color Clinical Judgment
"There are so many studies labeled 'hard to reach' -- that's code for black and Latino MSM," Leo Moore, M.D., M.S.H.P.M., associate medical director at the Los Angeles Department of Public Health, told TheBodyPRO. "So, the question becomes, are they hard to reach because we don't have the right people at the table? Are they hard to reach because we haven't found a way to identify with them?"
The problem, Moore said, is that if the right people aren't at the table, there can be a gulf between patient and provider that leaves room for old stories and beliefs about black men and MSM to color clinical judgment.
To tackle the problem, the National Association of State and Territorial AIDS Directors (NASTAD) partnered with health care groups such as the HIV Medical Association (HIVMA) and the Association of Nurses in AIDS Care (ANAC) to help providers become the right people for their patients.
Called His Health, the free online tool is the answer to one central challenge: educating providers so that when they are confronted with a situation with which they are unpracticed, they can draw on real facts and put their patients' needs first.
The training is now accredited and available online. It satisfies continuing education credits for health care providers that are good through 2019.
"How great is it," said Omoro Omoighe, NASTAD's associate director of health equity and health care access, "to have a training resource for health care providers that satisfies a requirement of their profession to maintain their license while offering the latest cutting-edge information on clinical courses of care. And we're doing all of that in a framework of social justice."
Implicit Bias in Health Care
The problem, said Omoighe, isn't that providers intend to provide inappropriate care for young black MSM. It's implicit bias -- that is, the misconceptions about race, gender and sexuality we all have and must unlearn as we grow. The problem for providers who want to better serve black MSM is that they don't know what they don't know and so may be operating from old beliefs without knowing it.
Whether they know it or not, that implicit bias in medicine can literally hurt patients. Take the study published earlier this year in the Proceedings of the National Academy of Sciences. It found that medical students and residents believed outlandish ideas about African-American pain tolerance -- and they used these beliefs to justify lower painkiller prescription rates among black patients.
The same bias applies around HIV. In 2001, a survey of providers asked if they would start patients on antiretroviral treatment, based on a number of demographic and behavioral factors. It found that physicians assumed that black men would be less likely to adhere to treatment, and were therefore less likely to begin them on treatment. Since then, more data has come out on the topic.
And it's not just among African Americans. Implicit bias can impact care for everyone. And it's not just among African Americans. Implicit bias can impact care for everyone. A study presented at the HIV Research for Prevention conference: in October found that when providers were confronted with a theoretical patient who reported he planned to stop using condoms after being prescribed pre-exposure prophylaxis (PrEP), they were less likely to prescribe it to him -- even though people like him are exactly the ones who are at highest risk for HIV. Likewise, studies have found that providers have been less willing to provide PrEP to people who inject drugs or to women, based on beliefs about HIV, risk and responsibility that don't match up with the literature. Implicit beliefs about promiscuity among Black MSM or MSM in general can also influence providers' behaviors with their patients, said Moore.
"We don't have control over how we got here, but we have to address those biases," Omoighe adds. "It's hard but necessary work."
Educating Providers, Not Patients
Each His Health module begins with a young African American man talking into the camera as if he were recording a personal diary to be uploaded to YouTube or some other social network. In it, he talks about his health, sure. But he also talks about the other things happening in his life.
In one module, a character named Andre talks about Hank "hitting it" with him sexually, and then acting like he didn't know him. He talks about his fear of being shot by a cop when driving across town and the anxiety that seeing Confederate flags on big trucks creates.
And then there's the issue of the anal itching he's been having for three weeks.
He doesn't want to go to the sexual health clinic, and he certainly wasn't going to tell his family doctor, who sings in the church choir with his mom, about Hank or anything else. He could drive across town to another clinic, but what if the receptionist gives him that look he's seen before -- that look that says, "Oh, all you doing is getting high and sleeping with everybody." What if, as has happened before, the doctor starts by asking about his girlfriends?
"A lot of times we think, 'Hey, you're a black man,' or, 'Hey, you're a gay man.' [We] don't really think that you're black and gay," David Malebranche, M.D., M.P.H., an internal medicine doctor at the Cobb County Adult Detention Center in Georgia, said in one module.
"As a provider, it's up to us to make sure we're addressing both these issues, both family histories, both sexual histories, both clinical contexts, and saying, you know, what is this whole person coming in front of me? And how can I, as a provider, actually help facilitate and empower their care?"
And, that's exactly what the modules aim to do. In the four courses -- on whole health assessments, PrEP, linkage and engagement to care, and transgender health -- experts on black MSM and transgender health walk providers through clinical guidelines for the practices.
Providers get a sense of how to approach a black MSM or transgender person about sexual health (hint: It's not by immediately asking how often the patient has anal sex), what vaccines to suggest to a sexually active black gay man and what the science really does say about why HIV rates are so high among young black MSM.
But, beyond that, providers are asked to think about the context of the lives of the young black MSM who walk into their clinics.
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."