The DMV (D.C., Maryland, Virginia), also known as the greater Washington Metropolitan area, is incredibly rich in culture, largely due to the influx of black and immigrant communities in the 20th century. This melting pot of language, beliefs, and culture is a big draw to the area, and as such, the DMV has had a notable rise in its population. Unfortunately, with the newcomers does not always come an influx of resources for those previously living in the area. Historic issues in access due to the impact of gentrification and displacement of locals has created an environment wherein those with the least are the last to receive health care. This disparity is directly reflected in who is newly diagnosed with HIV: specifically and disproportionately teenagers native to this area.
In Maryland, nearly three out of four new HIV diagnoses are among black youth, and 50% of positive youth don't know their status. In Washington, D.C., youth represent 41% of new diagnoses, the highest it's been in the past 10 years. Of all age groups, youth are the least likely to obtain viral suppression, yet most HIV programs aren't created with them in mind. Much of the epidemic facing youth in the DMV is caused by structural issues plaguing youth at a national level. Spaces for teenagers to talk freely about sex with without possible repercussions from a guardian are few and far between. Improving teenage sexual health requires us to examine parental consent laws, lack of access points to care, and teenage risk perception.
Guardianship and Consent Laws
Communities of color in the DMV are often plagued by a disproportionate amount of health disparities caused by lack of consistent health care coverage and quality. Guardianship restrictions and medical consent laws create an added layer of difficulty for young adults looking for care. If asked about it, most guardians would state that their teenager isn't at risk for HIV or any other sexually transmitted infection (STI), and directly telling one's parents, "Hey, I'm having unprotected sex, can you take me to get an HIV test?" doesn't always go too smoothly.
Most parents stay in the medical provider room during their child's visit, removing the space for teens to talk with their providers about their sexual health concerns. Having guardians assume their children are not at risk and therefore not in need of things like condoms, HIV/STI testing, and pre-exposure prophylaxis (PrEP) removes the room for teenagers to advocate for themselves. The assumption makes access to things like PrEP or insertive condoms harder, despite their proven effectiveness.
There can also be difficulties in communication between providers and patients' families; while this area is high in diversity, the providers available don't mirror the diversity of the people they are treating. Language and cultural barriers result in the patient, the teen, being put into the role of passing information between the provider and the parent. This can make communicating one's own needs hard, especially when policy surrounding parental consent changes.
This happened earlier this year in Maryland, when PrEP consent laws were changed, allowing minors to request the prescription without needing to obtain parental consent. While this is a huge stride toward improving access, not all medical providers in Maryland are aware of the change, and many aren't sure of how to relay these changes to the patients or families they are already struggling to communicate with.
Lack of Access Points
There's a joke in this area that the DMV stretches as far as the Metro system reaches. Unfortunately for most of Maryland, Virginia, and even parts of D.C., this doesn't include a solid portion of this region. Public transportation is how most teens in this area get around. Those in sections far from a Metro or bus stop are limited to the health resources within walking distance, which are scarce, if present at all. Limits and inconsistencies in public transit are especially rough for more suburban and rural parts of the DMV, such as sections of Montgomery and Prince George's County. These counties have some of the highest prevalence of HIV among teens in Maryland. It's also where the only options for free, confidential HIV testing for teens are the county health departments, both of which are closed on the weekends and stop testing by 3 p.m. on most weekdays.
Considering most teens are in school between the hours of 7:30 a.m. and 3 p.m., using these resources often isn't possible. What's further frustrating about this is that the DMV has a huge public health network. Major public health institutions, such as George Washington University School of Medicine, Johns Hopkins University, Georgetown University Medical Center, and University of Maryland Medical Center, are aware of the problem and attempting to create programming for teens, though prevalence rates aren't changing. "Instead of changing the model, things continue to be funded the exact same way," commented Jasmine Pope, HIV Prevention Program manager for Star Track, an adolescent clinic operating out of University of Maryland Medical Center. "The approach has to be centered in a way that works for the kids."
Risk Perception and Communication
Many of the programs being created continue to fall short because they aren't being created with the teenage perspective in mind. "The hierarchy of the importance of health care is different for the young adult population," Pope says. James Burrell Jr., a PrEP navigator at Baltimore's Chase Brexton Health Care, echoed these sentiments. "Teens often make jokes and ridicule things they don't understand, which in turn may make someone who is seeking information second-guess themselves during that quest." It doesn't help that school-based education is highly varied when it comes to discussing HIV and sexual health, especially in some of the more rural and underfunded areas of the DMV.
This lack of open discussion is also reflected in how providers think of teenage patients. Some providers assume that it isn't worth it to have the conversation about PrEP with teenage patients, due to issues with medication adherence. "That [provider] bias creates disproportionate rates in who's taking PrEP, who's accessing PEP [post-exposure prophylaxis]. Providers assume, 'You're under 18, there's no way you're gonna take an HIV medication everyday,'" Pope states. This results in a missed prevention opportunity, and sometimes seroconversion. These factors are particularly detrimental to homeless youth in the D.C.-Maryland area. "Youth experiencing homelessness are constantly weighing their likelihood of survival. When none of your basic needs are met, you haven't eaten in days, have no safe place to sleep at night, it's incredibly challenging to prioritize health care," according to Gray Hargrove, a coordinator at the Youth Empowered Society, a center for those 14 to 25 experiencing homelessness in Baltimore city.
Alleviating the Gap
Though there are numerous structural barriers to care, organizations at the local level are trying to alleviate the gap. One Tent Health is a student-run organization that offers HIV testing and sexual health education, along with PrEP linkage referrals in various neighborhoods in D.C. Other groups, like Star Track, offer Chill Sessions, support groups where teens can come and openly talk about their sexual experiences and concerns. They're held in the same space as the clinic, which helps make receiving clinical care a seamless process. Pope states, "We make sure we're talking to folks that are going to be receiving these interventions about what it is they need. That's the only way to do it that will really make a lasting effect in the community." These sessions work similarly to D.C. Health's Sex Is… campaign, an online platform that spreads sex positivity and tackles stigma surrounding sexual health education. They intentionally work with D.C. high school students, teachers, and community organizations to give out condoms and start conversations about safe and healthy sexual relations. The D.C. Department of Health has additionally partnered with D.C. public schools to provide HIV testing and PrEP connection.
We need to be more comfortable talking to kids about the sex they are already having. So much of the culture and innovative nature of the DMV stems from the youth, and they have a right to be given health care services. While these structural barriers to care can seem overwhelming, there are small things we can all do to support the youth in our lives. Talk to teenagers about their sexual health. Respect their autonomy in medical visits and give them space to confidentially express their concerns and needs. Open communication surrounding sex, acknowledging where our health care system falls short, and supporting present teen-focused health care programming is essential to better serving those in the DMV and nationwide.