Mathew Rodriguez

Associate Editor

A transgender person sitting in a hospital gown sitting in an exam room

"Providers need to not make assumptions about what black and brown and, more generally, trans patients of color need," one study co-author said.

Transgender People of Color Often Face Choice Between Racist and Transphobic Health Care Providers

Sony Salzman

nurse preparing vaccine

A chlamydia infection makes HIV acquisition more likely.

The First In-Human Chlamydia Vaccine Trial Shows Positive Immune Response

Barbara Jungwirth

young woman taking blue pill

Four recent studies in JAIDS chiefly focused on PrEP provision to cisgender women and gay and bisexual men.

Four PrEP Studies Address Challenges and Best Practices for Uptake and Retention

Hand holding syringe in backlight

The ECHO trial faces backlash and criticism.

Controversy Erupts Around Study on Contraception and HIV Risk

Kenyon Farrow

Senior Editor

Smiling man holding a banner reading "I AIN'T SORRY" during Stockholm Pride Parade

Racial segregation and medical mistrust in Milwaukee may keep pre-exposure prophylaxis out of their hands.

Racism and Homophobia in Health Care Settings May Reduce PrEP Uptake for Young Black Gay and Bisexual Men, Study Finds

Demetre Daskalakis credit Estelle Yu of NYC DOHMH

On-demand pre-exposure prophylaxis may be best for people with episodic risk who cannot or would prefer not to take the pill every day.

In New York City, PrEP on Demand Is Now on the Menu for Men Who Have Sex With Men

cotton swabs

Could home-based self-swabs and mobile technology be helpful tools in the future of HIV prevention?

Can Self-Swabs Make HIV Exposure and Risk Reporting More Accurate?

Hand of doctor holding syringe and medicine bottle. Preparing for injection

No meaningful difference was found in either injectable or implant birth control when compared to an IUD.

Hormonal Contraception Does Not Increase HIV Risk, Study Finds

Stephen Hicks

Doctor preparing African American patient for blood test

Black men who have sex with men test in high numbers over a lifetime, but not frequently or recently.

HIV Testing Among Black Gay and Bisexual Men Remains 'Suboptimal,' Study Finds

Person picking up prescription from pharmacy

The US Preventive Services Task Force released its final ruling in *JAMA*.

Government Panel Finds PrEP Is Effective, Must Be Available Free of Cost to Patients

*When people are looking for pre-exposure prophylaxis (PrEP) resources, they probably want to speak to someone in real time, not make a clinic appointment. Shannon Weber, M.S.W., may have a solution: [PleasePrEPMe](https://pleaseprepme.org/), an online chat service and provider search.*

*Weber, the director of the sexual health resource [HIVE](https://hiveonline.org/){target=_blank} at the University of California-San Francisco, gave a presentation on PleasePrEPMe at the National HIV Prevention Conference in mid-March in Atlanta.*

*Her poster was called, "PrEP and PrEP Access is Challenging: Changing the Paradigm with Online Navigation Services." Terri Wilder, M.S.W., interviewed Weber about this innovative new prevention awareness tool.*

__Terri Wilder:__ Tell us about your poster, and tell us about what's happening. I know you always have lots of exciting things going on with your work.

__Shannon Weber:__ The background is that we launched PleasePrEPMe in 2015 as the California PrEP provider directory. And it was searchable and location-responsive. We then worked with PrEP Locator to help build the national directory, and got our website also to have the national directory, and then built out resources for each of the 50 states.

And then from that, the question was: OK, now that we have all these amazing resources, are there people online who are not already connected with services who could use services, but they need help navigating this?

And so we've created this chat program. So you can come on PleasePrEPMe.org and chat with a trained navigator in English and Spanish. And we launched this with funds from California Department of Health, so it's California-specific, although we're getting ready to expand to Arizona.

__TW:__ When you say that folks can go to this website and chat, who did you hire to chat? Are these folks who are on PrEP? Are they just folks that are really savvy, excited, activist kind of folks?

__SW:__ We have the most amazing human on the planet personing our chat, and that is Charlie Romero. So, Charlie, they were one of the first PrEP navigators in California and came to us from Children's Hospital LA, an absolutely extraordinary human who has this profound ability to approach any chat with a lack of judgment and warm regard. You might question, "How do you do that in chat?"

But that's one of the things I'm so proud that we've been able to do. We've developed this sexual health coaching model, which we share on our poster here. And these are our values. How do we bring our values that we live in our life, or we might have in our workplace? How do we bring this to this online chat experience, so that someone who is not already connected with care can feel this human connection and develop trust and rapport, and that might help bridge them from the question that they have to a clinic where they can get the help that they need?

__TW:__ Can you talk a little bit about the core values around your work?

__SW:__ We are very sex positive. We believe sex is part of how we engage with each other, and how we express ourselves. And so we delight in whatever your desire is around sex. We are problem solvers. So, we don't already know the answer. We've got built out in our chat platform over 100 shortcuts that help us quickly answer people's questions. But if we don't know the answer, we love going after it and figuring it out. So, please come ask us hard questions.

We have a huge commitment to using really clear and truthful language. And this became so apparent when you're in that online space, and words -- those letters you type, the spaces between them, the words you write -- that's all you have to communicate, in a sense, who we are and how we want to connect with folks. 

And so we've spent a lot of time in our shortcuts, and also analyzing our chats, really asking ourselves, "Are we using very clear and truthful language?" 

We always engage with warm regard. We take a person-centered approach and follow the person's lead. We always rely on data and clinical best practices, though, and then have figured out ways to share information. When someone has a belief or assumption that doesn't line up with the facts or data, you know, finding ways with warm regard to engage and help share that information with them.

We meet people where they are on their journey. So people can come to us with questions. I think sometimes in the beginning we were like, "Oh, my gosh. We're going to get pills in hands." And, you know, people come on and ask questions. And maybe they're not there yet. And so, what is it like for us to leave aside our attachment to the outcome, and just be with you where you are on your journey?

And then we always are staying curious. One of the amazing experiences about doing chat is you can maybe guess where someone is coming from by where the link tells you they showed up, or the ad that was run. But the reality is, you don't see the person, and you don't know who they are. And it's a beautiful practice and experiment, just [being] profoundly curious about who's on the other side of that chat. And how are you going to engage with them in a way that they will want to stay connected and get the help that they came looking for?

__TW:__ You have an actual kind of condensed example -- an example of an actual chats load that covers a lot of topics. Can you just kind of share with us this example of a chat? 

__SW:__ We had really built out well the PrEP piece. And then we were like, well, if we are really going to meet people where they're at, it can't be just PrEP. It has to be PEP; it has to be U=U [undetectable equals untransmittable], also. And we're building up better language around condoms and STDs [sexually transmitted diseases] and, you know, all the things.

So this is a chat that's about U=U. And the person comes in asking a question to get clarity about what U=U means. So our navigator shares the science behind it. And then the person asking for help asks, "Well, why might you need PrEP?"

So then our navigator helps to talk about individual choice and then reiterates that U=U works alone; PrEP works alone; but they can be combined, depending on your situation. And then talks about [how] different prevention methods can work well with different partners or different partnerships.

There is also a discussion of provider bias and misconceptions about U=U, which is a huge challenge for folks. So they might come on PleasePrEPMe and get educated about U=U. But taking that back to their provider is another thing -- an emotional discussion talking with the person about learning that their partner has HIV. And the person chatting with us has a lot of concerns about their partner living with HIV and the side effects of their medication, which -- we talk about that. We talk a lot about stigma. 

And then it really ends in this beautiful way, where the person who came on to chat had this real affirmation that they can fight the ignorance and stigma that's in their family and their community with the information that they receive from chatting with the navigator.

__TW:__ That's great. How many visitors have you had since you guys launched?

__SW:__ We've had over 2,000 chats at this point.

__TW:__ Great. And you're just for the folks in California. But you mentioned that other jurisdictions had reached out because they're interested in what you guys have created.

__SW:__ Yeah. We have a contract with the State of Arizona, so we're expanding to Arizona next. And we're super interested in talking with other jurisdictions about offering this chat service to them. We can land our chat widget on other people's websites. 

And I would say another thing that's coming next that we're going to be playing with is: Are there ways that we can automate a chatbot, so to speak? After taking 2,000 chats, we see some themes. And so there's some frequently asked questions, and frequent ways people ask those questions. So we're going to look at, can we automate some of the responses, so even when we're not there, live, 9 to 5, folks overnight could get some of their chats answered?

That's another way that we can decrease the cost and increase the access to information for people in other jurisdictions, as well.

__TW:__ So what are the hours of operation to chat?

__SW:__ We're 9 to 5, Monday through Friday. We've played with being open other hours, although visitors to the website can be very dependent on when you run ads. Like, we had a special campaign with Squirt [a hookup app]. So we worked on Saturday because that's, they said, the best time for their DMs [direct messages] to go out. So we're happy to do that as well. But generally that 9 to 5 has been what's worked.

__TW:__ Do you have any demographics of your chatters?

__SW:__ In the beginning, we had this whole survey. We were asking people, because we wanted to collect these demographics. Because we just really, really wanted to be able to show that we were able to serve people who were not already connected in care, and really impacting some of the disparities in the epidemic.

Well, people who come on chat want to chat anonymously. So they were not so pleased with all the questions that we had; feeling like they were being in a research study and whatnot. And so, because we do take that user-centered approach, we said, "Oh, yes. That doesn't feel very good, does it, when you come to ask me a question and I turn around and ask you 10?"

So we've had to dial quite a bit of that back. We do a follow-up survey and ask folks for some demographics. So we don't have the kind of demographics that we would like, with regard to race, ethnicity, age, for example -- gender, sexual orientation, or gender identity. We do have quite a bit of data about geographically where people are coming from. And that can be super helpful for targeting. If you have outbreaks in certain areas, or you have areas in which you haven't seen PrEP uptake that you need, you can target ads there, and then we can track and see if we get chats from those areas.

__TW:__ Great. And if folks were interested in getting more information, how would they get more information?

__SW:__ [Email me or call me](https://hiveonline.org/about/).


Terri Wilder, M.S.W.

PleasePrEPMe screenshot: St. Louis provider search

A team led by Shannon Weber, M.S.W., has developed PleasePrEPMe, an online PrEP provider search and chat service.

New Website Helps People Trying to Navigate Their PrEP Options

HIV Prevention

illustration of mixed-status couples from 'PrEP and HIV Prevention: A Quick Primer on a Hot Topic'

News, analysis, research, and key information for health care providers on HIV epidemiology, testing, and transmission.

Spotlight Center: HIV Prevention Today

  
After years of programs focusing on prevention for positives, we've learned that treatment is in fact the best prevention option for people who are HIV positive. In fact, treatment works so well that people who successfully achieve viral suppression are not at risk of passing the virus on to their partners, even without using condoms or other barrier methods.

While over the last decade the science was quickly mounting evidence that this was true, it took a push from people living with HIV to begin making public health and medicine shift clinical guidelines, policies, and program priorities to address this reality. Due to [community pressure and activism](https://www.preventionaccess.org/undetectable), the language that physicians, scientists, and public health bodies use to describe the potential for HIV transmission when a person has an undetectable viral load is now much clearer.

The slogan "Undetectable = Untransmittable" (U=U) is simple and easy to grasp. Moreover, as Anthony S. Fauci, M.D., the director of the National Institute of Allergy and Infectious Diseases (NIAID), has said, "[The science really does verify and validate U=U](https://www.youtube.com/watch?v=LffrIfipgwc&feature=youtu.be)."

U=U expresses the fact that people living with HIV who take antiretroviral medications daily as prescribed and who maintain a durable undetectable viral load do not transmit HIV to their sexual partners. When a person has had an undetectable viral load for at least six months and maintains good adherence, there is effectively no risk that he or she will sexually transmit the virus.

  

Talking About U=U
-----------------

Language matters. When speaking with people living with HIV, their sexual partners, and the wider community, it is important to describe these facts in a way that inspires confidence and does not promote unnecessary doubts or fear.

For example, it is scientifically accurate to say that the risk of transmission in these circumstances is "negligible." However, this can sometimes be misinterpreted to suggest that a risk still needs to be taken into account or remains of practical significance.

It is preferable to use terminology that is less likely to be misunderstood. For example the Centers for Disease Control and Prevention (CDC) [uses the phrase](https://www.cdc.gov/hiv/library/dcl/dcl/092717.html) "effectively no risk" and states that effective antiretroviral therapy "prevents sexual HIV transmission." Others say that those with a durable undetectable viral load "do not transmit," "cannot transmit," or "will not transmit" HIV.

  

The Science Behind U=U
----------------------

Data showing the relationship between an HIV-positive person's viral load and their HIV-negative partner's risk of acquiring HIV have been available for almost two decades. [A key study, from a Ugandan cohort](http://www.nejm.org/doi/full/10.1056/NEJM200003303421303), was published in the _New England Journal of Medicine_ in 2000.

However, the key evidence supporting U=U comes from three international research studies published since 2011. Each one recruited couples in which one partner was living with HIV and the other was not. Between them, [HPTN 052](/article/hptn-052-no-partner-infections-with-viral-suppress), [PARTNER](/article/zero-no-linked-hiv-transmissions-in-partner-study-), and [Opposites Attract](/article/no-hiv-transmissions-between-gay-couples-when-vira) recruited over 3,000 couples. During the latter two studies, couples reported engaging in more than 74,000 episodes of condomless vaginal or anal intercourse.

Between these three studies, not a single HIV transmission was observed from an HIV-positive partner who had a durable undetectable viral load to an HIV-negative partner.

Although it had been hypothesized that transmission would be more likely during anal sex than vaginal sex, or if one of the partners had a sexually transmitted infection, in fact, the number of linked HIV transmissions was zero in each of these circumstances.

Some HIV transmissions did, however, occur in the first few months of a person taking antiretroviral therapy in the HPTN 052 study, before his or her viral load was durably suppressed. Individuals can, therefore, be advised to use other prevention methods if their viral load has not been undetectable for at least six months. A number of HIV-negative study participants also acquired HIV from outside their main relationships, with viral strains that were different from those of their primary partners. People who are in a relationship with a person living with undetectable HIV may need counseling on prevention with other sexual partners.

Have a look at "Key U=U Studies," below, to find out more about these studies.

It is notable that since the data from HPTN 052, PARTNER, and Opposites Attract have been released, there have been no case reports of HIV transmission from a person with HIV who had an undetectable viral load. Given the high level of public and scientific interest in this topic, it might be expected than any suspected cases would be investigated and published.

Summing up, there isn't any evidence that sexual HIV transmission occurs when a person's viral load is durably undetectable.

  

Factsheets and Overviews
------------------------

[**HIV Undetectable = Untransmittable (U=U): Information for Providers**](/content/80817/hiv-undetectable--untransmittable-uu-information-f.html) (February 12, 2018)  
_From the New York City Department of Health and Mental Hygiene_  
Provides key facts about U=U and suggestions for counseling patients.

[**The Evidence for U=U: Why Negligible Risk Is Zero Risk**](/content/80301/the-evidence-for-uu-why-negligible-risk-is-zero-ri.html) (August 10, 2017)  
_In_ HIV Treatment Bulletin_, from HIV i-Base_  
While the dramatic impact of antiretroviral treatment (ART) on reducing HIV transmission has been known for a long time, it is new to say that ART stops transmission completely. This article provides a thorough review of key studies from the past 20 years.

  

News & Opinion
--------------

[**Pregnancy and Infant Feeding: Can We Say U=U About the Risk of Passing HIV to an Infant?**](/content/80820/pregnancy-and-infant-feeding-can-we-say-uu-about-t.html) (February 14, 2018)  
_In_ Prevention in Focus: Spotlight on Programming and Research_, from Canadian AIDS Treatment Information Exchange_  
Can an undetectable viral load eliminate the risk of passing HIV to an infant? This article examines what we know about the risk of passing HIV through pregnancy, childbirth, and infant feeding.

[**What Should We Do About Persistent Low-Level Viremia?**](/content/80505/what-should-we-do-about-persistent-low-level-virem.html) (October 10, 2017)  
_From Journal Watch_  
Paul E. Sax, M.D., answers a question about a patient with a persistently low viral load, of around 70-100 copies/mL. Does "undetectable = uninfectious" still count?

[**CDC Corrects Misleading HIV Conception Guidance, Responding to Community Pressure**](/content/80323/cdc-corrects-misleading-hiv-conception-guidance-re.html) (August 17, 2017)  
_From TheBodyPRO_  
The CDC is finally up-to-date with its HIV-affected conception guidance. It now quotes data from HIV trials showing that treatment alone can prevent HIV transmission when couples with mixed HIV status desire to have a baby.

[**Swaziland Dramatically Reduces HIV Incidence Through Test-and-Treat Programs**](/content/80232/swaziland-dramatically-reduces-hiv-incidence-throu.html) (August 1, 2017)  
_From TheBodyPRO_  
The Kingdom of Swaziland has dramatically reduced the number of new HIV infections thanks to a massively expanded testing-and-treatment program, as reported at the 9th International AIDS Society Conference on HIV Science (IAS 2017).

[**Viral Loads Becoming Undetectable in More People Across the United States**](/content/79873/viral-loads-becoming-undetectable-in-more-people-a.html) (May 4, 2017)  
_From the Center for AIDS Information & Advocacy_  
Among HIV-positive people in care in the U.S., the proportion reaching an undetectable viral load rose steadily from 2009 through 2013. Women, blacks, Latinx, and younger people were less likely to have an undetectable viral load.

[**HIV Researchers Reassert Treatment Is Prevention**](/content/79495/hiv-researchers-reassert-treatment-is-prevention.html) (March 8, 2017)  
_From TheBodyPRO_  
In an interview at the 24th Conference on Retroviruses and Opportunistic Infections, (CROI 2017), Fred Schaich spoke with Deborah Donnell and Matthew Golden about how getting people onto HIV treatment also prevents the spread of the virus.

[**HIV Undetectable Does Equal Uninfectious: The Swiss Statement and the Vindication of Pietro Vernazza**](/content/78550/hiv-undetectable-does-equal-uninfectious-the-swiss.html) (October 7, 2016)  
_From TheBody_  
In 2008, the "Swiss Statement" clearly stated that people with an undetectable viral load cannot pass on HIV. This is the story of how the Swiss Statement went from policy pariah to documented fact.

[**The Undetectable Problem: Dating, Sex, and Criminalization (Part 2)**](/content/78494/the-undetectable-problem-dating-sex-and-criminaliz.html) (September 30, 2016)  
_From TheBodyPRO_  
Expressing the author's concern that with increased focus on getting everyone seropositive to undetectable, we are creating a larger divide between people with access to care and bodily stability and those without.

[**Treatment as Prevention Could Nearly Eliminate HIV in MSM, Danish Study Predicts**](/content/78393/treatment-as-prevention-could-nearly-eliminate-hiv.html) (September 16, 2016)  
_From TheBodyPRO_  
Antiretroviral treatment as prevention in Denmark could nearly eliminate the HIV epidemic among men who have sex with men, according to predictions of a Bayesian back-calculation model.

[**HIV Transmission Risk Remains During First 6 Months of Treatment**](/content/75595/hiv-transmission-risk-remains-during-first-6-month.html) (March 12, 2015)  
_From TheBodyPRO_  
A study from Uganda shows that in the first six months of antiretroviral therapy, a residual risk of sexual transmission exists of about 2% per year.

[**Minimal Risk of Sexual HIV Transmission for Heterosexual Couples When the HIV-Positive Partner Has an Undetectable Viral Load**](/content/70469/minimal-risk-of-sexual-hiv-transmission-for-hetero.html) (January/February 2013)  
_In_ HIV Treatment Bulletin_, from HIV i-Base_  
A systematic review of publications reporting on rates of HIV transmission between heterosexual couples where the HIV-positive partner has an undetectable viral load on ART revealed minimum risk of transmission.

  

Key U=U Studies
---------------

[**No HIV Transmissions in Couples With Positive Partner Undetectable on Treatment**](/content/78862/no-hiv-transmissions-in-couples-with-positive-part.html) (November 23, 2016)  
_From TheBodyPRO_  
Results from the PARTNER study, as reported in _JAMA_.

[**Negligible Risk: Updated Results From Two Studies Continue to Show That Antiretroviral Treatment and an Undetectable Viral Load Is a Highly Effective HIV Prevention Strategy**](/content/78315/negligible-risk-updated-results-from-two-studies-c.html) (September 6, 2016)  
_In_ CATIE News_, from Canadian AIDS Treatment Information Exchange_  
Final results from HPTN 052, as reported in the _New England Journal of Medicine_, and results from the PARTNER study, as reported in _JAMA_.

[**Early HIV Treatment Lowers Transmission Risk by Up to 93%: HPTN 052 Final Results**](/content/78131/early-hiv-treatment-lowers-transmission-risk-by-up.html) (August 10, 2016)  
_From TheBodyPRO_  
Final results from HPTN 052, as reported at the 21st International AIDS Conference (AIDS 2016).

[**Zero: No Linked HIV Transmissions in PARTNER Study After Couples Had Sex 58,000 Times Without Condoms**](/content/77903/zero-no-linked-hiv-transmissions-in-partner-study-.html) (July 12, 2016)  
_From HIV i-Base_  
Results from the PARTNER study, as reported in _JAMA_.

[**HPTN 052: No HIV Transmissions on Effective Antiretroviral Therapy but Only Limited Data on Viral Failure and Drug Resistance**](/content/76263/hptn-052-no-hiv-transmissions-on-effective-antiret.html) (August 1, 2015)  
_In_ HIV Treatment Bulletin_, from HIV i-Base_  
Results from HPTN 052, as reported at IAS 2015.

[**HPTN 052: No Partner Infections With Viral Suppression**](/content/76169/hptn-052-no-partner-infections-with-viral-suppress.html) (July 21, 2015)  
_From_ BETA  
Results from HPTN 052, as reported at IAS 2015.

[**No HIV Transmissions Between Gay Couples When Viral Load Is Undetectable: Preliminary Results**](/content/75652/no-hiv-transmissions-between-gay-couples-when-vira.html) (March 24, 2015)  
_In_ HIV Treatment Bulletin_, from HIV i-Base_  
Interim results from [Opposites Attract](http://www.aidsmap.com/International-study-of-gay-couples-reports-no-transmissions-from-an-HIV-positive-partner-on-treatment/page/3159177/), as reported at CROI 2015.

[**Real-World Antiretroviral Therapy as Prevention: A Top HIV Clinical Development of 2014**](/content/75285/real-world-antiretroviral-therapy-as-prevention-a-.html) (December 15, 2014)  
_From TheBodyPRO_  
Results from the PARTNER study, as reported at CROI 2014.

[**Insight Into HIV Transmission Risk When the Viral Load Is Undetectable and No Condom Is Used**](/content/74305/insight-into-hiv-transmission-risk-when-the-viral-.html) (April 10, 2014)  
_In_ CATIE News_, from Canadian AIDS Treatment Information Exchange_  
Results from the PARTNER study, as reported at CROI 2014.

[**Zero HIV Infections Seen Through Condomless Sex When HIV-Positive Partner Is on Effective Treatment**](/content/73978/zero-hiv-infections-seen-through-condomless-sex-wh.html) (March 4, 2014)  
_From TheBodyPRO_  
Results from the PARTNER study, as reported at CROI 2014.

[**Early Treatment Reduces HIV Transmission in Heterosexual Serodiscordant Couples**](/content/68659/early-treatment-reduces-hiv-transmission-in-hetero.html) (Fall 2011)  
_In_ Prevention in Focus: Spotlight on Programming and Research_, from Canadian AIDS Treatment Information Exchange_  
Results from HPTN 052, as reported at IAS 2011.

[**Treatment Is Prevention: ARV Treatment in HPTN-052 Reduces Transmission by at Least 96%: Single Transmission in Treatment Arm Occurred Prior to Viral Suppression**](/content/63683/treatment-is-prevention-arv-treatment-in-hptn-052-.html) (July/August 2011)  
_In_ HIV Treatment Bulletin_, from HIV i-Base_  
Results from HPTN 052, as reported at IAS 2011.

Roger Pebody

U=U t-shirt

Featured image for U=U: What HIV Providers Should Know

Due to community pressure and activism, the language that physicians, scientists, and public health bodies use to describe the potential for HIV transmission when a person has an undetectable viral load is now much clearer....

Due to community pressure and activism, the language that physicians, scientists, and public health bodies use to describe the potential for HIV transmission when a person has an undetectable viral load is now much clearer.

U=U: What HIV Providers Should Know

This assessment tool, created primarily for HIV medication prescribers and health care providers in the United States, will help you determine whether HIV pre-exposure prophylaxis (PrEP) is an optimal fit for your patients or clients. 

This tool is free of advertiser influence; it was produced by the editorial team of TheBodyPRO and is periodically reviewed by a rotating panel of respected HIV care providers and community advocates. The tool was last updated in March 2018.

physician discussing/consulting with patient 300x300

Is PrEP -- the HIV prevention pill -- a good fit for your patient or client? Take the assessment.

Is HIV PrEP Right for Your Patient or Client?

Have you taken both a sexual history and a drug use history from your patient?

In the past six months, with how many different people has your patient engaged in receptive or insertive intercourse?

In the past six months, has your patient consistently used condoms when engaging in receptive or insertive intercourse?

In the past six months, has your patient had condomless, receptive or insertive intercourse with a person whose HIV status is 1) unknown with certainty or 2) known to be HIV positive with a detectable viral load?

In the past six months, has your patient been diagnosed with a bacterial sexually transmitted infection (such as chlamydia, syphilis or gonorrhea)?

In the past six months, has your patient exchanged insertive or receptive intercourse for money, food, shelter, alcohol or drugs?

Has your patient used methamphetamines during receptive or insertive intercourse at any time within the past six months?

In the past six months, has your patient injected drugs using needles, syringes, or other drug preparation equipment that have already been used by another person?

In the past six months, has your patient injected 1) illegal drugs or 2) prescription medications for nonmedical reasons, despite recently taking part in a methadone or other medication-based drug treatment program?

Has your patient tested HIV negative in the past week?

Within the past four weeks, has your patient exhibited any possible signs or symptoms of acute (primary) HIV infection?

Has your patient recently tested negative for hepatitis B virus infection?

Your responses to the assessment you just completed yielded no clear indications that your patient is currently at substantial risk of acquiring HIV. Although PrEP may still be worth considering for this patient, it is not strongly recommended.

That said, if your patient has expressed an interest in PrEP regardless of specific risk factors, the subject is worth further discussion. [Read this article on TheBodyPRO.com](http://www.thebodypro.com/content/80117/yes-to-prep-a-prescribers-next-steps.html){target="_blank"} for more information regarding next steps in discussing, and potentially prescribing, PrEP to your patient.

PrEP's Benefits for Your Patient or Client Are Unclear

One or more of your responses to the questions in this brief assessment suggest that your patient may be at risk for acquiring HIV, thus making it worthwhile for them to strongly consider taking PrEP.

[Read this article on TheBodyPRO.com](http://www.thebodypro.com/content/80117/yes-to-prep-a-prescribers-next-steps.html){target="_blank"} for more information regarding next steps in discussing, and potentially prescribing, PrEP to your patient.

PrEP Should Be Considered for Your Patient or Client

Your responses to the questions in this assessment suggest that, regardless of whether your patient may benefit from PrEP, there are clinical considerations -- e.g., lack of a recent HIV-negative test result, possible symptoms of acute HIV infection, or relatively low creatinine clearance -- that could make it unwise for them to begin PrEP at this particular time. As you and your patient/client seek to address and resolve those considerations, you may want to ensure they are aware of additional HIV prevention methods.

[Read this article from TheBodyPRO.com](http://www.thebodypro.com/content/79818/current-hiv-prevention-methods.html){target="_blank"} outlining the current armamentareum of HIV prevention methods.

Use Caution Before Moving Forward With PrEP

Is PrEP -- the HIV prevention pill -- a good fit for your patient or client?

Assessment Tool: Is HIV PrEP Right for Your Patient or Client?

Immigrants to the United States are, generally, highly resilient. As people who had the motivation and abilities to relocate with great effort and expense across long distances to work and study in the U.S., many immigrants prove to be highly adaptive and entrepreneurial and are able to draw on social and family networks in the U.S. to start small businesses and advance in education and employment.

Many African immigrants fit into this pattern of initiative, entrepreneurship, and education. For example, compared to 31% of U.S.-born Americans who have at least a college education, 39% of African immigrants [have bachelor's or higher degrees](https://www.migrationpolicy.org/article/sub-saharan-african-immigrants-united-states), with the highest rates of advanced education and training among immigrants from Egypt (64%), Nigeria and South Africa (57%), Kenya (44%), and Ghana (40%).

But migrants fleeing violence and persecution and seeking asylum in the U.S., and particularly LGBTQ migrants seeking asylum, are different in that many come with histories of pre-migration trauma. Furthermore, many LGBTQ asylum seekers have migrated independently from family, experience stigma and discrimination from family and immigrant communities in the U.S., and have specific needs for trauma-informed health care, targeted social services, and community-building.

Research and public media have typically overlooked the ways in which these needs of LGBTQ asylum seekers are different from those of the general asylum-seeker population. Filling this gap, several recent studies have looked at the health needs of African-born LGBTQ migrants in the U.S. and their needs for targeted, trauma-informed services to engage them in mental health care, sexual health care, and other health and social services.

Factors Impacting Mental Health of African LGBTQ Immigrants
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**Traumatic histories from Africa:** Homosexuality is highly stigmatized in many African settings, as evidenced by current national laws in more than 25 African countries that [make same-sex sexual activity illegal](https://ilga.org/maps-sexual-orientation-laws). LGBTQ migrants from Africa describe high rates of rejection from family and community, harassment, blackmail, violence, and sexual violence, all of which contribute to ongoing mental health issues, such as depression or other post-traumatic stress disorders.

**Lack of support from African migrant communities in the U.S.:** African LGBTQ migrants who fled their countries because of violence or persecution related to their sexuality or gender frequently migrate independently from family. This means that they lack the family and community support that helps many other immigrants in resettling and accessing work and education. Many African LGBTQ immigrants also experience or fear homophobia from family members and African communities in the U.S. [This "sexual minority stress"](https://link.springer.com/article/10.1007%2Fs10903-018-0849-8) includes actual or anticipated discrimination and rejection and a dynamic in which people live closeted lives, concealing core aspects of their emotional, social, and sexual lives.

**Migration-related stress:** Migration is stressful, especially for refugees who have fled their countries with few resources and face initially insecure employment and housing, social isolation in a new place, and anxiety and depression deriving from the effort to navigate a new language, new cultures, and new systems.

The Combined Effect of Trauma on Health
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The combination of these multiple traumas pre- and post-migration and lack of support networks in the U.S. has consequences for people's health. Traumatic histories, minority stress, and migration-related stress together cause a greater likelihood of mental health issues, including substance use and addiction disorders.

For example, a [recent study](https://link.springer.com/article/10.1007%2Fs10903-018-0849-8) interviewing 70 African-born gay and bisexual men living in New York City in 2015 found that immigrant African gay and bisexual men who had post-traumatic stress disorder (PTSD) were more likely to experience depression. Men in the study who had histories of homophobia or sexual violence in their home countries, had internalized homophobia, and/or had economic issues such as housing instability in the U.S. were significantly more likely to have substance use and addiction issues.

"The interrelatedness of these factors points to the need for interventions that address both home and host country experiences that contribute to the current disposition of this highly resilient community," says Adedotun Ogunbajo, co-author of the study.

Despite these needs, with limited family, social, or community supports, African-born LGBTQ migrants who have fled their countries may not know of available services, may not be able to navigate access to appropriate services, or may not trust or may fear rejection from service providers. This is especially true of LGBTQ Africans who are undocumented migrants seeking asylum in the U.S.

Evidence-Based Components of Effective Services for African LGBTQ Immigrants
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**Engagement of African LGBTQ asylum seekers:** Open social and cultural events and regular support groups are an [important strategy](https://link.springer.com/article/10.1007%2Fs10903-016-0431-1) to help asylum seekers link to social networks, social services, and health care. Community advisory groups can also be formed to advise about program design, implementation, and evaluation, and to help develop health education messages that are culturally and linguistically appropriate, disseminate information through social media and peer networks, and help asylum seekers to access and navigate services.

**Sexual health services for LGBTQ asylum seekers:** LGBTQ migrants need [high-quality sexual and reproductive health services](https://www1.nyc.gov/assets/doh/downloads/pdf/ms/srh-clinical-guide.pdf) that are affordable and accessible for undocumented migrants, and attentive to and centered on people's needs. HIV and other sexually transmitted infections (STIs) are a specific health concern for African gay and bisexual men in the U.S. Relatively high HIV and STI prevalence has been documented among gay men across all regions of Africa, including major countries of origin for migrants to the U.S., such as Ethiopia, Ghana, Kenya, and Nigeria. Beginning in 2010, HIV was lifted as an exclusion criterion for people seeking to come to the U.S. African gay and bisexual men in the U.S. may also be at elevated risk for HIV and other STIs for the same reasons as U.S.-born African Americans, notably, high background STI prevalence within sexual networks and a lack of high-quality affirming sexual health services targeted to gay and bisexual men.

**Clinical and social service programs that are trauma-informed:** [Trauma-informed services](www.samhsa.gov/nctic/trauma-interventions) are defined as services with protocols and training to recognize and identify signs and symptoms of trauma, provide access to appropriate services and support, and avoid practices that re-traumatize people. For African LGBTQ immigrants, trauma-informed services emphasize trust, safety, and peer support; specifically recognize and address mental health issues related to migration and/or sexuality and gender identity; and promote people's recovery and resilience.

Like countless waves of immigrants coming before, African-born LGBTQ people in the U.S. bring a rich diversity of talents, cultures, and life experiences to the United States and have abilities and resilience rooted in their willingness to uproot and move long distances to forge new creative and entrepreneurial lives in this country.

The experiences and voices of African LGBTQ people in America, and particularly of those fleeing persecution and seeking asylum in the U.S., are centrally important in informing and improving health services and community-based services.

**Further reading:**

*   [Ogunbajo A, Anyamele C, Restar AJ, et al. Substance use and depression among recently migrated African gay and bisexual men living in the United States. J Immigrant Minority Health (2018).](https://link.springer.com/article/10.1007%2Fs10903-018-0849-8)
*   Keuroghlian AS, McDowell MJ, and Stern TA. Providing care for LGBT immigrants at health centers and clinics. Psychosomatics (2018) 59:193–198.
*   [Hopkinson RA, Keatley E, Glaeser E, et al. Persecution experiences and mental health of LGBT asylum seekers. J Homosexuality (2017) 64:1650–1666.](https://www.tandfonline.com/doi/abs/10.1080/00918369.2016.1253392)
*   [Kwakwa HA, Wahome R, Goines DS, et al. Engaging African and Caribbean immigrants in HIV testing and care in a large US city: lessons learned from the African Diaspora Health Initiative. J Immigrant Minority Health (2017) 19:818–824.](https://link.springer.com/article/10.1007%2Fs10903-016-0431-1)
*   [Zong J and Batalova J. Sub-Saharan African immigrants in the United States. Migration Policy Institute. Spotlight, May 2017.](https://www.migrationpolicy.org/print/15914#.XDtLPc9Khp8)
*   [Alessi EJ. Resilience in sexual and gender minority forced migrants: a qualitative exploration. Traumatology (2016) 22(3):203–213.](http://psycnet.apa.org/record/2016-27907-001)

**Additional resources:**

*   [African Services Committee](www.africanservices.org)
[](www.africanservices.org)*   [](www.africanservices.org)[Immigration Equality](www.immigrationequality.org)
*   [National LGBT Health Education Center at Fenway Institute](www.lgbthealtheducation.org)
*   [RIF Asylum Support](www.rifnyc.org)

Sam Avrett

Rainbow flag in contour of Africa

Featured image for How to Support African LGBTQ Immigrants at Risk for HIV in the U.S.

As the Trump Administration makes it harder for immigrants to enter the U.S. and access services, understanding the challenges and needs of African LGBTQ iImmigrants is critical for providers....

As the Trump Administration makes it harder for immigrants to enter the U.S. and access services, understanding the challenges and needs of African LGBTQ iImmigrants is critical for providers.