This transcript has been lightly edited for clarity.
Hello. My name is Latesha Elopre. I’m an infectious disease provider and researcher at the University of Alabama at Birmingham. And I’m really excited because I get to talk to you about two aspects of my job that I greatly enjoy, which is being a researcher and being able to provide patient care—which I’m very passionate about, because I feel like it allows you to be able to engage with people in some of the most vulnerable and some of the most special parts of their lives.
As a provider, I think we want to be able to really improve the lives of our patients. A part of that is being able to improve their sexual health and be able to address things that we know are causing inequities or disparities in outcomes for them. One of the biggest ones—that, I think, the government has drawn light to and public health officials are trying to end—is disparities we’re seeing in HIV diagnoses.
Overall, we have seen major gains in the [course of the] past 40 years of the HIV epidemic in the United States. We have seen huge declines in the number of new diagnoses—except for in the past decade. There’s been a stagnant overall change in the prevalence of HIV diagnoses: Over the past few years, we saw slight decreases, but in 2022 it kind of stayed the same, where about 37,000 new infections occurred. Over half of those infections occurred in the South and over 2/3 occurred among racial and ethnic minority groups, who do not make up 2/3 of the U.S. population.
I think the question is: Why is that occurring?
It’s why health disparities oftentimes occur among racial and ethnic minority groups. The same thing we’re finding is occurring when it comes to new effective medications that we know could end the epidemic. And when we’re talking about ending the epidemic, that means getting to zero new diagnoses, having no new infections—which we have amazingly done in one location, which is Australia, and we want to be able to do in the United States.
Something that has been kind of miraculous is HIV pre-exposure prophylaxis, or PrEP. When taken effectively, it can decrease the risk of getting a new diagnosis up to 99% in certain populations. Unfortunately, we’re not seeing PrEP use being distributed equitably.
Right now the CDC [Centers for Disease Control and Prevention] predicts about 1.2 million have an indication for PrEP. In order for us to really have an impact and see these huge public health gains that we want to see [on] new diagnoses, we need to get PrEP into the populations that are having the burden of HIV the greatest.
Unfortunately, what we’re seeing is that, right now, the populations that we know have the highest rates of new diagnoses—which we just reviewed are usually racial and ethnic groups—are not currently getting prescribed PrEP. Right now about 94% of [white] people who have an indication [for PrEP have received a prescription]. Only about 12% are occurring among Black individuals, and about a quarter among Hispanic individuals. So, the coverage is not equitable.
The only way that we’re going to be able to close those gaps is to improve, and meet all of these multilevel barriers that we know that exist that cause these disparities among racial, and ethnic, and sexual, and gender minority groups—these groups that are oftentimes marginalized in society.
I’m going to talk to you about one way that I think we can accomplish this, which is decentralization of where we are currently providing health care services for PrEP—which is with HIV providers like myself. Which saddens me, to a certain degree, because I love taking care of patients, like I said. I love being a PrEP provider, and I will continue being a PrEP provider. But overwhelmingly, data has shown that when we’re providing patient-centered care, that patient-centered care oftentimes does not include an HIV provider, just because of the stigma that still exists within HIV diagnosis.
As an example: I’ve done some work, and others have done a lot of work, trying to work with populations that we know face huge disparities when it comes to HIV outcomes and HIV diagnoses. One population that I’ve been working with is Black cisgender women. They have overwhelmingly, within my state of Alabama, said: We want to receive PrEP services from our gynecologists. That is where we more frequently access health care services. That’s where we feel comfortable accessing health care services. And that’s where we desire to receive them.
I think ultimately, when we’re offering patient-centered care, it may look different for different populations in different geographic settings for different sexual- and gender-minority groups. So that means that we may have to go to pharmacies to deliver PrEP care; we may have to go to urgent care centers to deliver PrEP care; we may have to go to emergency rooms to deliver PrEP care; and that ultimately, basically, wherever someone feels the safest to receive those services, it is available.
So, in this specific setting, we said: “OK. We’re going to do everything we can to make this happen,” which requires a multilevel approach. We have to make the clinic a safe environment—as culturally appropriate and tailored and trauma-informed [as possible]. What that means is that we have now transformed and tried to increase our providers’ knowledge of what [it means] in the HIV epidemic to not have equitable access to PrEP services, and the disparities that are currently occurring among HIV rates for Black cisgender women.
We had to also make them aware, from a cultural standpoint: What does it mean for you to offer care that is not going to stigmatize a group? That means that you’re offering culturally appropriate health care—culturally appropriate, sexually comprehensive care—to everyone, so that when you’re encountering someone who is marginalized, you recognize their lived experiences, and you alter your message to make sure you are not further traumatizing them and that you are making access to health care services easier for them.
So, we reviewed that with the providers. And I know, just like you, [that] most providers want to have the best health care outcomes; they want to have the best patient care possible that they can provide. These providers said the same thing: No one goes into health care wanting to offer bad health care services. So, digging in—trying to understand how you can do that—is a worthwhile investment.
Outside of that, we also made sure that we delivered PrEP messaging in ways that women said that they would be receptive to it. Sometimes in Southern locales—like where I live, which is slightly more conservative, unfortunately, and maybe more stigmatized—that means that we do not put HIV on our brochures. We do not have what I consider to be really sex-positive messaging on outlets that were advertising about PrEP. We asked women to click [a “more” button on a website] if they cared about women’s health, and then after they clicked “more,” they could learn about HIV pre-exposure prophylaxis and sexual health, because that’s how they said they want to receive that message.
Outside of that, that also means that we are addressing the system at organizational barriers that occur. And we are working within the workflow of that clinic to try to make it as easy as possible for them to deliver PrEP services in a way that I think is conducive with how they are operating on a day-to-day basis.
That is just one small example. It doesn’t address some of the larger barriers that our women at that clinic may face—[a clinic] which, by the way, [is comprised] 60% of individuals who are only receiving Medicaid, and the other 40% are uninsured or underinsured. In a state like this, you’re going to have major barriers to be able to access a medication that usually requires you to have some form of insurance to receive services. So having something like a universal, national PrEP program may be required to mitigate all barriers to PrEP access.
Again, this is one aspect, one way that may help in regards to increasing equity. It’s something that you can do to be able to fight disparities. We can do this by trying to provide more educational services; work with groups—like pharmacists, nurse practitioners, OB/GYN doctors, and every form of provider that you think might be willing and able and readily accessible to offering PrEP services—and train them. Train them on offering culturally appropriate care. Train them on offering sexual health care services. And train them on becoming PrEP providers.
Thank you.
