Racial and ethnic disparities have been a problem in the HIV epidemic since the very beginning. Recently, the National HIV/AIDS Strategy for the United States for 2022-2025 was released, and within that strategy there are 4 goals, 2 of which are pertinent to this topic. One goal is the reduction of racial disparities and health inequities, and another is the prevention of new infections, targeting a 75% reduction (from 37,000 in 2017 to just 9250 in 2025) and increasing preexposure prophylaxis (PrEP) coverage from 13% to 50% of those who are eligible.
HIV affects racial minorities with a higher frequency than their White counterparts. These disparities are not associated with behavioral differences. A study out of Washington, DC (one of the CDC’s HIV infection hot spots) compared Black and White men with HIV infection and risk behaviors. They found that Black men were at much higher risk of getting HIV despite lower frequency of behavioral risks such as unprotected anal intercourse or sociological risks like being in jail.
Strategies to Overcome Racial Disparities
The disproportionate numbers of new infections in racial and ethnic minority patients are largely due to the amount of HIV in the community, and that in turn has to do with several other factors, including lack of access to comprehensive healthcare. There's a lot of stigma in the community that are often reinforced by healthcare providers and systems of care. We’ve got to start changing this, and there are a number of ways we can.
Medical practitioners, for one thing, need to be represented by larger numbers of people of color—we need more diversification of the medical workforce. But there's a huge barrier in access to clinical education. It's beginning to be addressed, but it's not something we can count on in the short term. And we need action right now.
So in the meantime, we must address some of the other barriers to care, such as linkage to healthcare coverage for PrEP. There are many such programs available, but they must be advertised so that people know how to access the medications they need, not run out of medications, and have a way to easily get back on a medication if they do run out. With PrEP, there are follow-up visits needed for sexually transmitted infection (STI) and HIV testing, which are often out of reach for racial and ethnic minorities.
So how do we get to these populations? Well, besides expanding healthcare so that it's available to people in need, one thing that's not being done as much as it must is testing for all who need it. Currently, over 14% of people who have HIV don't know they have it. In 2006, the CDC recommended that all people over the age of 13 be tested at least once for HIV. Primary care clinicians need to be doing that with every patient, especially for those at higher risk. You're not going to know if somebody's at higher risk unless you ask for a sexual history. In addition, PrEP should be offered to all sexually active patients. Anybody who comes in with a STI or for birth control should be tested for HIV and offered PrEP.
So what is the appropriate type of PrEP? For some patients, an injectable option might be appealing. We must be aware, however, that this option requires more frequent visits than daily oral pills because the injections need to be given every 2 months with associated testing. Cost and implementation challenges with injectable options may worsen disparities. Whichever PrEP options patients choose, shared decision-making with patients is important to ensure they have access.
But again, all these things will require a team-based approach where somebody is available to help patients with accessing ways to pay for the visits, test for HIV, and get access to PrEP.
Healthcare disparities have been around since the beginning of our country’s history. And we're just beginning to make some inroads into ways to get people access to care. But if we don't take care of those people who are now in greatest need, they will continue to suffer disproportionately from HIV at a time when that's no longer necessary.
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