HIV may not discriminate, but structural inequalities do

The term acquired immune deficiency syndrome (AIDS) was used for the first time more than 35 years ago. This new disease was gripping the nation, causing a wave of unprecedented stigma and discrimination, especially for gay and bisexual men. In 1982, President Ronald Reagan’s press secretary made homophobic jokes about AIDS — as 1,118 people died from it that year.

As a nation we have come a long way — December is now AIDS Awareness Month — but the stigma, the discrimination and the fight is far from over, especially for minoritized and marginalized groups in the United States.

The Centers for Disease Control and Prevention warned that if current HIV diagnoses persist, approximately 1 in 2 black men who have sex with men will be diagnosed with HIV. The rate is 1 in 4 for Latino men who have sex with men and 1 in 11 for white men who have sex with men.

The question is: Why?

The answer is that while HIV does not discriminate biologically, structural inequalities do.

HIV/AIDS-related diseases thrive on the vulnerabilities of those already facing significant other negative cultural and structural determinants. Layers of oppression based on race, sexual orientation, gender, class, age, location and health status affect every aspect of a marginalized person’s life.

That is why we see black men who need access to medications that reduce their chances of contracting HIV, such as Truvada for PrEP, and viral suppression drugs that eliminate the risk of passing along the virus, such as regimens known as TasP, are the ones facing the most barriers to access.

It is also why we see only 24 percent of black gay and bisexual men living with HIV staying in care and 16 percent achieving viral suppression, compared with 43 percent and 34 percent for white men, according to The Lancet.

For years, the field of public health operated under the belief that education about how to avoid HIV/AIDS would inspire people to behave in “healthy” ways — to avoid sex, to use condoms, to reduce the number of partners. These efforts have largely worked, and most studies show that gay and bisexual men who are minorities use these strategies more often than their white peers.

Yet prevalence rates among black men remain, showing the approach is ineffective. It ignores the human and systemic issues that prevent people from fully accessing their health and well-being.

Widener University’s Interdisciplinary Sexuality Research Collaborative wants to shift the narrative around sexuality education in Baltimore.

In 2017, our team received a grant that has allowed us to take a dual approach to this problem in Baltimore and Jackson, Miss. — two cities that rank nationally in the top 10 for the highest HIV diagnosis rates.

First, we are offering sex education tools to empower black gay and bisexual men and amplify their voices.

Second, we are targeting doctors, receptionists, social workers, medical billing specialists and mental health providers to make sure they know how to serve black gay men and are aware of the importance of viral suppression drugs.

We are taking a holistic approach that centers on people’s individual and collective experiences, while addressing the systemic barriers that people face in pursuing their sexual health and well-being.

We are committed to consciously engaging in a concerted effort to create resources that help people at every point of the journey, from calling to make the appointment, arriving at the appointment, meeting with the provider and engaging with referral agencies. We want the experience for all men to be based on cultural humility and dignity, grounded in their needs.

The best part is, this approach seems to be working. Preliminary findings from our pilot program indicate black men who have sex with men valued it and felt empowered by the array of topics offered through the education programs, especially since they center on relationships and people’s complex experiences and are not solely focused on risk reduction.

We also need your help. While we can continue to provide education, the funding that supports HIV prevention and treatment has largely moved to a biomedical model that relies on the health care system.

Solutions will only accelerate if we collectively dismantle stigmas and the inequities built into the health care system that make it untrustworthy and unreliable for black men. Demand that your elected officials write policies and fund HIV/AIDS reduction strategies that address today’s HIV climate.

We have come a long way since 1982, but the fight is far from over, and our strategies must change.

Justin Sitron (jasitron@widener.edu) is director of Widener’s Interdisciplinary Research Collaborative and Widener’s Center for Human Sexuality Studies. He is also associate dean of the School of Human Service Professions. Tyler Burns (tgburns@widener.edu) and Lindsay Lock (lrlock@widener.edu) are graduate research assistants at Widener. Ahyana King, a clinical education research specialist at Widener, also contributed to this piece.

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