Guests featured in this episode:

Keosha Bond, M.D., Assistant Medical Professor, City University of New York School of Medicine

Tori Cooper, Director of Community Engagement for the Trans Justice Initiative, Human Rights Campaign

Latesha Elopre, M.D., Associate Professor, Division of Infectious Diseases, University of Alabama at Birmingham


Moderator: Alexandra Walker, Director of Digital Communications, National Association of Community Health Centers

Alexandra:. Welcome to Health Centers on the Frontlines, the podcast of the National Association of Community Health Centers. Today is the third and last in a three-episode series we've been doing about an epidemic that the nation's health centers have been battling for decades: HIV and AIDS. PrEP access and use remain unequal in the United States, with women overall accessing it at a fraction of the rates of men. Meanwhile, one in five new HIV cases annually occurs in women. The overwhelming majority of Black women. Transgender women specifically, are at an even greater risk for HIV acquisition and oftentimes lack access to competent care to access primary care. When we think about health centers and all the work that is done with Black communities, we cannot leave HIV prevention and care for Black women out of the conversation.

To discuss today, we are joined by a panel of experts, Dr. Keosha Bond, Assistant Medical Professor at the City College of New York. Tori Cooper, Director of Community Engagement for the Trans Justice Initiative at Human Rights Campaign, and Dr. Latesha Elopre, Associate Professor in the Division of Infectious Diseases at the University of Alabama at Birmingham.

We start this conversation about ways that health centers can improve the engagement of Black cisgender and transgender women in HIV testing, prevention, and care. So if we could start with you, Latesha, how can we improve messaging about HIV prevention and care to improve acceptance of services among all Black women?

Latesha: Thank you. So, my name's Latesha and my pronouns are she and her, and I am really excited to be able to talk about this topic. I think that when we’re talking about access and we’re talking about it for specific populations, we have to do it in the framing and the understanding that access is not equitable to begin with. So number one, there is a system-level barrier in regards to who's able to receive the services. So when we’re understanding why, we’re seeing inequalities in regards to certain geographic locations. We're talking about things like being in a non-Medicaid expansion state, having poor public transit opportunities available to you where you live, being impoverished, and being a victim of systemic racism, those are all barriers that communities of color face a lot of times on a day-to-day basis that make access difficult.

But when we're talking about specifically, how do we improve messaging and understanding around PrEP and HIV testing and prevention, I think that we have to do it from a framework where we're not talking about risk, but we're talking about health. And that's something that we haven't been doing well in regards to public health in general. So I've been very excited, I think, where a lot of conversations have been moving and shifting, because right now if you were to ask many people in America right now, do you think you're at risk for HIV? Should you be tested? They would say no. And based on how we've defined risk from a public health standpoint, you know, the answer actually would be not based on CDC guidelines and recommendations, a lot of times would put people, quote-unquote, at risk is nothing more than where you live. And that's social determinants of health that are currently impacting you.

So, I think we just have to change our messaging, be more sex-positive, be more health-focused and oriented, more talking about HIV testing, PrEP, and messaging.

Alexandra: Thank you. And turning to you, Tori, thank you for joining us. What are some of the things that you believe health centers can do to improve engagement of Black, cisgender, and transgender women, HIV testing and prevention, like PrEP?

Tori: Well, thank you for having me. My name is Tori Cooper and my pronouns are she and her. And I'm a Black trans woman. So I speak on behalf of a lot of women who have similar backgrounds as I do. We're Black, we're transgender, we live in the South. One of the things really kind of going along with what we just heard, Black women, regardless of how you got to your Black woman, how you got to your womanhood, we often put others' needs ahead of ours. We trust people, perhaps, who don't deserve our trust, and yet we're distrustful of medical systems. And so one of the programs I'm involved with is changing Risks to Reasons (From Risk to Reasons)where we're actually helping Black women to reframe what risk is in terms of reasons.

When we think about risk for HIV, we really are putting the responsibility, the power in someone else's hands. Sex for me as a Black woman is risky because my partner may have HIV versus when we reframe our thinking, when we collectively reframe as Black women and think, well, “You know what? My reason for protecting myself against HIV is because I don't want to have to take this medicine for the rest of my life, or I have children, or I want to be healthier, I want to take, my reason for taking PrEP is because I don't want HIV.” “My reason, if I do have HIV, to get into care is because I want to be able to take better care of myself.”

So part of that is speaking to Black women the way that we understand. Risk implies danger. Reasons imply empowerment, and for Black women, we get it all done all the time. We can speak from an empowerment standpoint and are stronger and better and can make healthier decisions when we speak from an empowerment standpoint when we speak from the standpoint of a victim.

Alexandra: Thank you. And Keosha, turning to you. What do you believe needs to change in the broader public health system to help Black, cisgender, and transgender women who are living with HIV achieve the goal of sustained viral suppression?

Keosha: Well, thank you again for inviting me. My name is Keosha Bond, and my pronouns are she and her. And I think that's a really great question, because it is something that constantly comes up, and especially in our research setting and in our health settings. We had so long spent so much time focused on the individual in the sense of thinking that it’s the individual issue, that's the problem, that's why people are vulnerable to HIV. instead of looking at the environments that people are living in and the policies that are influencing those environments.

So, I honestly think it starts from multiple levels. We do need a lot of policy changes, that is on the larger societal level, as well as in our health care facilities and how they are engaging in care, centering the patients, which we don't do in all honesty in our health care settings. And we have, honestly, have separated how we look at sexual health from overall primary care. And that in itself has created a barrier to women of all experiences engaging in health care because we are not training our providers to provide gender-affirmative care. We're not training them in cultural humility and competency, and that creates barriers for people when they are in, and encourages, I feel like it increases the medical mistrust because why would you want to engage in a system that constantly disrespects you and doesn't see you as a full person? So when I think about what needs to change, it's on so many different levels, but really what we're looking at are the policies and how we are giving people access to health care, as well as how we are engaging people in this health care and not assuming that it is the individual who needs to change, but the system that they are living in that needs to change.

Alexandra: I'm wondering, can you think of off the top of your head any examples of that type of patient-centered care that's an example of what we need to see more of?

Keosha: I think even how we approach one of the lectures I usually give our medical students is about how to engage in, do sexual health assessments in primary care and prioritizing different things being so that people are aware of your vulnerability, but really they are aware of the different factors that influence your overall sexual health.

So it's not just about if you're having sex, but who you having sex with, what type of sex you're having, are you engaging in, what kind of practices you're engaging in, what are your plans? And so these are things that are inclusive of it. And so, I think combining frameworks like gender affirmative framework as well as the reproductive or social justice framework really will kind of center that if you're speaking to the person and asking in them in general, like what, who, how would you like to engage in care,basically, what are your options? We have so many missed opportunities, especially when it comes to women and PrEP engagement. Women are coming in and they are may be presenting with an STI and no one's talking to them beyond that, they're treating the STI, but they're not talking to them about other options of what they can do, like maybe PrEP is an option for them, maybe PEP is an option, and giving them those choices, and giving them the right accurate information of what that may entail.