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A literature review of issues affecting PrEP Education and Implementation in racism mistrust in black communities (HIV/AIDS)

Cazeau P

Public Health Diplomat, Committee Member at Mayor Thomas A Masters Citizens Response Team, USA

E-mail : aa

Jackson R

Chair HIV Program, Northwood University, USA

Theodore L

Chief medical in HACI, University of Cincinati, USA

Balatien B

Chief medical in HACI, University of Cincinati, USA

DOI: 10.15761/IMM.1000270

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Abstract

Background: Racism in black communities has complicated diagnosis and treatment of the HIV/AIDS epidemic. Individuals most affected by HIV are also most disadvantaged in terms of race and economic status. Sixty percent of all new HIV infections take place among young black MSM between the ages 13 to 29, which explains why AIDS has been cast as a social and not bio-medical problem.  Most of them will live in disbelief that they could be at risk for HIV, and so are reluctant to try new preventative treatments such as PrEP.

Methodology: This study is a literature review to explore how pre-exposure prophylaxix is related to health, behavioral, stigma, racism, and psycho behavioral. A descriptive statistics were generated for demographics, sexual behaviors, concerns and interests about PrEP. Thirty-three participants were recruited from eastern and western counties of HIV-uninfected men who report having sex with men (MSM) through their level of agreement on statements listing concerns about the impact of PrEP use on health, behavior, stigma, and interest in psycho-behavioral support services to PrEP.Bivariate and multivariable logistic regression procedures examined a willingness to use the oral PrEP.

Results: Mean age of participants was 13-29 YMSM.  Participants were enrolled in the PrEP Program compared with MSM and IDU (inject drug) of PrEP use on health, behavior, stigma, and interest in psycho-behavioral support services to PrEP. We found 5 percent has more than half reporting more than two partners.  Whereas 6 percent of IDU reported inconsistent condom used; 33 percent had previously heard of PrEP, whereas 6% reported to use oral PrEP if available after being educated about its potential. In multivariable analysis controlling for age and race/ethnicity demographic significant to use oral PrEP included the following: less education [odds ratio (OR) = 7.7; P = 0.04], moderate income (OR = 13.0; P = 0.04), no perceived side effects from taking PrEP (OR = 3.5; P = 0.001), and not having to pay for PrEP (OR = 4.2; P = 0.05).

 

Conclusion: Black MSM who were HIV negative and who took PrEP while involving in relationship with HIV positive men remained HIV negative. Knowledge of PrEP and its implementation must overcome the same level of mistrust in the black community in order to become recognized as an important factor in reducing the AIDS virus.

 

Key words

 PrEP, Stigma, Racism, HIV/AIDS

Introduction

World Health Organization (WHO), 1948 stated health is more than the absence of diseases, as a negative definition of health will never entail the positive aspects of possessing health. WHO has stated that health necessarily includes social, psychological and physical well-being. This means that any measurement of health needs to include non-epidemiologic factors that points to the positive components in the construction of health. Engel (1960) employed the “Biopsychosocial model” to clarify the different elements that must be understood, evaluated, and treated when faced with caring for unhealthy patients. This model for Engel also meant that health must include social, biological, psychology and other determinants.

Caldwell (1993) noted how behavioral and lifestyle practices are key determinants in health, and the lack thereof leading to mortality is not new. Despite this, Bharat (2002) has pointed out an acknowledged truism known throughout the world that those individuals most affected by HIV are also the most disadvantaged in terms of race, economic status, age, sexual orientation or gender [1-3]. He documented how the nearly two decades-old global history of the HIV epidemic undergirds once again the well-established interplay of disease, stigma and identities gone bad based on race, ethnicity, and sexuality. The strong connections established early between HIV/AIDS and gay men plus other risk groups appear to have blinded social researchers and others to indicators of racial, class and gender relations that cast AIDS as a social and not a bio-medical problem. Williams (1997) relates how race is pertinent to questions of public health, care and treatment issues, and how it’s crucial to first examine the phenomena of stigma and discrimination and secondly how its related to illness and disease. Goffman (1963) defined stigma as a discrediting characteristic which in the eyes of society reduces the person who has it [4]. Goffman said the stigmatized individual was seen to be a person with “an undesirable difference” and maintained stigmas are constructed by society using perceived difference or deviance and carried through socially approved roles and sanctions.

AIDS appeared to have come quickly on the scene from nowhere, and as terrifying as it seemed, health officials and the media gave assurances to the public that its cause came from the consequences of gay promiscuity and not pathogens. While African-Americans individually disbelieved, they were at risk for HIV infection, they knew perfectly well its threat to their communities [5-9]. A study revealed that although Blacks account for only 14 percent of the total U.S. population, they unfortunately represent nearly one-half of the estimated 50,000 new cases of HIV that occur every year and secondly about 500,000 of the almost 1.2 million people living with HIV/AIDS (HRSA,2012) (Table 1 and 2).

Gender

White

Hispanic

Black

Male

15.9

39.9

103.9

Female

  2.6

11.8

1,189

Table 1. Source: CDC. CDC fact sheet: Estimates of new HIV infections in the United States,

2006-2009. Available at www.cdc.gov/nchhstp/newsroom/docs/HIV-Infections-2006-2009.pdf.

 Accessed December 15, 2011.

City

Eastern/ Western

Living HIV/AIDS

Cases

Percent of

Living Cases

Belle Glade**

495

6%

 

Boca Raton

456

6%

 

Boynton Beach

853

10%

 

Delray Beach

952

12%

 

Greenacres

134

2%

 

Jupiter

114

1%

 

Lake Worth

1063

13%

 

Lantana

144

2%

 

Pahokee**

91

1%

 

Palm Beach Gardens

112

1%

 

Riviera Beach

484

6%

 

West Palm Beach                       

 

2676

33%

All Other Cities*

609

7%

 

Total

           8183

 

100%

Table 2. Palm Beach Living HIV/AIDS Cases Currently Living in Palm Beach County

Another study uncovered how black MSM have been the most heavily impacted by HIV/AIDS in their community. Despite only 4 percent of males age 13 and older in the United States are MSM, they accounted for 61 percent of all new HIV infections in 2009 [10-17].  The African-American MSM constitute a majority of these cases, with sixty percent of all new HIV infections taking place among young black MSM between the ages 13 to 29.

The CDC Young Men’s Survey (1994-2000) showed how black MSM were diagnosed with HIV at rates five times those of their white counterparts. This study revealed that 82 percent were not aware they were infected until a later time and most denied they were at risk for HIV in their lifetime [18,19]. The study revealed how homophobia plays a determinant in preventing black MSM from understanding their risk for HIV, or avoiding HIV prevention and testing plus treatment and care services.  African-American MSM will continue to have relationships with older black MSM for access to housing, food and other resources in order to survive. Although these relationships are often caring, they have helped perpetuate HIV across several generations of black MSM.

Researchers are showing interest into an effective HIV prevention using a pill, with dozens of studies having queried potential target users on their willingness to undergo a daily dose of antiretroviral drugs in order to protect themselves from HIV [20-22]. Studies have reported on the willingness to use PrEP with interest factors in association with a daily oral prevention pill and pinpoint user’s concerns with taking a daily drug as prevention intervention. Another study reported on the acceptability of daily oral pre-exposure prophylaxis (PrEP) involving men who have sex with men (MSM) and recorded a wide range of acceptability from a low of 28 percent to a high of 96 percent. Meyers et al., (2014) stated these studies aimed to identify demographic and behavioral factors, particularly sexual risk factors associated with a higher interest in daily oral PrEP [23-24].

Methodology

Thirty-six literature reviews were identified to investigate how pre-exposure prophylaxix is related to health, behavioral, stigma, racism, and psycho behavioral. A study by Meyers et al., (2014) set out to extend these research questions to explore the willingness to use long-acting injectable (LAI) formulations of PrEp. All participants were evaluated for LAI-PrEP using information from trained interviewers on the possible side effects of oral and LAI-PrEP. Participants were asked to recall the number of partners in the last three months and frequency of condom use [25-27]. Descriptive statistics of PrEP were employed for purposes of demographics, sexual behavior, concerns and interest (Figure 1)

Haire (2015) stated that PrEP will work provided it is taken, making adherence a significant challenge of effective PrEP implementation together with issues of access and uptake [28-31]. A PrEP-related stigma has emerged among research participants, as reported by trial participants from a variety of trial sites. Liu et al., found that experiencing a stigma was the most commonly reported social harm stemming from study participants, with 15 of 20 listed social harms connected to stigma. A qualitative study of MSM who participated in the iPrEX study in Chiang Mai, Thailand Tang-munkongvorakul et al., found that stigma was a challenge to medication adherence, and noted several different kinds of stigma experienced by study participants [32-35]. (Haire, 2005). Smith et al., noted how the anticipated negative reaction of peers, friends, and family members was seen as a factor mitigating against PrEP uptake among African-Americans between ages 18-24 [36].

Measures

Researchers have cautioned that although PrEP may offer some prevention to MSM who find condom use difficult, it could also promote lack of condom use [37]. Although researchers have found no evidence of condom neglect in clinical trials, the absence of evidence may be attributable to the wide-ranging psychosocial services offered as part of the trials (e.g., access to behavioral counseling, free condoms, treatment for sexually transmitted infections (STI), regular HIV testing, and frequent medical evaluation) as well as a limited number of recruited youth.  (Bauermeister et al., 2013). A recent study by Mustanski and colleagues found PrEP intentions were associated with fewer acts of unprotected anal sex [38]. It therefore remains unclear whether YMSM’s health promotion and risk practices may influence their PrEP intentions, or whether these findings can be generalized to other geographic areas. 

Data analysis

For this study, thirty-three participants were recruited from eastern and western counties of Florida by zip code that were enrolled in the PrEP Program compared with MSM and IDU (inject drug) [39].   Participants were asked to state their level of agreement on statements listing concerns about the impact of PrEP use on health, behavior, stigma, and interest in psycho-behavioral support services to PrEP [40]. A second set of recruits consisted of 1449 participants of MSM living with HIV and sexually active with HIV negative taking PrEP. Descriptive statistics were generated for demographics, sexual behaviors, concerns and interests about PrEP. Chi-square and when suitable a Fisher's Exact Test were employed to test independent associations among outcomes, plus demographic and behavioral predictors. We modeled each of the two outcomes with bivariate analysis using demographic and behavioral factors as well as previous reported concerns connected to a willingness to use oral PrEP. A small sample size involving the multivariable model included factors that were significant at p<0.10 level in the bivariate model, therefore there is no significant difference.

Results

There was a wide distribution of the number of male sexual partners between January 2016- October 2016 in eastern and western counties of Florida with more than half reporting more than two partners (5% n=179) [41].  We found 6% (n=436) of IDU reported inconsistent condom use in eastern Palm Beach living with HIV while 33% (n=2507) MSM reported hardly ever or never using condoms [42].  We found 6% (n=40) of IDU reported inconsistent condom use in western Palm Beach living with HIV, while 0% (n=1) MSM reported using condoms and participated in taking oral PrEP. We found 33% had previously heard about PrEP, whereas 6% reported to use oral PrEP if available. A Multivariable analysis used to control for age, race, demographic, social behavior to use oral PrEP. significant to use oral PrEP included the following: less education [odds ratio (OR) = 7.7; P = 0.04], moderate income (OR = 13.0; P = 0.04), no perceived side effects from taking PrEP (OR = 3.5; P = 0.001), and not having to pay for PrEP (OR = 4.2; P = 0.05) [43].

Conclusion

Since the beginning of the HIV epidemic, those most effected have also been the most disadvantaged in terms of race, economic status, and most importantly sexual orientation. But HIV has also been plagued by a stigma ranging from researchers to society with the net result ending with discrimination. This stigma has prevented black men from not only undergoing testing but also seeking treatment including a daily oral pre-exposure proplylaxis (PrEP).  Black MSM who were HIV negative and who took PrEP while involving in relationship with HIV positive men remained HIV negative. Knowledge of PrEP and its implementation must overcome the same level of mistrust in the black community in order to become recognized as an important factor in reducing the AIDS virus.

Reference

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Editorial Information

Editor-in-Chief

Ivan Gout
University College London

Article Type

Review Article

Publication history

Received date: January 16, 2017
Accepted date: February 11, 2017
Published date: February 14, 2017

Copyright

©2017 Cazeau P This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Cazeau P (2017) A literature review of issues affecting PrEP Education and Implementation in racism mistrust in black communities (HIV/AIDS). Integr Mol Med 4: DOI: 10.15761/IMM.1000270

Corresponding author

Cazeau P

Cazeau P, Public Health Diplomat, Committee Member at Mayor Thomas A Masters Citizens Response Team, USA

Gender

White

Hispanic

Black

Male

15.9

39.9

103.9

Female

  2.6

11.8

1,189

Table 1. Source: CDC. CDC fact sheet: Estimates of new HIV infections in the United States,

2006-2009. Available at www.cdc.gov/nchhstp/newsroom/docs/HIV-Infections-2006-2009.pdf.

 Accessed December 15, 2011.

City

Eastern/ Western

Living HIV/AIDS

Cases

Percent of

Living Cases

Belle Glade**

495

6%

 

Boca Raton

456

6%

 

Boynton Beach

853

10%

 

Delray Beach

952

12%

 

Greenacres

134

2%

 

Jupiter

114

1%

 

Lake Worth

1063

13%

 

Lantana

144

2%

 

Pahokee**

91

1%

 

Palm Beach Gardens

112

1%

 

Riviera Beach

484

6%

 

West Palm Beach                       

 

2676

33%

All Other Cities*

609

7%

 

Total

           8183

 

100%

Table 2. Palm Beach Living HIV/AIDS Cases Currently Living in Palm Beach County

Figure 1. Percent of Living HIV/AIDS by Eastern/Western County n= 8183

Data Source: FL DOH, Bureau of Communicable Diseases, HIV/AIDS and Hepatitis Section, data as of October 31, 2016.

  • Other cities are combination of the cities that had less than 100 cases per city.
  • Western Palm Beach includes Belle Glade, Pahokee, South Bay, Canal Point, Lake Harbor and Bryant.
  • Eastern Palm Beach includes all cities not listed as Western Palm Beach.