In this interview by Dr. Sara Weibel in the Infectious Disease Advisor, Nabila El-Bassel, the Willma and Albert Musher Professor of Social Work at Columbia University, discusses why people who inject drugs, sex workers and incarcerated people are particularly vulnerable to contracting HIV, including the effect of the opioid epidemic. Dr. El-Bassell also speaks about her groundbreaking studies of couples-based behavior interventions and the advantages of such approaches in addressing HIV risk behaviors.
Disparities in HIV Healthcare: An Expert Perspective
Interview with Nabila El-Bassel, the Willma and Albert Musher Professor of Social Work at Columbia University
by Sara Gianella Weibel, MD, Infectious Disease Advisor
February 8, 2018
Roughly 1.1 million people are living with HIV/AIDS in the United States, and about 15% of those are unaware of their HIV infection.1Although prevention efforts have led to a significant decline in new diagnoses among some populations, up to 40,000 people become newly infected each year within the United States.1These new infections are not equally distributed across the population. In fact, 2016 Centers for Disease Control and Prevention (CDC) data show that US subpopulations with the largest numbers of new HIV infections are as follows: black men who have sex with men (MSM; 10,223 new infections), Hispanic MSM (7425), white MSM (7390), black heterosexual women (4189), and black heterosexual men (1926), followed by white heterosexual women (1032) and Latino heterosexual women (1025).1
In addition, people who inject drugs (PWID), sex workers, and incarcerated people are particularly vulnerable and underserved key populations who are at high risk for HIV infection.
During the annual CFAR Research Day at the University of California, San Diego, Sara Gianella Weibel, MD, on behalf of Infectious Disease Advisor, talked with the keynote speaker Nabila El-Bassel, PhD, the Willma and Albert Musher Professor of Social Work at Columbia University, New York City, about factors that affect HIV health disparities, particularly in PWID, sex workers, and incarcerated people, as well as possible intervention strategies.
Infectious Disease Advisor: Dr El-Bassel, can you tell us a little more about why PWID, sex workers, and incarcerated people are particularly vulnerable to contracting HIV?
Nabila El-Bassel, PhD: PWID are significantly affected by the HIV epidemics. In 2016, 9% of the HIV diagnoses (n=3425) in the United States were attributed to injection drug users.1 The recent epidemics of prescription and nonmedical opioids has led to increased numbers of injection drug users, placing new populations at significant risk for HIV. In particular, nonurban areas with limited HIV services and substance use disorder treatment programs were formerly areas at low risk for HIV; during the last years, those areas have been disproportionately affected by the opioid epidemic, and HIV has started to spread rapidly.2 Control of these outbreaks requires coordinated efforts by state, federal, local, and academic institutions. This should include the implementation of on-site programs and services, contact tracing, testing and syringe exchange programs, rehabilitation, insurance enrollment, care coordination, preexposure prophylaxis (PrEP), and HIV treatment.3
Unfortunately, PWID are often viewed as criminals rather than as having a medical issue that requires treatment. Stigma and mistrust in the healthcare system may prevent PWID from seeking HIV testing and treatment. Injecting drugs can also cause other severe illnesses, such as viral hepatitis, or result in overdose, which further complicates HIV treatment.
Similarly, persons who exchange sex are at significantly increased risk for HIV (and other sexually transmitted infections). Many persons who exchange sex face stigma, poverty, and lack of access to healthcare and other social services even within the United States. The illegal nature of exchanging sex for money or drugs makes it difficult to gather population-level data on HIV risk among sex workers. Therefore, few large-scale studies have been performed on HIV among this group of people. Lack of data creates barriers to developing targeted HIV prevention and intervention strategies. Further, previous or current drug use, homelessness, unemployment, incarceration, mental health issues, violence, and abuse by clients, intimate partners, and the police complicate screening and treating this population.
Another underserved group at high risk for HIV infection is the incarcerated population. One in 100 Americans is behind bars.4 One in 3 black men and 1 in 6 Latino men will spend time behind bars compared with 1 of every 17 white males.5 US prisons include one-third of the world's incarcerated women.6 In 2015, the rate of HIV infection among inmates in state and federal prisons was more than 5 times greater7 than the infection rate among those not incarcerated, and unfortunately, HIV testing programs are not systematically implemented in this setting. This is partially the result of a lack of resources for HIV testing and treatment in correctional facilities and the necessity of prioritizing other needs for the allocation of resources. In addition, rapid turnover among jail populations (often less than 72 hours) makes it hard to test inmates for HIV and help them initiate adequate treatment.7 Finally[MS1] , inmates also have concerns about privacy and fear of stigma. Many do not disclose their high-risk behaviors, such as anal sex or injection drug use, because they fear being stigmatized.
Community corrections settings, jails, and prisons represent an untapped venue to reach and engage historically undeserved key populations who are at increased risk for HIV.8 Systematic HIV testing is important to identify inmates with HIV before they are released. Early diagnosis and treatment can potentially reduce the level of HIV in communities to which inmates return.7 Also[MS2] , healthcare providers should keep inmate's healthcare information confidential and inform them about the public health confidentiality and reporting laws.
Infectious Disease Advisor: Which are the most important factors that affect health disparities in the setting of HIV in the United States?
Dr El-Bassel: In addition to risk behaviors, a range of social and economic factors places certain people in the United States at increased risk for HIV infection.
Key affected populations are confronted with a myriad of structural and social barriers to HIV testing and accessing antiretroviral therapy (ART) and services that prevent the propagation of the HIV/AIDS epidemic. These barriers include gender inequality and harmful gender norms that are deeply rooted in cultural practices and laws, the influence of masculine ideology on risk-taking behaviors, and stigma, racism, heterosexism, poverty, unemployment, and homophobia. In many cases, the United States is as regressive as less developed countries by failing to overturn HIV criminalization laws. In this country, more than 30 states support laws to prosecute people living with HIV.9 For example, a number of these laws criminalize HIV transmission if a person does not disclose their HIV-positive status before sex, whether or not the person transmits the virus to another. Most of those discriminatory laws were passed before science demonstrated that ART reduces HIV transmission risk, and most laws do not account for HIV prevention tools that reduce transmission, such as condom use, ART, or pre- or postexposure prophylaxis.
Infectious Disease Advisor: What are some additional factors that affect health disparities in the setting of HIV in the United States?
Dr El-Bassel: Poverty, discrimination, incarceration, language barriers, and opioid addiction are some additional factors fueling the HIV epidemic.
Poverty limits access to healthcare, HIV/STI testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford basic life necessities are more likely to end up in circumstances that increase their risk for HIV infection (eg, engaging in survival sex work). Poverty is a key factor associated with HIV infection.10 Individuals below the poverty line are twice as likely to be HIV infected as those who live in the same community but are above the poverty line (2.3% vs 1.0%).10[MS3] HIV infection is also more common among those who are unemployed and have less than a high school education.10
Discrimination, stigma, and homophobia remain prevalent against racial/ethnic and sexual minorities, PWID, and HIV-positive individuals. These factors may discourage individuals from seeking testing, prevention, and treatment services.
Higher rates of incarceration among men, especially black men, disrupts social and sexual networks in the broader community and decreases the number of available partners for women, which can fuel the spread of HIV.
Language barriers and concerns about immigration status present additional challenges to accessing HIV testing, prevention, and treatment.
Rising rates of opioid addiction increase the risk for HIV acquisition and transmission. Lack of appropriate harm reduction and drug treatment services is a barrier to reducing the spread of HIV.
Infectious Disease Advisor: What type of interventions do you see as hopeful in the future of HIV disparities research and care?
Dr El-Bassel: Unfortunately, no single HIV intervention offers a magic bullet. We need multilevel prevention strategies such as couple, community, and structural combination preventions (biomedical and multilevel behavioral) to address this epidemic. We must address the root causes of HIV transmission and acquisition. An AIDS-free generation is not possible without achieving equality and empowering key affected populations and supporting the communities in which they live and work.
We also need to focus our efforts on at-risk populations that are still HIV-negative. We need to improve access to prevention strategies including PrEP. As we know, the uptake of PrEP is quite low. Most individuals without insurance cannot still afford it. Although PrEP is highly effective in preventing HIV acquisition among people at high risk for infection, few have access to the necessary medications. In the United States, only approximately 10% of high-risk individuals who could benefit from PrEP are actually receiving the drugs, and this is not good enough.11
The scientific community needs to remain engaged and keep working with local and federal political and administrative entities to reach out to the poor and all the underserved populations.
A coordinated, collaborative approach that integrates health and human rights is integral to addressing the needs and cultural barriers of these populations and ensuring that all key populations will be effectively represented in future research efforts and healthcare.
Infectious Disease Advisor: One of your most important and unique contributions to the HIV prevention field is couple-based HIV interventions. Can you tell us a little bit about this strategy and how it can help reduce HIV transmission rates?
Dr El-Bassel: I have conducted a number of couple-based behavior interventions in the United States and in Central Asia. Project Connect is 1 of the first behavioral HIV interventions conducted in the United States and other countries.12 This project was initially designed to examine the efficacy of a relationship-based HIV/sexually transmitted infections prevention program for heterosexual couples, and whether it is more effective when delivered to the couple or to the woman alone.
When I designed this study (back in 2003), many did not believe I could get both individuals in a couple to join a study together to learn how to reduce HIV risk behaviors. The intervention was effective in reducing the proportion of unprotected sex acts and increasing the proportion of protected sexual acts.
Subsequently, I conducted similar studies among black couples in the United States,13 as well as couples who use drugs,14 with very positive results.
All my studies showed that working with couples can be a great modality to reduce HIV risks in various settings. This type of intervention can be integrated with biomedical research to increase ART adherence and linkage to care. As a consequence, the CDC requires all CDC-funded agencies to use the Connect intervention.15 We worked with CDC to adapt our strategies and develop the ConnectHIP. ConnectHIP is a 3-session, relationship-based intervention that helps couples to learn techniques and skills to improve the quality of their relationship, improve communication, and shared commitment to safer behaviors. ConnectHIP integrates techniques commonly used in family therapy, which will allow couples to work together to solve shared problems.
Infectious Disease Advisor: What are the specific advantages of using couple-based approaches (compared with targeting single individuals), and how can this be implemented to address HIV health disparities in particular?
Dr El-Bassel: There are several advantages to using a couple-based approach: it allows for both members to recognize their mutual responsibility in protecting each other from HIV transmission and encourages them to work together to stay healthy. It highlights the relationship's context (ie, commitment, love, trust) and its connection to HIV acquisition, subsequently drawing attention to the value and power of the relationship in behavioral change. Couple-based prevention aids in the creation of a safe environment to discuss sensitive topics such as sexual concurrency, power imbalances, and sexual coercion. It allows for couples to learn about and practice important skills such as communication and problem-solving with the support and guidance of trained facilitators. Finally, it promotes accountability and increases commitment to change. Couple-based prevention has also been shown to increase adherence to ART and has the potential to not only improve the health of persons living with HIV but also lower the risk for transmission within the pair by reducing the viral load of the infected partner.
Despite these many advantages, couple-based HIV prevention and intervention efforts remain limited, with most efforts focusing on individual approaches. In addition, couple-based HIV intervention studies have rarely targeted MSM or drug-involved couples, and none has targeted couples in casual, short-term relationships; sex workers who have regular sexual partners; or transgender couples.16 Future research would benefit from attention to these key populations, and careful consideration should be given to developing and testing couple-based HIV prevention interventions for different types of couples.
Infectious Disease Advisor: Can providers implement this type of intervention in their daily practice?
Dr El-Bassel: Yes, we have implemented couple-based interventions in the United States in different settings, as well as in Central Asia. The providers face some challenges related to learning how to work with the dyad, rather than focusing on an individual. There is a severe lack of knowledge about how to address dyadic health issues, and universally a lack of support from treatment agencies. There is some confusion about the definition of couples, as well as some barriers related to financial reimbursement for using such a modality as an intervention as well as assuring privacy and safety for each part. More training is required in different settings to promote couple-based prevention for behavioral and promotion of biomedical strategies, such as PrEP and ART.
Nabila El-Bassel, PhD, serves as the director of the Social Intervention Group, which is a multidisciplinary center focusing on developing and testing HIV interventions among key affected populations, with a special focus on PWID, sex workers, people in the criminal justice system, and MSM. In 2007, Dr El-Bassel established the Columbia University Global Health Research Center of Central Asia, which also focuses on the design and implementation of prevention and intervention studies for key populations affected by HIV.
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