Latesha Elopre, MD MSPHby Latesha Elopre, MD, MSPH

I believe that physicians have patient experiences that shape how they practice medicine and, frequently, inspire research questions that launch careers. For me, these experiences center on my time as a fellow at the 1917 HIV Clinic. I remember the shame and sometimes horror experienced by a number of patients who were establishing care.

One such case occurred for a Black woman in her late 30s. I remember after reviewing her chart, I came into the room to see a woman frantically pacing across the room in tears. Before I could even introduce myself, she told me that she recognized someone in the waiting room from her neighborhood and was terrified that now everyone would know her status. That clinic visit, I spent the majority of my time trying to console and reassure her. To help her understand that her infection was not shameful nor a “scarlet A” for all to see on her chest. That individual she saw in the waiting room was there because he also was infected. Moreover, our understanding of HIV was not the same as it was 30 years ago. But, her tears continued and she did not return to see me for her scheduled follow-up appointment or the next. Finally, 6 months later she returned to the clinic with the support of her son.

The other case that has stayed with me was of a young, Black man in his early 20s. Again, I reviewed his chart and prepared the talk I give all new patients about the natural progression of HIV without treatment and all of the scientific advances made to improve care. Again, tears met me when I opened the door. He expressed the shame he felt and his guilt from how he contracted HIV. He told me that he knew it was wrong to be gay, but he continued to sleep with men, and now God had finally punished him. I remember imploring him to speak with his family for support, thinking that this had worked so well for my other patients. He actually did return for his follow up appointment and, at that time, told me he now needed housing. His mother had kicked him out after learning he was gay and told him he was a disgrace.

Both of these patients are now virally suppressed and engaging in care with more comfort at the clinic. But, their stories are not singular, and the stigma they faced which led to their delay in optimization of their care is unacceptable. In fact, in the United States today, young, Black men who have sex with men (MSM) are one of the only risk groups that are still seeing increasing rates of HIV infection. The CDC now predicts that 1 in 2 Black MSM will be infected with HIV in their lifetime.(1) Fortunately, rates among Black women are decreasing, but they are still disproportionately infected when compared to their white counterparts. One in 50 Black women will become infected with HIV in their lifetime.(2) While these health disparities are present throughout the nation, they are more striking in the Southern U.S.(3) Important individual and structural factors that predict higher risks for HIV acquisition among Black MSM and women include social marginalization, structural inequalities and high levels of intersectional stigma related to overlapping social identities, which may have unique aspects in the Southern U.S.

The FDA approval in 2012 of daily oral Truvada® for HIV pre-exposure prophylaxis (PrEP) reinvigorated HIV biomedical prevention research. A 92% reduction in HIV acquisition is seen with consistent use of PrEP.(4) However, the CDC has shown that while two-thirds of the people in the U.S. who have indication for PrEP are Black or Hispanic, they receive only 1% of prescriptions. The goal of my research is to understand how we can get effective HIV prevention tools like PrEP into the hands of the people who need them the most, namely young, Black MSM and Black women in the South.

The Hippocratic Oath calls on us as physicians to “prevent disease whenever [we] can, for prevention is preferable to cure.” I have taken this oath to heart and implore other researchers to do the same, for the pain our patients feel once infected with a highly stigmatized disease can last a lifetime.

References:

1. Center for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 26. http://www.cdc.gov/hiv/library/reports/surveillance/. Published November 2016. Accessed March 3, 2016.
2. Women and HIV/AIDS in the United States. 2014. Available from: http://kff.org/hivaids/fact-sheet/women-and-hivaids-in-the-united-states/. Accessed March 3, 2018
3. Center for Disease Control and Prevention. Vital signs: HIV prevention through care and treatment--United States. MMWR Morbidity and mortality weekly report. 2011;60(47):1618.
4. Cohen MS, McCauley M, Gamble TR. HIV treatment as prevention and HPTN 052. Current opinion in HIV and AIDS. 2012;7(2):99.