HIV Prevention, Young Gay Men of Color and the Fourth Wave of HIV Activism
November 15, 2013
Johnson, a gay-identified white male, echoed those sentiments, saying, "Everywhere I go, every social event I go to as a gay man, there's some poster up talking about HIV. I worry that it can enhance that sense of inevitability that you're going to get HIV."
Both Martinez and Usher expressed concern that the crafting of prevention messaging, which often includes messages of inevitability, has turned young gay men of color away from "authoritative" message purveyors and made the population more reliant on social networks. "[Prevention has] become more dinner conversation with friends versus going to some workshop, or some support group, trying to get counseled." Usher added, "It has to be done in a way that it's relevant, it's relatable; people actually want to hear it."
Caught in this tension between "relatable" prevention and the implementation of PrEP is the question of young gay men of color's relationship to the medical community. Martinez commented, "I think a lack of cultural competency between the medical community and young black gay men is a huge barrier."
This is a rift that Steever knows all too well. Describing the young gay men of color who walk through his clinic, he said, "Most of them have had not such great experiences with the medical field before. I try to be very open and welcome exploring what they are interested in doing. You don't want to scare somebody; you don't want to do things that make people feel uncomfortable."
While HIV-positive individuals can rely on infectious disease doctors who know about HIV and are often more willing to talk about sexual health and sexual relationships, there is a palpable fear among many PrEP advocates that primary care doctors, who will be the ones prescribing Truvada (tenofovir/FTC) as PrEP for HIV-negative patients, may be slow to write the prescriptions.
Usher, who asked his own gay-friendly doctor about PrEP, said he was met with hesitancy and excuses. "He knows about PrEP. His comment to me was, 'It's still relatively new. You're not at risk. You're only having protected sex.' If I knew nothing about PrEP and I went in and asked a doctor about it, and then he just automatically shut it down ... I want to take that extra protection for myself right now." Martinez quickly pointed out, however, "But it was an eligibility thing. You're not at high risk, right?"
Is it the doctor's right to determine whether it's best for a patient to take a medication that the patient thinks will help him to keep himself HIV negative? Opponents of PrEP point to poor rates of protection with low adherence and the need for more testing, while advocates for PrEP cite its better protection rates than birth control pills. While daily PrEP taking can have up to 99 percent efficacy, most hormonal contraceptives for women -- including "the pill" -- have a 9 percent failure rate.
Usher pointed to the difficulty for young men to take an active role in their health in current power structures. "When you're a young black male -- forget gay, but just young black male -- [you] listen to the doctor. So there's no questioning whatever it is that they recommend, or they view. Because that's the authority; that's the power." He added, "I do think a lot of men, especially black men, probably have low health literacy, when it comes to whatever the hell pill that they're prescribing me. Just know that I'm just going to take it; it's going to work for me."
With PrEP requiring a medical provider who's competent -- both in meeting the needs of sexually active clients who wish to discuss their sex lives, and on matters of PrEP -- and young black men often having a rocky relationship with the medical community, PrEP's uptake is slower than many had hoped. Not helping the situation is that the CDC has not yet released guidelines on PrEP, only "interim guidance" on its use -- meaning many providers might not feel confident in prescribing it. The early figures on PrEP uptake seem to indicate that women -- especially Southern women -- are at the forefront of PrEP consumption (outside of clinical trials).
Whether PrEP is useful on a community level or only on a case-by-case basis has yet to be seen. Whether to focus on a macro or micro approach is what Johnson called one of the "necessary tensions within public health ... There are just certain things that you can't totally reconcile. One is a population focus and an individual focus. What works for advocacy at the population level could have a really different effect on one individual."
Martinez and Usher had many disagreements on the data being used to describe young gay men of color. Infection rates among the group are skyrocketing, even though studies show, as Martinez pointed out, "We're getting tested at the same rate that white gay men are. We have fewer sexual partners than white gay men." Johnson corroborated that, saying, "We have actually seen that certain reported risk factors in communities of color may be less than we're seeing in white gay men. For example, number of sexual partners has been seen to be less in communities of color."
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