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The Rising Rates of HIV Among Black and Latino Men: What's Going On?

June 23, 2010

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Kenyon Farrow: Now, I want to move on to a couple of different kinds of trends in HIV prevention that we're hearing more about. As many of you know, the stories in the paper over the last couple of days have named a new HIV test that is able to test new infections faster than the test that we've currently used most readily, which tests for the HIV antibodies; and people seeing this as a way to test people earlier and get folks into care sooner, as a way of stemming the tide of the epidemic.

We hear a lot of folks talking about the community viral load, right? So, in a particular, either geographic, or community, or sexual network, or amongst, say, black or Latino MSM -- if we get people into treatment and lower the overall community viral load, how will that potentially decrease new infections?

And we hear a lot of those different components under this rubric of test-and-treat, right? As a new medicalized intervention model. So I would just like your opinion about the test-and-treat model as a potential way to decrease new infections, and whether you see it as useful, or where you see different problems with it. We'll start with Vaughn.

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Vaughn Taylor-Akutagawa: Well. It's interesting. Whenever I hear the test-and-treat concept, my first thought is to ask the question: What happened to primary prevention? It seems that we've just given up on keeping people uninfected.

While I think testing and treating is a great medical application of reducing community viral load, it does not in any way address access-to-care services from a client's perspective. Almost everyone said, "Let's partner with a medical provider, and things are going to happen. OK." Most of these testing services here in New York City have no clear mechanism for connecting someone who turns up positive to services after 9 p.m. at night. If you do a quick analysis of Web sites and where people meet, most of the time they meet under risky behavior after 9 o'clock at night.

"So while it's great to say that we're going to get people in there, and we're going to reduce the community viral load, most people can't give you a clear definition of what they consider 'community.' And for those who aren't out, they don't know the names or the status of their partners. They don't even ask. They barely ask about condom usage."
-- Vaughn Taylor-Akutagawa

The barrage of paperwork in getting someone access, too, is intimidating. So while it's great to say that we're going to get people in there, and we're going to reduce the community viral load, most people can't give you a clear definition of what they consider "community." And for those who aren't out as openly gay or bisexual, they don't know the names or the status of their partners. They don't even ask. They barely ask about condom usage.

So it's one clear platform. But I think there need to be more things used in conjunction with that to actually think about seriously reducing community viral loads.

Kenyon Farrow: OK. Sheldon?

Sheldon Fields: As a medical approach, yes; we have no doubt that if you test people, they get to know their status. And once they know their status, then one would hope that they would engage in preventive behaviors, or be brought into a system and taught preventive behaviors so that they do not pass their infection onto anyone else.

We also know that if we put people on antiretroviral medications, we decrease their viral load; we [decrease] the efficiency at which they are able to pass HIV infection onto another potential partner. Those are medical facts. We know that.

I agree with one of the things that Vaughn just mentioned, though -- which gets us into the whole: Do we test everyone for HIV? And I say, we only make HIV testing mandatory if there's an absolute guarantee of access to medical services. I think it's unethical to test someone, give them a diagnosis, and not provide them with treatment.

Now, as someone who also is very much interested in health policy, and is currently doing a health policy fellowship: There was a reason why a lot of things pertaining to HIV were not folded into health care reform. Because we cannot yet guarantee that the primary care workforce, those initial front-line people who are going to intake a lot of people into the medical system; we cannot assure that they have the knowledge and the ability to deal with people who actually have HIV. A lot of those providers have never had training in HIV, beyond what they got in either their medical program, physician assistant program or nurse practitioner program. They have no depth of knowledge.

Until we are able to provide that depth of knowledge to all primary care providers, we just cannot throw open that floodgate. Because you're going to have people who then are going to be severely mistreated and abused once they come into the system by people who just don't know any better. And once those people are turned off to treatment, it's going to be very hard to get them back in.

Kenyon Farrow: And Francisco, your perspective?

Francisco Roque:If you were to ask me, I would absolutely say to you I would want as many people as possible tested and treated. Right? That's absolutely certainly the case.

I think that we do a disservice to think that we can create this test-and-treat agenda as preventionists, and that we'll be able to successfully bully our way into having communities of color tested and treated. Right? There are certainly cultural factors at play here. And there is a lot of resistance in folks. Still, there's a lot of distrust of the medical institutions, and care.

Again, this takes me back to the urgency around including community in the development of interventions and messaging, and the development of our approaches. We cannot expect that folks will just come along and begin to test and treat at higher numbers, because that's how we're promoting our services, and because funding streams are dictating that we simply test and treat.

I think that it becomes really important that we look for ways in which we can develop interventions that look to actually have an impact on a cultural level, on the dynamic of folks who are not looking to be tested and treated, as well. We certainly have access to care issues. I can certainly speak for myself; something almost needs to be falling off before I go to the doctor. That's the case for most men, and that's the case for, certainly, most men of color.

And then it becomes even more complicated when you think about the stigma related to HIV and homophobia, and what it actually looks like to access care consistently -- and the fact that we are conditioned to medicate ourselves with drugs and alcohol when we are in crisis. That becomes our go-to. Our go-to is often not to get into mental health services. It's just not.

Until we look to create some creative ways to address that, and model behavior for folks, and offer up options that meet people where they're at, we will not successfully test and treat high-risk individuals within our communities. It's just going to be extremely challenging. And we do a disservice to not address that tertiary area first.

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