As PrEP rolls out in communities throughout the U.S., it has become clear that not everyone has equal access to this groundbreaking HIV prevention medication. In many small cities and rural areas, PrEP is still a foreign idea instead of an exciting new approach that can save lives.
While the white gay community has hosted community forums, conducted outreach, and recruited men into prevention programs, there has been a lack of that type of support and enthusiasm from the Latino community. This has left a majority of men of color without knowledge about or access to PrEP. And even those who do know about it are unsure whether they should take it. It's all about cultural differences.
HIV in Latinos
In December of 2015, the CDC reported that new HIV diagnoses declined by 19% from 2005 to 2014. Unfortunately, that number continues to rise among Latino gay and bisexual men, and their new infections are up 24% -- the highest increase of any group. New diagnoses of HIV infection rose sharply from 2008 to 2013 among Latino men who have sex with men (MSM), despite an overall decline in infection among Latinos during the same period.
For the Latino community, there are many barriers to accessing PrEP. These became apparent to me when I facilitated a session of a Latino Men's Group last October. This group has met weekly for the past 23 years. Men of all ages and backgrounds attend, and topics range from sex, dating, and career plans to spirituality. The group also provides a space for self-discovery, community engagement, and learning to become effective social justice advocates.
In the meeting, a member by the name of Victor shared that after many years of having anonymous sex, he finally met someone he was interested in dating. It was then that he decided to start PrEP. He stated that finding that certain special man made him want to make an investment in his own sexual life and this new relationship.
This was a monumental step for Victor. He was going to do something that was proactive in his sexual life and he finally found someone special to share part of his life. In his excitement he posted on his social media page that he had met someone special and that he was going on PrEP.
As soon as he posted it, his ex-partner delivered a harsh comment equating the PrEP regimen to becoming a male whore. Victor fought back, stating that going on PrEP simply makes a statement that he is proud of who he is as a gay man. It shows his determination to enjoy intimate sex with a man he loves, while staying safe.
Once Victor made up his mind and took action, the world opened up for him. He made a conscious decision to move away from shame to a place of power. With that power came community advocacy.
Victor's story is powerful. It takes us on a journey from living under a shell to the normalization of sex, love, health, and wellness. It also highlights several issues specific to Latino culture. The coming-out process looks very different for each individual, and is a lifelong process. For many in our community, an open conversation about sex is still very much a taboo. For many, sex is still about secrets and shame.
A Latino man has to travel a long road to go on PrEP. First, he has to go to a medical provider for an exam. This is not something that most people in our community usually do. Then, he has to engage the doctor in the topic of sex. That can be very difficult for many Latinos, because they have to have a conversation that discloses intimate personal information.
That evening, other members of the Latino Men's Group shared that their primary care providers were not knowledgeable about PrEP. Many felt they had to train their providers themselves. Some felt uncomfortable about talking to their doctor about PrEP because the provider seemed unknowledgeable about gay sex -- a harsh reality of today's medical training.
Cultural Barriers to PrEP
Here in Los Angeles, clinical trials of PrEP were conducted in primarily white communities, making it difficult for people of color to participate. Even now, as PrEP is becoming more available in large cities, the number of Latinos taking it remains low. One reason is the lack of awareness and education about PrEP in certain groups.
In areas where PrEP is widely available, men are often encouraged to consider it after they have tested negative for HIV. Basic information about PrEP is provided and referrals are made. However, many Latinos are underinsured and visit the doctor only when they are seriously ill. You can't expect them to rush into a doctor's office and request an HIV prevention pill without first hearing some culturally appropriate outreach.
Research shows that many other barriers also contribute to the underuse of health care by Latinos, including poor interactions with providers, perceived health status, and cultural beliefs and traditions. Perhaps most importantly, many Latinos don't feel comfortable about talking about sex with their partners and friends -- that's part of our culture.
That discussion during the Latino Men's Group made it clear to me that the current roll-out of PrEP lacks in-depth conversations about the barriers it faces in many communities and the remedies to those barriers. For example, most Latino men do not talk openly about sex. And when we do, the conversation is usually not sex-positive. I try to imagine a Latino man walking into a doctor's office and talking about his sexual activities -- not likely.
Additional barriers to outreach for Latinos are language and cultural sensitivity. Outreach and education efforts for men in New York or Los Angeles should be very different from those in El Paso, Texas, or Kansas City. In addition, there are differences between Puerto Ricans, Mexicans, Caribbeans, and Central Americans. The differences may not be great, but they're still a major factor when providing services to Latino men. The prevention community must be sensitive to the cultural and ethnic diversity of the area where a program takes place.
According to David Flores of the University of Texas School of Public Health, "Understanding the perceptions of Latinos and their barriers to health care could directly affect health care delivery."
- Prevention efforts that speak to Latino men in their own language are very much needed. Such efforts must include outreach and recruitment into an empowering setting that promotes a sex-positive approach. Only then will Latino men feel at liberty to own up to their sexual experiences.
- All social media PrEP campaigns must be culturally competent.
- The CDC must fund research into the barriers that keep Latinos from accessing PrEP, in order to create recommendations for addressing the problem. That funding must also support prevention programs in our communities.
- Although behavioral HIV interventions are becoming a thing of the past, there is still a great need for programs that validate Latino men's sexual orientation and identity. They have to own their sexual experience, validate themselves, and take ownership of their health.
- We must normalize sex as Latino men. The more we do, the more we build pride. Only then will be able to have real conversations about HIV and sexual health.
- More PrEP capacity-building training must be given to health care professionals who work in communities of color. More training is needed in small cities and rural areas, which are usually the last to have access to and implement new practices.
Early in the epidemic, the government supported prevention efforts in communities of color around condom education. PrEP is no different. Men of color need to be provided with information that is culturally relevant. If we want to see more men of color on PrEP, new prevention campaigns are needed that target them. We need the financial and moral commitment to educate our communities about all available prevention options, including PrEP.
Richard L. Zaldivar is the Founder and Executive Director of The Wall Las Memorias Project in Los Angeles.