In November 2014, the Office of HIV Planning held focus groups with adult heterosexuals. The groups discussed the men’s and women’s experiences with health care, their ideal health care experience, and HIV testing in Philadelphia. The full analysis and recommendations can be found here.
A low perception of HIV risk persists among heterosexuals in Philadelphia, despite the fact that there are almost equal numbers of heterosexuals living with HIV/AIDS (3,153) as men who have sex with men (3,140). However in recent years, diagnoses of HIV among heterosexuals have been decreasing in Philadelphia, from 316 in 2010 to 254 in 2014. Despite declining numbers of new infections in the overall heterosexual population, racial disparities among heterosexuals are stark. In 2014, there were 5,105 Black heterosexuals living with HIV/AIDS in Philly, 8 times as many as Whites (612) and 5 times as many as Hispanics (985). In 2014, there were 4,026 Black women living with HIV/AIDS, 7 times more than White women and 5 times more than Hispanic women.
According to the CDC, sexual risk among heterosexuals is quite common, including unprotected anal and vaginal intercourse and recent diagnosis of sexually transmitted infections. Many people have high-risk sex but do not recognize their own risk. In Philadelphia, 82% of men in the National HIV Behavioral Surveillance System sample had vaginal sex without a condom and 36% had anal sex without a condom in the previous year. For the women in the same sample, 86% had vaginal sex without a condom and 21% had anal sex without a condom in the previous year.
Racial disparities in HIV infection rates are not due to behavior alone. Powerful social factors like poverty, gender inequality, racial segregation and discrimination, and gender norms drive the epidemic in African American and other minority communities. Geography and racial segregation matter because people tend to socialize with people similar to themselves. This is a major factor in how HIV is concentrated in certain geographic and cultural communities. When examined geographically, areas with significant numbers of people living with HIV/AIDS are often areas with concentrated poverty and minority populations.
One of the major themes of the focus group discussions was how trauma impacts individual’s access to and comfort with medical care. Trauma is prevalent among many of the same communities that are most at risk for HIV including those in this report: women of color, African American men, especially those who have experienced homelessness and incarceration. The effects of trauma on health are varied. Trauma may cause healthcare avoidance, particularly for survivors of intimate partner violence. Health exams can be invasive and trigger traumatic responses, because of feeling a lack of control over one’s body. Evidence is growing that trauma negatively impacts immune function. Trauma is associated with poorer metal health, substance abuse, ART adherence and immunologic outcomes.
The following recommendations are based on the experiences and opinions of the focus group participants as well as the current literature and epidemiological data in Philadelphia (see full report for all references). These recommendations seek to address health disparities and decrease the number of new HIV cases in Philadelphia.
1. Trauma-informed care should be the standard of care. Considering the pervasive experiences of trauma for men and women of low socio-economic status (childhood and adult), all healthcare settings should work towards a trauma-informed culture.
2. Sexual and reproductive health care must be trauma-informed. All women should be screened for current intimate partner violence, as well as childhood and past sexual and emotional abuse. Appropriate referrals should be made for mental health and social support services.
3. Honor and maintain a patient’s dignity in all care settings. Patients who feel they are treated with dignity and are active participants in healthcare decision-making are more likely to adhere to treatment and trust their medical provider.
4. Holistic care that includes services for mental and physical health is essential for long-term health and continued engagement in primary and HIV care. Social support should be integrated into all health care settings, whether through case management, navigation services or peer support. Service providers should consider incorporation of childcare and respite services in services targeted to women, considering their caregiving responsibilities.
5. Continue and expand current efforts to make HIV testing routine in all primary care. Efforts should ensure routine screenings are happening in communities where HIV is most prevalent. Routine testing doesn’t rely on patient disclosure or recognition of HIV risk behaviors and will increase the likelihood that individuals are diagnosed and linked to care in a timely matter.
6. Include information about PrEP during pre- and/or post- test HIV counseling services. Individuals who test HIV-negative (for whom PrEP is appropriate) should receive information about where and how to access PrEP and provided with relevant referrals.
7. Community-level campaigns to raise awareness about HIV risk and prevention in the Black and Latino communities are needed. The campaigns should be broadly marketed to all members of the Black and Latino communities, not just to individuals of a certain risk profile or class. Local community leaders should be the messengers of the campaign.
8. Provide adult health education in community settings to improve health literacy to decrease health disparities. Programs should include information about sexual health and HIV/STI prevention, hygiene, nutrition, sleep, and the importance of health screenings. Specific interventions should focus on the health needs of Black men.