Sex-positive HIV prevention that moves beyond perceptions of risk may improve PrEP uptake among young adults who identify as sexual/gender minorities of color.
“There are so many inequities and barriers that impact access to healthcare, healthcare quality, and health outcomes for young adults who identify as sexual/gender minorities of color (YSGM of color),” Allysha Maragh-Bass, PhD MPH, notes. “In terms of social determinants of health, structural racism, homophobia, transphobia, and political landscapes that aren’t supportive of affordable and gender/identity-affirming care are huge. Then, even with access to care, folx often cannot find clinicians who are trained in providing appropriate care for them or willing to engage in conversations about sexual health beyond reduction of STI risk.”
A “renewed focus” on HIV prevention in recent years includes Ending the HIV Epidemic priority funding from HHS, and the use of proven interventions such as PrEP, Dr. Maragh-Bass and colleagues wrote in a commentary published in AIDS. However, PrEP uptake remains low among groups at greater risk for HIV infection, including young adults of color who identify as YSGM in the United States.
Key collaborators of Dr. Maragh-Bass include Drs. Adam Sukhija-Cohen, Marie Stoner, Antón Castellanos-Usigli, Parya Saberi, and Sonya Arreola, along with Ms. Henna Patani, Ms. Ariana Katz, Mr. Harsh Agarwal, and Ms. Ashwini Deshpande. They discuss the need for updated strategies in HIV prevention counseling, including ones that reframe the concept of risk for YSGM of color. Physician’s Weekly spoke with Dr. Maragh-Bass to learn more.
PW: How does the perception that clinicians are judging them, and not their behavior, as risky influence willingness among YSGM to discuss HIV risk?
Dr. Maragh-Bass: The detrimental perception being conveyed is that the person is “risky,” rather than their behavior. It is one of the biggest drawbacks to engagement in care and taking PrEP that we’ve learned about in previous studies with youth of color who may identify as YSGM. Feeling judged and as though you are doing something wrong essentially adds insult to injury for young people who are already stigmatized based on factors like race, gender identity, and/or sexual orientation. Healthcare professionals may not consciously do this, but they still often conflate sexual practices with sexuality and sexual orientation. These are grave mistakes that can alienate young people who are still finding their way in terms of what sexual health means in their daily lives. It minimizes the chance for an open discussion about HIV prevention needs, reduces the chances that individuals will learn about, and get access to, innovations like PrEP, and increases the chance they may be diagnosed with HIV.
What might sex-positive PrEP counseling look like?
Sex-positive approaches to counseling are non-judgmental of sexual and gender expression and are more mindful of things like individuals’ personal autonomy as being central to their needs and decision-making around PrEP.
The concept of sex positivity in HIV prevention counseling is not new, but we argue for a new take on it. In the past, HIV prevention approaches that utilized sex positivity, including empowerment and skill-based interventions, still assumed that avoidance of disease and risk compensation were clients’ main motivators for choosing PrEP.
Our newer take is that risk is NOT the end-all, be-all. It is a part of the conversation, but that conversation should actually center on sexual health, sexual rights, and sexual pleasure. Normalizing routine discussion of priorities beyond minimizing risk helps to take the onus off patients, so that they aren’t always having to advocate for themselves and educate healthcare professionals about what they need. Young patients describe having to do this often—or avoiding care entirely!
What challenges impact the implementation of such counseling?
We should be careful and meticulous to ensure that we do not treat YSGM of color as one monolithic group. We must understand that this term YSGM of color refers to many different lived experiences and distinct identities. The first big challenge is that knowledge gap and being sensitive to it, as well as how it impacts HIV preventive care needs.
I’ve worked in clinics for many years. ANY type of change is hard and feels like one more thing for healthcare professionals in terms of workflow. So, how do we make these changes a routine part of the questions clinicians ask? It has to do with training, clinic and systems policies, and a continued focus on metrics to assess how well organizations are doing at retaining their clients who identify as YSGM of color AND having their care highly rated by these clients. Lack of accountability remains a large challenge as well.
I mentioned before that sex positivity is not an entirely new concept. All the same, another challenge is getting funders to understand and support this type of intervention approach that is seen as ‘edgy.’ While it may not have been our intention, we are definitely challenging the paradigms of how we have done decades’ worth of HIV prevention work. Put simply, we need to try something new because we aren’t achieving what we should have in many communities, not just with YSGM of color!
What additional research is needed?
We have so much more research to do! We are testing the impact of a toolkit developed to promote sex-positive HIV prevention counseling. The Pleasuremeter is a tool that healthcare professionals can use that asks clients to rate their experiences across seven topics, including physical and psychological satisfaction or enjoyment, self-determination, consent, confidence, privacy, safety, and communication/negotiation with partners.
Clinicians can choose the range of the scale (for example, 1-5 or 1-10) for each of the topics and the timeframe during which they want participant to reflect (for example, the past 3, 6, or 12 months). This allows them to tailor the tool for each client to promote comfort, as well as honest answers.
Beyond that, all researchers who work in areas like LGBTQ+ health inequities need to be doing more research that engages their communities directly and as early as possible in the research process; is inclusive of sexual pleasure and sex-positive approaches; fairly compensates all individuals for their time and lived expertise; and takes an intersectional approach in any stigma reduction interventions.
