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ClinicalThought: Combating Racial Inequities in HIV
How Can Healthcare Professionals Reduce Racial Inequities in HIV Care?

Released: September 15, 2021

Expiration: September 14, 2022

David Malebranche
David Malebranche, MD, MPH
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The HIV epidemic has persisted in the United States and worldwide for more than 40 years. Although many scientific advancements regarding HIV prevention and treatment have been achieved over the decades, social and structural advances in healthcare have lagged behind, leading to sustained racial inequities among Black and Brown people with HIV. 

As healthcare professionals, we have all experienced patients who were lost to follow-up in the HIV care continuum. Patients are linked to care and started on antiretroviral therapy (ART), but eventually fall out of care, and many never achieve viral suppression. This loss to follow-up is particularly pronounced among Black and Brown people.

Although many could explain these HIV inequities as the logical extension of racialized social inequities—in income, housing, transportation, employment, education, health insurance, and access to care—even when those variables are controlled for, the inequities in HIV persist. 

As a healthcare professional with more than 20 years of experience working in the HIV field, here are some thoughts on how we can improve engagement in HIV care among our Black and Brown patients. Spoiler alert: It’s not about new and improved single-tablet regimens!

Listen
Our patients come from varied backgrounds: different races/ethnicities, socioeconomic backgrounds, sexual and gender identities, religious beliefs. Health means different things to different people, and we should acknowledge that although we as healthcare professionals may be well trained in understanding the human body and the various conditions that can plague it, our patients are the experts of their bodies.

The word “doctor” comes from the Latin word “teacher.” The first part of teaching is not lecturing; it’s listening to what our patients are trying to tell us.

Creating a clinical environment where our patients feel heard above all else will go a long way in keeping them engaged in care and trusting that we have their best interests at heart.

Set a Tone With Your Language, Both Verbal and Nonverbal
You can’t talk about HIV without talking about sex, sexuality, and gender/gender identity. If you want patients to feel comfortable discussing these topics with you, set the tone. This starts with how you introduce yourself and getting pronouns/names right when addressing your patients. It then involves inviting open and honest conversation about sex and HIV into sterile clinical spaces so that real transparency can happen—without fear of judgment and discrimination. Be careful with phrases such as “HIV infected” or “risky sex.” Instead, discuss “living with HIV” or “sexual health.” While you’re at it, be cognizant of your body language during the clinical encounter. Are you looking them in the eyes? Are you doing a physical exam that lets them know you aren’t afraid to touch them? Do you lift your head up from your computer screen to show empathy and connection?

Many of our patients experience stigma and discrimination in their day-to-day lives; they don’t need to encounter more of it from healthcare professionals who are supposed to be partners in their health. People will initially come to medical appointments out of necessity. If they feel honored and respected, they will return for follow-up.

Do Unto Others
When connecting to the person sitting across from you as your patient, imagine yourself, a family member, or a loved one sitting in that same space—scared, vulnerable, facing a diagnosis that is not just like other conditions, but carries a particular social stigma and uncertainty with it. Even if their abundance of melanin is different from yours or their gender identity may not be how you would exhibit it, see yourself in them. See color, but don’t judge them by it. 

Imagine how you would like to be spoken to, how you would like to be heard, how you would like to be treated.

Consider all these things when addressing your patients’ lives, when discussing scientific advances with them, and when proclaiming that “HIV is not the death sentence that it used to be.” The art of HIV medicine lies in the interpersonal nuances between the healthcare professional and patient that should transcend racial stereotyping and bias and go beyond p values and confidence intervals. Your personal approach will keep people engaged so our scientific advances don’t go to waste. 

Your Thoughts?
When caring for people with HIV, have you practiced the skills of listening and choosing your language wisely? Answer the polling question and join the conversation by posting in the discussion section.

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How comfortable are you with encouraging open and honest conversation about sexual health with your patients?
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