Inequalities around HIV transmission and prevention fall along racial lines for a variety of reasons. Detroit, where more than three-quarters of the population is Black, has the highest prevalence of HIV in Michigan, according to the state’s Department of Health and Human Services. For every two white men living with HIV, there are 15 Black men living with the virus, according to the department. That’s partly due to the lack of access to PrEP, which when used as prescribed is highly effective in preventing HIV acquisition.
Numbers from the Centers for Disease Control and Prevention (CDC) show that, nationally, among PrEP users, 69% are White, 13% are Hispanic or Latinx, 4.5% are Asian American, but only 11% are Black. The disparities may seem overwhelming, but researchers at one of the region’s largest health systems, Henry Ford Health, hope a new computer-based PrEP training module for primary care providers will go a long way toward closing those gaps. Still in development, the module would teach doctors how to prescribe PrEP and simulate interactions with patients who could most benefit from it. And it’s hoped that it would get doctors talking about a patients’ sexual history as part of routine care, something that both doctors and many African American patients, experts say, are typically squeamish about bringing up.
Talking about sex
One goal of the physician intervention is to encourage primary care doctors to interact with patients like one family medicine doctor at Ford Health, Bianca Pittiglio, MD, already does, by opening up a sexual health discussion as part of routine care. “I will start with simple questions,” Pittiglio said. “‘Are you sexually active?’ And generally, if they say that they have more than one partner, I’ll ask if they ever heard of PrEP.”
If they don’t know about PrEP, and almost half of her patients know little or nothing about it when she brings it up, Dr. Pittiglio provides a handout and discusses the importance of the medication. If they choose to start PrEP, Pittligio will initiate testing that day (a negative HIV test result is necessary to start PrEP). This discussion is done even if the patient has come for an annual physical. But Pittiglio admits her approach is not typical. “With some of my colleagues, when a patient comes in and asks for PrEP, they have no idea how to start it, what to do and what the follow-up is,” she said. Pittiglio admits that many doctors didn’t learn about PrEP in med school or in residency, even if they’re relatively new doctors, unless they already had an interest in HIV prevention.
Another roadblock to PrEP access is departmental silo-ing. Even if a primary care doctor and the patient are comfortable talking about sex, and if the patient shows a need or desire for PrEP, there will be a hand off to an infectious disease doctor, throwing up one more barrier to getting the medication. “These aren’t really necessary referrals, and if physicians had information on how to prescribe it and what the follow-up looks like, I think that that would help physicians feel more comfortable with prescribing as well,” Pittiglio said.
With some of my colleagues, when a patient comes in and asks for PrEP, they have no idea how to start it.
Helping patients feel comfortable with their care provider is key. An issue in Detroit, and in Black communities, is often medical mistrust, according to Brianna Kline, a nurse practitioner at Detroit Public Health STD Clinic. Kline said that historical instances of medical mistreatment in communities of color have played a major role in why medical mistrust exists today, and that mistrust can prevent Black patients from opening up, or from coming to a healthcare facility at all.
“As an African American woman, I'm very transparent with my patients and telling them directly, that their communities, communities of color, or men who have sex with men, are highly affected, but HIV is a possibility no matter who they are,” Kline said. “[By saying that] they won’t feel like I’m labeling them, or making them think PrEP services are only for ‘certain types’ of people. Every day I feel like we are combating the issues related to stigma and medical mistrust in various ways.”
Kline underscored another issue facing some of the clinic’s patients: a lack of access to primary care doctors. “We might be helping them out by connecting them to a primary care doctor because they may have other things going on with their blood pressure that we checked while they were there, or not having seen a primary care doctor for an annual physical. Sometimes we create a pathway to get patients to other aspects of their care.”
In other cases patients have a primary care doctor, but that doctor won’t discuss sexual health. “Some patients say they feel uncomfortable talking to their primary care provider about sexual health needs, or feel they are being judged if they need services related to HIV testing or prevention,” Kline said.
Some patients may not feel comfortable going to a sexual health clinic, either. Pittiglio worries those patients, especially if they could benefit from PrEP, will fall by the wayside.
Removing some barriers to PrEP
At Henry Ford, about 10% of all people who are eligible have been prescribed PrEP. That’s unacceptable, said Elizabeth Lockhart, assistant scientist at Henry Ford’s Center for Health Policy and Health Services Research. Lockhart is researching the best ways to boost the percentage of PrEP users. The module she’s developing won’t necessarily remove the barriers of medical mistrust or lack of physician access, but she said it should go far in spreading awareness of PrEP among doctors and patients.
One of the unique aspects of being at Henry Ford Health is that we are in the city of Detroit but also serve a large patient population that may be either vulnerable to or living with HIV
“For physicians, that will involve some training on who’s eligible for PrEP, how to prescribe PrEP, the tests that go with it, the types of medications that are currently available and what follow-up is needed.” Lockhart said. In another part of the training, primary care doctors view scripted interactions between patients and providers to provide a model for talking to patients about sex in general, with the goal of taking PrEP out of the infectious diseases department and make prescribing it routine for a wider range of physicians.
An educational video will be “Detroit-specific,” she said. “There are some TV commercials about PrEP, but what we’re hearing thus far is that people don’t necessarily identify with those commercials. And specifically in the case of Detroit we’ve heard from some people that having different skin tones is important; having specific language and identities where people can identify with the city is important.”
The project also includes an interactive HIV risk assessment tool for patients, which Lockhart hopes will spur them to bring up the topic with their doctors. And to help them become more proactive about prevention, another goal is to give patients the option for a home HIV test.
“The idea is that we'll be sending this [test] to patients who have an appointment with primary care prior to their appointment,” she said. “That way they can either request the HIV test ahead of time or decide if they want to talk with their provider about an HIV test during their appointment, and then be connected with results and resources at that point.”
As for helping doctors to become more PrEP-savvy, Lockhart said the project is in the information-gathering stage, with an internal survey to see what tips would be most useful for providers to help patients open up about sex and take a sexual health history.
“We want to provide them concrete examples of standardized language, and how to talk with patients about sex,” she said. “The hope is that we give providers the tools that they will be able to use to work into their clinical workflow. We’re not trying to overburden them with additional things that they need to do. But sexual health is a huge part of individuals’ lives, and we want to equip care providers with tools that will eventually make [discussion of sex] a standard practice.”
Sexual history should also be part of a patient’s record, especially if they might be at risk for HIV, Lockhart said. “Being in a healthcare system, we have access to knowing if somebody has been diagnosed with an STI in the last six months. We can see the last time somebody was tested for HIV, for example. So we’re going to be basing these kind of PrEP alerts off of STI status, and other indicators, based off of the CDC protocol guidelines.”
Detroit, where more than three-quarters of the population is Black, has the highest prevalence of HIV in Michigan.
Lockhart said the next area of research will be how to identify people who may need PrEP in other settings, like urgent care, and get them connected to primary care for follow-up. “One of the unique aspects of being at Henry Ford Health is that we are in the city of Detroit but also serve a large patient population that may be either vulnerable to or living with HIV,” she said. “I hope once we figure out which combination of different factors works best, that it could be made applicable in other large healthcare systems and other cities.”
LARRY BUHL is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, The New York Times and others.