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Dr. Cheeley:
While it’s true that HIV diagnoses in the United States have declined two-thirds since the start of the pandemic in the 1980s, the Latinx community are still facing high risk of infections.  So what are the risk factors for this population?  And how can we improve their outcomes? 

Welcome to Clinician’s Roundtable on ReachMD.  I’m your host, Dr. Mary Katherine Cheeley.  And joining me today is Dr. Valeria Cantos Lucio, who’s an Associate Professor of Medicine in the Department of Infectious Diseases at Emory University in Atlanta, Georgia.  She’s also an investigator at the Ponce de Leon research site. 

Dr. Cantos, bienvenida el programa.  Welcome to the program. 

Dr. Cantos: 
Thank you so much, Mary Katherine.  Thank you for inviting me, and I’m very excited to talk about this important topic. 

Dr. Cheeley:
So let’s help set the stage.  How is HIV currently affecting the Latino community in the United States? 

Dr. Cantos: 
So for the Latino community living in the United States, HIV is disproportionately impacting gay, bisexual, and other men who have sex with men, especially those between ages 25 and 34 years old.  As you know, over half of all HIV infections in the United States occur in the South, so it is no surprise that the second highest incidence of HIV after Black men who have sex with men is among Latino men who have sex with men. 

Patrick Sullivan conducted a study a few years ago comparing HIV risk with certain factors between Black and White men who have sex with men, and the big conclusion was that individual risk behaviors were the same and that what actually impacted HIV risk the most were social and structural factors that represent barriers to Black communities to access the service to prevent HIV.  In research that we have conducted in a group, we have found a similar pattern where Latino gay and bisexual men, so it’s not based on individual risk factors, but it is more about lack of knowledge of ways to prevent HIV, such as PrEP; lack of access to culturally concordant and language-concordant services that provide sexual health services in the communities that they know and trust; and huge difficulty navigating the U.S. health system to get to those services.

And then in addition to that, there are similar risk factors that occur among other minority communities such as poverty, intersectional stigma, so not only being stigmatized because you are gay, because you don’t speak the language, because you may be undocumented, so it’s a complex situation because Latino groups, in addition to facing the same barriers of other minorities have added specific barriers, like the ones I mentioned—the language, the poverty.  They have competing priorities.  They have employments that do not allow them to leave to go to a PrEP appointment because they are working construction, because they work in kitchens, so there are no employer-based protections to allow them to access these services. 

Dr. Cheeley:
That’s a really great point and something that I hadn’t thought about that—I think we all think about the social factors, but there’s barriers even before you get to the doors of the health system, like you mentioned. 

 So are there unique barriers for the Latino community with diagnosis, first of all, and then access to treatment as well? 

Dr. Cantos: 
So we see basically the same patterns across all the status-neutral HIV continuum, so even for people without HIV, and then people with HIV, and most of them is a lack of social and structural support.  So people know that they need to get tested.  They just don’t know where to go to get tested.  Because of HIV-related stigma, they’re terrified of actually getting tested and finding out they have HIV.  They have this fear of perceived cost, so they already feel like they are on the outskirts of society; like they have been completely neglected, and they feel they’re not eligible for much, so they already know that, "I don’t want to go to that clinic because they’re going to charge me a lot of money, which I don’t have,” and two, “There’s not going to be any financial support because I’m uninsured,” and often undocumented.  A few years ago, we started doing HIV testing in clubs and bars very popular among the Latino population, and we noticed that people did not want to get tested because they didn’t want to go into the room where people could be talking like “Oh, that guy went to get tested for HIV.  I wonder why he’s going to go get tested.”  “Is he worried that he has it?”  So we’ve been trying to overcome these barriers by doing mail-in self-HIV testing, by normalizing conversations about HIV testing and treatment, by emphasizing concepts, such as undetectable equals untransmissible, etc., but it’s going to be a process, and it’s going to be a series of matters that would eventually lead to increase the rates of HIV testing among Latinos. 

For the treatment aspect, once they are linked to care, their HIV care continuum usually does great.  As a population, they have great outcomes once they have linked to a healthcare system that is affirmative and supportive. 

Dr. Cheeley:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD.  I’m Dr. Mary Katherine Cheeley, and I’m speaking with Dr. Valeria Cantos Lucio about HIV risk factors and barriers in the Latino community. 

So I want to dig a little bit more into these barriers and what specifically you guys have done at the Ponce de Leon Center to tear these down because it breaks my heart that folks don’t know that resources exist.  How do we make sure that everybody has the same level of access?  So loop me in on what you guys are working on. 

Dr. Cantos: 
What we have done with our group here—so first is understanding exactly what you just told us—so why are people not getting tested?  Why are people not accessing PrEP?  That was the first phase, understanding the route of the problem.  Because as a result of that, we encounter that difficulty accessing the service with one of the greatest programs, we developed a project, which is funded by CFAR, the Centers for AIDS Research, and it is part of the Ending HIV Epidemic program by the Federal Government and where we said, “The problem is access.  Let’s help with access.” 

So we developed first a community outreach program to raise awareness of, what is sexual health?  How do we keep each other healthy in a positive, nonstigmatizing way?  And then once we launched the campaign, that was routed to a peer navigation system.  So we trained a navigator.  The navigator is a Latino, bilingual, gay man, and then we did a list of health services in the local Atlanta area that do provide free or low-cost HIV prevention and treatment care.  And then we opened the campaign, and it was outpouring.  The navigator has navigated close to 60 people to HIV testing, PrEP, STI diagnosis and treatment, and so far the feedback from the community is so positive, and it makes us realize how much this is needed in a broader scale. 

What still is left to do is optimize the actual service provision, so even though they are known partners of ours, there have been delays, people have waited two to three weeks to get started on PrEP when we know that there are local services that offer same-day PrEP,  so that will be the next step—using an implementation science approach, how do we optimize the existing services for the Latino community? 

Dr. Cheeley:
So let’s talk a little bit more about the prevention side of things.  I feel like there are stigmas associated with it.  I feel like we’ve talked about that a little bit, but what do you think it’s going to take to decrease the rates of infections within the Latino community? 

Dr. Cantos: 
That’s a great question.  I think it’s going to be a combination of strategies to increase the uptake of the biomedical strategies that we know work, so it’s going to require increasing rates of HIV testing, increase the uptake of PrEP, increase the frequency of STI testing and diagnoses, and then increasing the rates of virally suppressed Latino people who are currently living with HIV. 

To reach all of these goals, there’s going to need to be policy, state, and federal support.  There is a paper that was published that, in states where Medicaid has been approved, uptake of PrEP has gone up in compared to people, to states that elected not to expand Medicaid.  Unfortunately, many of these states are in the South where over 50 percent of HIV cases occur and where many Black and Latino folks live.  And then another example is what has happened in California and in New York where it doesn’t really matter if you’re uninsured, if you’re undocumented, if you don’t speak the language.  There’s no wrong door policy that you can come in for HIV testing, and then you get routed to PrEP.  If you come in because you have syphilis, you get tested for HIV, and you get connected to PrEP.  So I think the HIV status-neutral approach, if it’s successfully implemented, will help to end the HIV epidemic in this community. 

Dr. Cheeley:
That’s a great point, and I almost want to close with that, but I know that you have so much more to offer me.  So do you have any other final thoughts you want to leave our audience with? 

Dr. Cantos: 
I know that many of our listeners are doctors and not all of them provide PrEP, but I do think that HIV prevention is something that all physicians can do.  We can all do it as part of our routine provision of healthcare.  It doesn’t matter if they’re Latino or not.  All of our patients should get HIV testing.  We need all of us providers, APPs, pharmacists, physicians to normalize conversations with our patients about sex. 

I usually practice with our internal medicine residents who come into our clinic on how to have these discussions in a nonstigmatizing and sex-positive way because that’s the only way that we’re going to know what our patients are doing.  So having these discussions, normalizing the same way that we have colon cancer screening, lung cancer screening, vaccination, just add HIV testing there, and then same thing goes for PrEP.  All sexually active people should be at least proactively by doctors, at least talk about PrEP.  

Dr. Cheeley:
This has been such a great discussion.  I would love to thank my guest, Dr. Valeria Cantos Lucio, for joining me today and sharing your passion with us and sharing your expertise on HIV in general, but specifically, in the Latino community.  Dr. Cantos, it was a pleasure hanging out with you today. 

Dr. Cantos: 
Thank you, Dr. Cheeley. 

Dr. Cheeley:
For ReachMD, I’m Dr. Mary Katherine Cheeley.  To access this and other episodes in our series, visit ReachMD.com/CliniciansRoundtable where you can Be Part of the Knowledge.  Thanks for listening.