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Data from HIV Prevention England and the Terrence Higgins Trust show much lower levels of knowledge about HIV pre-exposure prophylaxis (PrEP) in people of Black African origin living in England than there is among gay and bis*xual men, despite continuing high levels of risk behaviour and a much higher prevalence of HIV than people from other ethnic minorities. Chamut Kifetew told the recent joint conference of the British HIV Association and the British Association for Sexual Health and HIV about the impact of a short educational campaign, PrEP Protects, and responses to its self-assessment tool.

Although only 1.8% of the English adult population are of Black African ethnicity, 14% of all new HIV diagnoses in 2019 were among Black African people, rising to 42% of diagnoses in heteros*xuals. In the recent IMPACT trial of PrEP, only 4% of participants were Black African.

In developing the campaign, Kifetew said, she and her team had found very little previous research on the attitudes of UK Black Africans towards PrEP: “It really shocked us,” she said. What little research there has been showed low levels of awareness, as in this survey among women in London and Glasgow.

Glossary
post-exposure prophylaxis (PEP)
transgender
risky behaviour
syphilis
The PrEP Protects campaign started in mid-October, engaging people through social media, influencers and digital advertising. In its two-month run, 80,000 viewed the campaign's information page on PrEP, 67,800 clicked through to the videos and other informational graphics on the website and its YouTube channel, and 1254 people took the PrEP self-assessment tool (still available here). Research prior to the campaign had shown that potential viewers trusted information given to them by a Black health professional and so Doctors Vanessa Apea and Michael Brady took part in a couple of the informational videos.

Although viewers of the videos were invited to comment publicly, few felt comfortable doing so. But many sent private messages asking about the effectiveness of PrEP, its side effects and so on.

One interesting illustration of the general lack of awareness of PrEP was that a number of viewers sent in comments to “correct” the campaign’s information, assuming they had meant to talk about post-exposure prophylaxis (PEP) and had got their facts wrong: “You have to take it after s*x, within 72 hours” was a typical one. Others were not aware it was available for free on the NHS and confidently asserted that it cost at least £30 a month.

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Inevitably there were a number of negative and stigmatising comments: “You maybe won’t get AIDS, you’ll get syphilis”, said one. Another asked: “Are you a pr******te to need this?”

Of the 1254 people who took part in the PrEP self-assessment tool and specified their gender, 902 were men (including seven trans men) and 346 were women (including five trans women).

Interestingly, only 29% of respondents specified their ethnicity when asked. Of those who did, 68% were Black African, 19% White, 7% Black of other origin (e.g. Caribbean), and 6% of other non-White ethnicity.

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Regarding s*xuality, two-thirds (66%) said they were heteros*xual, 29% said they were gay or bis*xual men, 4% were gay or bis*xual women, and 2% defined themselves in other ways.

Remarkably, not a single Black African respondent said they always used condoms (compared with 15% of the gay and bis*xual men) and 53% said they never used them (compared with 34% of gay and bis*xual men).

This was despite the fact that, perhaps even more remarkably, 100% of Black African respondents said they did not know the HIV status of their partner or partners. In contrast, 58% of gay men did not know, 33% said their primary partner was HIV negative, 7% HIV positive but virally undetectable, and 2% HIV positive and virally unsuppressed.

More news from BHIVA & BASHH 2021
Respondents were also asked if their partner or partners came from a group at higher risk of HIV and specified what groups these were, including other people from high-prevalence African countries. Sixty-eight per cent of respondents said they did have at least one partner from a higher risk group, and 76% of the women did.

Find out more: Pre-exposure prophylaxis (PrEP)
Kifetew noted that the COVID situation had prohibited face-to-face meetings and workshops to promote the campaign – something that previous HIV prevention campaigns show that Black Africans tend to prefer to internet interventions. However, she said that it did appear to reach its target population and showed that a considerable proportion continued to be at risk of HIV and would benefit from PrEP. She urged further research into the HIV prevention knowledge and needs of Black Africans in the UK and for health services to consider how to address these needs.

References
Kifetew CA, Mukiwa T, Sparrowhawk A. HIV pre-exposure prophylaxis and Black people in England: addressing heath information inequities through a national campaign. Fifth Joint Conference of the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASSH), abstract O015, 2021

People with HIV in England had double the risk of dying compared to the rest of the population during the first wave of the COVID-19 pandemic up to 16 June 2020, Dr Sara Croxford of Public Health England reported at the joint British HIV Association and British Association of Sexual Health and HIV conference today.

The findings are similar to those of two large studies published in 2020, which also found a raised risk of death from COVID-19 in people with HIV in the United Kingdom.

The Public Health England study found that over two-thirds of COVID-19 deaths in people living with HIV were in Black, Asian or other non-White ethnic groups.

A second study, looking at COVID-19 cases reported to HIV clinics in the UK in the second wave of the pandemic, found that Black Africans had a higher risk of severe illness, as did people who were obese. The study also found that people with CD4 counts below 200 had a higher risk of severe illness compared to people with higher CD4 counts.

Public Health England: risk factors for COVID-19 death
The Public Health England study used HIV surveillance data, which stores anonymised information on people by first initial, date of birth, gender and neighbourhood, and matched these data with reported deaths from COVID-19 to identify all adults with HIV who died from COVID-19 between 2 March and 16 June 2020, the first wave of the pandemic in England.

The researchers identified 99 deaths from COVID-19 in people living with HIV. Detailed clinical records were available in 94 cases. This represents approximately 0.1% of the population of people with HIV in England, showing that overall COVID-19 mortality remained low in people with HIV.

Find out more in our About HIV pages
Croxford compared crude mortality rates from COVID-19 in people living with HIV and the rest of the population, finding the highest levels of mortality in Black people with HIV over 60 (985 deaths per 100,000), Asian people with HIV over 60 (781 per 100,000), people living with HIV in London aged 60 or over (722 deaths per 100,000) and people with HIV over 60 living in the most deprived areas (538 deaths per 100,000).

Crude mortality rates were lower in people without HIV aged over 60 in London (521 per 100,000), Black over-60s (751 per 100,000) and Asian over-60s (460 per 100,000) but in most other respects, differences in mortality were less pronounced.

Looking at the entire population, including people with HIV, four factors increased the risk of dying from COVID-19:

Gender: women were 45% less likely to die from COVID-19 compared to men (adjusted risk ratio 0.55, 95% CI 0.51-0.69, p < 0.001).
Age: each 5-year increase in age raised the risk of death by 79% (aRR 1.79, 95% CI 1.77-1.81, p < 0.001).
Ethnicity: Black people were at more than three times greater risk of dying from COVID-19 (aRR 3.44, 95% CI 3.06-3.87, p < 0.001), Asian people at more than twice the risk (aRR 2.24, 95% CI 2.00-2.52, p < 0.001) and other ethnicities at more than three times the risk compared to White people (aRR 3.23, 95% CI 2.86-3.65, p < 0.001).
HIV status: people living with HIV were approximately twice as likely to die from COVID-19 as people without HIV (aRR 2.18, 95% CI 1.76-2.70, p < 0.001).
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Among people with HIV who died of COVID-19, 53% were aged 60 or over. Sixty-eight per cent were Black, Asian or another minority ethnic group, whereas 35% of people living with HIV in England are Black, Asian or another minority ethnicity.

Over half (58%) had a CD4 count below 350 at the time of death, 94% were on HIV treatment at the time of death and 91% had a last viral load result below 200.

Eighty-seven per cent of people with HIV who died had at least one underlying condition that increased the risk of a severe COVID-19 outcome, most commonly cardiovascular disease (69%), obesity (49%), type 2 diabetes (48%), chronic kidney disease (41%) or high blood pressure (39%). The study was not able to compare the prevalence of underlying conditions between people with HIV and the rest of the population, so it is not possible to say whether people with HIV had a higher number of underlying conditions than people without HIV, which might explain the increased risk of death.

British HIV Association registry of COVID-19 cases in people living with HIV
More news from BHIVA & BASHH 2021
The British HIV Association (BHIVA) carried out a registry study of COVID-19 cases in people attending HIV clinics in the United Kingdom, to identify factors associated with severe outcomes. The study collected data between October 2020 and March 2021, the second wave of the pandemic in the United Kingdom.

As this study depends on clinics to submit data, and on the quality of data collected by clinics, this study cannot calculate what proportion of people living with HIV contracted SARS-CoV-2 or experienced COVID-19 symptoms. Furthermore, cases were included on the basis of either a positive COVID-19 test or symptoms that were suggestive of COVID-19. People who had the infection without symptoms and people with infections that did not lead to hospital admission are likely to be under-represented in this study, potentially leading to an overestimate of the risk of severe illness.

Find out more: COVID-19 and coronavirus in people living with HIV
Clinics reported 1310 cases and supplied a standardised dataset of demographic, clinical and lifestyle information and HIV-related data including most recent CD4 and viral load. They also reported COVID-related clinical information including potential exposure risks, testing, symptoms, hospitalisation and severity of presentation.

The study looked for factors associated with two outcomes: severe illness requiring oxygen or invasive ventilation, and poor outcome (either death, or continued hospitalisation or symptoms lasting more than three months).

The 1310 cases were predominantly male (62%) and half were aged 50 or over. Thirty-eight per cent were Black African, 56% were born outside the UK or had an unknown country of birth, 34% had an occupational risk for COVID-19 exposure and 16% had close contact with a confirmed COVID-19 case.

Of the reported cases, 78% had symptoms, most commonly fever (47%), cough (51%), shortness of breath (36%) and loss of sense of smell (23%). Fifty-nine per cent of these symptomatic cases had been confirmed by a positive test result. Just under 10% of cases reported were asymptomatic, of which 95% were confirmed by testing.

Looking at the HIV-related characteristics of the reported cases, just under 5% had a CD4 count below 200. Four per cent had an AIDS-defining illness at the time they were diagnosed with COVID-19.

"The findings reinforce the importance of advice for prompt vaccination against COVID-19 for people with low CD4 counts and/or recent AIDS-defining illness."

Although the median lowest-ever CD4 count was 257, the median current CD4 count was 611. Just under 15% of the sample were judged to be at risk of having recently had a detectable viral load, either because they were not on antiretroviral treatment, had been diagnosed in 2019 or 2020, or had had a confirmed detectable viral load since January 2019.

As for underlying conditions, reported cases had a median of one underlying condition known to increase the risk of severe COVID-19, most commonly high blood pressure (24%), obesity (19%) or raised lipid levels (17%). Thirteen per cent were current smokers. The median body mass index was 28 (IQR 24.5-32.3), placing the majority of the reported cases in the ‘overweight’ or ‘obese’ weight categories.

Twenty-three per cent of cases were admitted to hospital and 18% of the entire caseload had severe COVID-19 presentation that required oxygen support or mechanical ventilation. A severe illness was almost four times more likely in Black African people (odds ratio 3.90, 95% CI 2.46-6.17, p = 0.0001) compared to White people.

Similarly, people who were obese (body mass index of 30 or above) were almost four times more likely to suffer severe illness (OR 3.95, 95% CI 1.87-8.38). Each underlying condition associated with increased COVID-19 risk in the general population increased the risk of severe illness in people with HIV by 24% (OR 1.24, 95% CI 1.14-1.36, p = 0.0001). A current AIDS-defining illness also increased the risk of severe illness (OR 3.32 (95% CI 1.61-6.82, p = 0.005).

Glossary
detectable viral load
AIDS defining condition
high blood pressure
symptomatic
body mass index (BMI)
Women were at lower risk of severe illness than men (OR 0.46, 95% CI 0.30-0.71, p = 0.0004), and people with CD4 counts above 200 were at lower risk than people with CD4 counts below this level. There was no difference in the risk of severe illness between people with CD4 counts in the 200-350 range and those with CD4 counts above 350 (OR 0.40 and 0.50 respectively, p = 0.02).

Fourteen per cent had a poor outcome (either death or still hospitalised or symptomatic three months after presentation). After controlling for severe illness at the time of presentation, poor outcome was associated with shortness of breath (OR 2.36, 95% CI 1.44-3.87, p = 0.0006), underlying conditions (OR 1.17, 95% CI 1.05-1.30 for each condition, p = 0.006) and severe illness (OR 8.47, 95% CI 4.87-14.73, p = 0.0001). Age and CD4 count did not affect the risk of a poor outcome.

The BHIVA group conclude that the findings reinforce the importance of advice for prompt vaccination against COVID-19 for people with low CD4 counts and/or recent AIDS-defining illness.

References
Sabin C et al. Coronavirus (COVID)-19 in people with HIV in the UK: Initial findings from the BHIVA COVID-19 Registry. Fifth Joint Conference of the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASSH), abstract 08, 2021.

Croxford S et al. COVID-19 mortality among people with HIV compared to the general population during the first wave of the epidemic in England. Fifth Joint Conference of the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASSH), abstract 09, 2021.

Islatravir (MK-8591) is an antiretroviral drug with a novel mode of operation that has excited a lot of interest in the last two years because of its extraordinary persistence in the body. This means it may only need to be given once a week as an HIV treatment, and a subcutaneous implant that releases the drug might only need to be replaced once a year when used as pre-exposure prophylaxis (PrEP).

Pending the results from studies of an implant, however, a study presented at the HIV Research for Prevention (HIVR4P) virtual conference yesterday showed that islatravir as PrEP can be given very easily as a pill that only needs to be taken once a month.

Professor Sharon Hillier of Pittsburgh University presented the results of a US-based phase IIa study whose aim was to establish the level and persistence of islatravir in the blood and tissues of 250 volunteers aged 18-65 who were at low risk of HIV infection. Drug-level data in blood plasma is available for 192 people up to the end of October, which was the most recent date of analysis.

Glossary
plasma
phase II
phase I
oral
implant
The volunteers were divided into three groups: 100 volunteers each received six oral monthly doses of either 60mg or 120mg tablets of islatravir, while 50 received a placebo. After the sixth dose, drug levels will continue to be measured for another three months while participants and researchers are still ‘blinded’, i.e. do not know which study arm they are in, and then for a further five months unblinded.

Based on single-dose phase I studies, drug levels over each month and their range were forecast to stay well above the level of 0.05 picomols of drug per million cells which is the threshold of efficacy. The purpose of the phase 2 study was to see how closely actual drug levels fitted this model.

The 192 people whose results were presented had an average age of 32, and two-thirds of them were women. Nearly two-thirds (64%) were White, of whom one in six were of Latino origin, while 30% were Black; only a few were mixed-race or of other ethnicities.

Find out more in our About HIV pages
Islatravir is not completely without side effects, and more than half (53%) reported at least one adverse event, which may or may not have been connected to the drug. The most common ones reported were gastrointestinal symptoms (nausea, stomach pain, diarrhoea) and headache. Two discontinued the drug due to adverse events, one due to a rash, and four had transient rises in their liver enzymes. However, no adverse events were classed as serious. Six others discontinued the trial early for reasons not related to side effects.

"The once-monthly dose provides enough forgiveness for people to be a couple of weeks late in taking their next dose.”

The key data reported to HIVR4P were drug levels reported immediately after dosing and then each week during the first and sixth month of the trial. For the months in between, just the trough levels (i.e. the ones immediately before taking the next dose) were measured.

The trough levels each month were in the order of one picomol per million cells in volunteers taking the 60mg dose (in other words, 20 times the estimated efficacy threshold) and in the order of 40-50 times the efficacy threshold in those taking the 120mg dose. All levels fell within the pre-modelled range and indeed the range between different volunteers was considerably narrower than forecast, with only a two- to threefold range between the lowest and highest levels at any time point. Levels neither increased nor decreased over the six months, with the peak and trough levels remarkably consistent.

In a minority of volunteers, data was available for drug levels up to 28 weeks, which is eight weeks after the last dose. These levels were still four to five times the estimated efficacy threshold. Hillier said that this showed that the once-monthly dose “provides enough forgiveness for people to be a couple of weeks late in taking their next dose.”

A subgroup of 54 participants had biopsies taken to measure drug levels in re**al and vaginal tissues and also intracellular levels, but these results are not yet available. The phase I studies suggest that these are not likely to be substantially different to plasma levels.

In terms of efficacy against HIV, so far the only data come from monkeys, who were completely protected from viral challenge by monthly islatravir.

More news from HIVR4P 2021
However, human efficacy studies are imminent. The IMPOWER 022 study will recruit 4500 cisgender women in the US and in sub-Saharan Africa, and the IMPOWER 024 study will recruit 2000 gay and bis*xual men and transgender women in a number of different countries. Both will compare the efficacy of monthly islatravir against daily tenofovir disoproxil fumarate (TDF)/emtricitabine or, in the case of IMPOWER 024, either TDF or tenofovir alafenamide (TAF) plus emtricitabine. The enrolment of US participants in IMPOWER 022 will start next month, African participants a few months after that, and IMPOWER 024 will start enrolling in late summer this year.

The dose tested will be 60mg because it was felt that 120mg was not likely to provide significantly greater efficacy to be worth risking more frequent side effects.

In terms of how monthly oral islatravir PrEP will eventually be provided (assuming it’s effective), Hillier said “We envisage people could go to a pharmacy once a month and either take it right there or take it home with them. This would be ideal for people who don’t want an injection but also don’t want to risk the discovery of a bottle of pills.”

References
Hillier S et al. Trial design, enrolment status, demographics, and pharmacokinetics (PK) data from a blinded interim analysis from a phase 2a trial of Islatravir once monthly (QM) for HIV pre-exposure prophylaxis (PrEP). HIV Research for Prevention (HIVR4P) virtual conference, abstract OA04.05, 2021.

View the abstract on the conference website.

Black and Latinx people living with HIV and in poverty in New York City describe how their sense of self-worth is diminished over time and they become increasingly socially isolated as a result of the multiple challenges resulting from intersecting forms of stigma, discrimination and structural barriers related to HIV, poverty and substance use.

These challenges contribute towards disengagement from HIV care and lapses in medication adherence while many people develop resilience in response to adversity, according to qualitative research published in the International Journal for Equity in Health by Dr. Robert Freeman and colleagues at New York University.

Despite biomedical advances that have resulted in greater life expectancy for those living with HIV, large inequalities still exist in terms of the distribution of these benefits in the United States. Black and Latinx people disproportionately carry the burden of new HIV infections in the US, have longer delays between diagnosis of HIV and starting antiretroviral treatment (ART), have more challenges with adherence, and are therefore less likely to achieve and sustain viral suppression when compared to White counterparts. Living in poverty exacerbates the challenges associated with HIV care engagement, while factors such as stigma, substance use and mental health challenges result in further barriers.

The study
In-depth semi-structured interviews were conducted with 59 Black and Latinx people living with HIV in New York City from 2017-2019. They had lived with HIV for 20 years on average (ranging from 3-33 years) and ranged in age from 23-69; over three-quarters were non-Hispanic Black; 71% were male and all were of a low socioeconomic status.

Glossary
stigma
virological suppression
systemic
disclosure
qualitative
All had taken ART at some point in the past, while approximately 60% of the participants were taking antiretroviral treatment at the time of the interview and reported good adherence. Most participants reported substance use treatment in the past and presented with a moderate-to-high risk of alcohol and drug problems. Some participants reported unstable housing and precarious employment, while many reported food insecurity and other measures of extreme poverty.

Many years of hardship
The authors described the participants’ experiences through the lens of symbolic violence. Symbolic violence is a non-physical form of violence that is directed towards marginalised groups in society through processes, actions and words that emphasise and exacerbate their marginal status.

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Examples of this were frequent in the lives of the participants and included language (for example, how words like addict or AIDS are used), dismissive healthcare workers, substandard housing, neglect, outright discrimination and the indignities of incarceration. This symbolic violence is internalised over time, resulting in feeling devalued and dehumanised and leading to a gradual decrease in self-worth.

Participants expressed a feeling of being ground down over time dealing with hardships.

Often, this affected their will to live and their ability to remain adherent to ART and to manage their health, as these interviewees explained:

More news from United States
“Yeah, so you know during my incarceration you know with the stigma of HIV, AIDS, you know, and you have to go to what’s called pill line to get your medicine. So then you know you got people [asking] what’s wrong with him?... So from that point on I felt like a monster who needs to be in a cage. You know and then every time I take that medicine it was like a constant reminder. All those feelings come back every time I take those pills, so that’s kind of why I’ve had a problem taking them.” – Black man, 52, living with HIV for 15 years.

“Money was hard, so people pay for [HIV] meds, and I needed money. Sometimes I needed the money not so much for recreational use, for drugs or nothing, sometimes I just needed money for food. Or some things I needed in the house, toiletries. So I just said, hey, [I miss a month of ART], I just sell a bottle, hey. Sometimes it’s because I just give up, I’m depressed. Sometimes I lay there and – the medicine’s right there and I just don’t get up and take it…” – Black man, 47, living with HIV for 16 years.

“I lost my purpose to live. That was my reason for struggling with the whole thing [HIV care and ART adherence].... But [even] now I’m stuck with this stigma of either I’m gay or I’m strung out on crack or something like that, and I get treated as such.” – Black man, 52, living with HIV for 12 years.

Social isolation
Participants avoided social interactions with family, friends and health and social care workers as a way of managing the stigma and discrimination that accompany HIV and poverty. Participants spoke of social isolation as a strategy to avoid disclosure of their HIV status and anticipated stigma. Often, social isolation and substance use formed a vicious cycle that would prevent participants from engaging in HIV care and deprive them of much-needed social support and empathy.

“That made them feel small, very small. They were inviting me over to come eat, and I wouldn't even go.... Because I didn't feel like being stereotyped. I didn't feel like you running behind me every time I go to use the bathroom. [Crying] I didn't want to deal with that at all, so I just stayed away from them.” – Black man, 41, living with HIV for 11 years.

“I always embraced venturing into the unknown, but when I started getting high it was just like I'm scared, you know, I've been doing this so long, I was getting high so long. And I secluded myself so long that it was like I was scared to go out, I was scared to succeed, I was scared to try…” – Black man, 47, living with HIV for 28 years.

Complexities of engaging in HIV care
The intersection of HIV-related stigma, poverty, and other forms of marginalisation, such as racism, often came to the fore when participants talked about engagement with HIV care. They described instances of overt discrimination, stereotyping and apathy from providers.

"Participants’ ambivalence and distrust of healthcare institutions was similar to their feelings about other organisations which subjected them to surveillance."

Interactions with healthcare providers were often a source of distress for participants and ultimately contributed towards medical mistrust, a diminished sense of self and avoidance of these interactions. Symbolic violence was often enacted verbally and non-verbally in these interactions.

“Finding the right doctor without being judged, without being discriminated against [is challenging]. I was going through several different doctors to get HIV under control, and the first thing they thought – okay, he's positive, he's Black, he had to get it from s*x, and I didn't get it through s*x.... No, I'm not a streetwalker. No, I'm not a call girl or a pr******te – nothing like that…” – Black man, 41, living with HIV for 11 years.

“They'd just rather you die. So the care was not accessible or – to me my experience was bigoted.... I had a little fight left in me, so I decided to go to [another clinic]... They just [communicated to me], you're not important…” – Black woman, 41, living with HIV for 14 years.

Participants’ ambivalence and distrust of healthcare institutions was similar to their feelings about other organisations which subjected them to surveillance, in relation to incarceration, parole, court-mandated substance use treatment, child protective services and so forth. In certain instances, participants would choose to avoid healthcare visits as a way of asserting autonomy and resisting interference in their lives.

“They would use my medicine as a carrot. They would make me jump through hoops and do all sorts of types of things in order to get medicated, and I didn't feel that I wanted to go through that.” – Black man, 37, living with HIV for three years.

Sense of personal failure
Consistent with medical providers’ views, many participants framed adherence to ART and viral suppression as markers of success, while lapses in adherence and engagement with care were viewed as personal failures, rather than being the consequences of numerous systematic barriers and lack of support. Thus, participants tended to internalise the stigma they experienced and engaged in self-blaming. Often, they did not celebrate their ability to overcome obstacles.

"Lapses in adherence and engagement with care were viewed as personal failures, rather than being the consequences of systematic barriers."

“But I’ll tell you one thing. I’ll get tired of taking this medication because right now I’m in crisis… Because it’s been a battle, man.” – Black man, 61, living with HIV for 21 years.

“I want to take my meds. I know and hear the importance of taking your meds. It’s already proven that without meds I become very ill…Right, but the biggest problem right now is money, right. And sometimes you say you just don’t feel like taking [the meds].”- Latina woman, 33, living with HIV for 10 years.

“I would make them [doctor’s appointments] but then I would break them because there was just so much going on. And then I’d get to drinking because I’m frustrated and [when I am] drinking I would just be like, oh, well, f**k it.” – Black man, 50, living with HIV for 15 years.

Resilience
Despite the hardships described, some participants found ways of being resilient – either through resisting stigma and discrimination or through the support of caring and empathic healthcare providers. Resilience worked as a means of counterbalancing numerous challenges and often contributed towards engagement in care, taking ART and better health outcomes. It took a substantial amount of effort for participants to resist systemic barriers and discrimination and in many instances, achievements and successes were not as apparent to participants as their ‘failures’.

“I've discovered that I'm really not a bad person at all. This is the overall, but I've discovered that I'm not a bad person, and I need to stop punishing myself…” – Black man, 54, living with HIV for 23 years.

“She was an excellent doctor, and very open and very understanding… Not stigmatizing.… So, she was very, proactive – telling me, well, the same routine that you do your street drugs, I would like you to take these HIV meds. So, that kind of clicked in and that made me adherent.”

Conclusion
The authors conclude by proposing multi-level policy changes in order to remedy some of the findings of their study. This begins with viewing poverty and stigma as fundamental causes of HIV-related health and other social inequalities.

“Health and health disparities are embedded in larger historical, geographic, sociocultural, economic, and political contexts,” they say. “Thus, changes in a broad range of public policies, including those outside traditional health policy, are likely to be central to effectively addressing racial/ethnic inequities such as those in HIV.”

References
Freeman R et al. Understanding long-term HIV survivorship among African American/Black and Latinx persons living with HIV in the United States: a qualitative exploration through the lens of symbolic violence. International Journal for Equity in Health 19: 146, 2020 (open access).