In February 2016, a Centers for Disease Control and Prevention (CDC) report revealed a stunning statistic: Half of black men who have sex with men (MSM) will be diagnosed with HIV in their lifetimes.
Among black gay and bisexual men, the rates of HIV diagnosis are so disproportionately high that doctors and other medical professionals have been left scrambling to figure out what's behind the disparity. While only 1 in 11 white MSM will contract the HIV virus, the rates for black gay and bi men are 1 in 2.
According to the National Alliance of State and Territorial AIDS Directors (NASTAD), one problem driving the epidemic is bias on the part of doctors.
"Finding a good doctor as a black gay man with HIV is incredibly difficult," Terrance Moore, Deputy Executive Director at NASTAD, said in a statement. "Research shows that implicit bias stops many doctors from providing high-quality care to black Americans. Add to that a lack of understanding about the sexual health care needs of LGBT patients—and many men I know would rather stay home."
Mounting research has shown that racial bias plays a role in the quality of medical care given to black patients. An April 2016 study published by the University of Virginia found that med students and residents were more likely to minimize complaints of pain in black patients if they also showed measured evidence of racial stereotyping. The white med students and residents who did not show signs of racial stereotyping were more likely to offer appropriate treatment plans to patients.
Not only does racial bias play a role, according to NASTAD, but two-thirds of doctors still don't know about PrEP—the revolutionary daily medication that can prevent transmission of the HIV virus among gay and bisexual men.
Without knowledge and information specific to black men who sleep with men, doctors and other medical professionals are unlikely to offer appropriate treatment—including methods of HIV prevention.
That's why NASTAD unveiled His Health, a new training platform that engages medical caregivers in accredited courses that help them learn about the needs of the black MSM population. On the His Health website, medical professionals can take courses in PrEP, transgender men's health care, holistic health assessments, and cultural competency and engagement.
The website also introduces doctors and other caregivers to some of the nation's most innovative models for black LGBTQ healthcare, including Pittsburgh's Project Silk; Oakland's Crush Project; Indianapolis' Brothers United and the Damien Center; and Memphis' Connect to Protect and SMILE projects. The four model health care projects all adhere to an ethos of community-based programming—His Health encourages healthcare providers to "go rogue" and offer PrEP and HIV counseling in non-clinical spaces like youth recreation centers in order to meet at-risk populations where they already are.
Dr. Theo Hodge, an HIV specialist based in Washington, D.C., helped create the PrEP curriculum for His Health. Hodge—who is himself a gay, black doctor— told NBC Out that his black patients frequently encounter bias in medical offices.
"The typical story among those recently diagnosed with HIV is that they've had to return to the clinic on several occasions before the discussion of treatment comes up—up to three to four visits," Hodge said. Typically, a patient with a new HIV diagnosis is asked to come back once for viral identification, and then put on a medication regime immediately.
"But my patients have heard doctors saying they didn't believe they would take their drugs or adhere to the treatment," Hodge said, "and assuming that the patient needs to come into the office in order to take the medication. So essentially the providers are testing the patient by making them show up for several appointments before starting medication."
That's not only a biased assumption that black MSM patients are less responsible when it comes to healthcare—it's dangerous. Leaving a large window between a new HIV diagnosis and the launch of medication to suppress the virus means doctors are knowingly sending an active virus back into the community.
Besides the prevalent issue of implicit bias among medical providers, said Hodges, there are a number of other obstacles preventing black gay and bisexual men from accessing health care—especially care that relates to sexual behavior and sexually transmitted infections.
The nation's highest rates of new HIV infections occur overwhelmingly in the South. According to at-home STD testing company Get Tested, the 10 cities with highest rate of new HIV diagnoses are Baton Rouge, Miami, New Orleans, Jackson, Orlando, Memphis, Atlanta, Columbia, Jacksonville and Baltimore.
Hodge said there are complex cultural reasons underlying the higher rates of HIV transmission among southern black MSM. Frequently traveling in the South to speak about HIV, Hodge said he often hears the community there citing religion and family as reasons why more gay and bi men tend to stay in the closet.
"In the church when the pastor says 'All gays are going to hell,' you say 'Amen' because your mother and grandmother are right there in the church," Hodge said. "That kind of environment drives people underground and makes them less likely to access HIV services."
There is also historical distrust of the medical establishment among black Americans. Hodges said that while his white gay and bisexual patients were usually enthusiastic about participation in any kind of HIV research study or trial medication, his black patients were nearly always reluctant and suspicious of trials—raising the specter of the Tuskegee syphilis experiment, a 40-year medical study in which the U.S. government intentionally chose not to issue medication to black syphilis patients in order to study the spread of the disease.
"Overcoming those obstacles is a never-ending fight. They are present for so many of my patients," said Hodge, who added that he believed something like Tuskegee is unlikely to happen today. "And it knows no socioeconomic class—it ranges from the college professors to the guys working the car wash."
Community initiatives have been popping up with increasing frequency in order to fill gaps left in medical education when it comes to LGBTQ health care. Where His Health aims to educate providers about the specific needs of black gay and bi men, a similar project, Trans Line, was created for doctors unsure about how to treat their transgender patients. Rather than offering continuing education courses, though, Trans Line pairs experienced transgender health care providers with doctors in need of their expertise for individualized case consultations.
Why aren't providers simply learning about things like transgender healthcare and PrEP in medical school? In an August 2015 interview, former president of the World Professional Association for Transgender Health Jamison Green said there wasn't a single course in a U.S. medical school devoted to LGBTQ health. That means many doctors come out of school with little knowledge of how to treat communities they may never have personally encountered.
Green told the Daily Dot that "there was no way [medical schools] were going to teach something that isn't going to be reimbursed by insurance," referring specifically to transgender healthcare.
When it comes to black gay and bisexual men and HIV, medical schools aren't solely to blame. According to a 2012 report from the Black AIDS Institute titled "Back of the Line," federal agencies don't bother to track projects that focus on HIV prevention among MSM, despite the community's higher risk factor.
"No population in the developed world has been as heavily affected by HIV as Black men in the U.S. who have sex with other men," reads the 2012 report. "Those who ought to care—government leaders at federal, state, and local levels; leaders from Black America; the lesbian, gay, bisexual, and transgender (LGBT) community; and private foundations— have largely failed to exhibit needed leadership and commitment in fighting AIDS among Black MSM."
The Black AIDS Project report cited several reasons why the community was more at-risk for HIV infections, including sexual behavior patterns among younger black MSM and systemic contributing factors like poverty and violence. But chief among the reasons for the higher HIV rates among black gay and bi men: "Diminished health care access and health service utilization among Black MSM, reflected in late diagnosis of HIV, sub-optimal receipt of life-prolonging and prevention-promoting antiretroviral treatment, and poorer prognosis among those who are living with HIV."
In medical schools and clinics across the country, the Hippocratic Oath remains the standard of care: "First, do no harm." As doctors and medical providers encounter myriad communities, however, they don't always know the ways in which doing harm can take shape. For Hodge, the His Health program is a way to illuminate the best path forward for medical caregivers who he says truly do have the best intentions.
"Any healthcare provider who really believes it's their mission to provide the highest possible care should participate in this project," Hodge said. "Go through the program, unlearn your bias, then go forth and do what you've pledged to do."