Medical mistrust among Black Americans, resulting from systemic racism and a history of unequal treatment in healthcare, may play a role in COVID-19 inequities, specifically among Black Americans living with HIV, explains Laura M. Bogart, PhD. “Black Americans have had issues with access to the vaccination: making appointments, getting to vaccination sites, or not being in the top tier for vaccination if they are considered high risk,” she says. “These inequities can heighten mistrust, especially if there is the appearance of intentional bias and of White people receiving better treatment.”

For a paper published in the Journal of Acquired Immune Deficiency Syndrome, Dr. Bogart and colleagues examined a convenience sample of Black Americans who are HIV-positive (n = 101) for associations of COVID-19-related medical mistrust with vaccine and treatment hesitancy in May-July 2020. They also collected data on the negative impacts of COVID-19 on antiretroviral therapy (ART) adherence using electronic monitoring. Dr. Bogart explains that the study team wanted to learn about the levels of mistrust around COVID-19, the vaccination, and treatment, given the prevalence of inconsistent information and misinformation about COVID-19 prevention and treatment.

COVID-19 Inequities Affect HIV Inequities

A key finding of the study, she notes, is that people who experienced negative issues related to COVID-19—losing a job or housing, for example, or having a harder time getting healthcare—were less adherent to ART. “This suggests that COVID-19 inequities can have a downstream effect on worsening HIV inequities,” she says. “Physicians who provide HIV care may want to ask patients about any negative life changes, especially due to COVID-19 and should also check in with those who have missed appointments to see whether they are avoiding healthcare due to fears about COVID-19.”

According to the study, participants had high levels of medical mistrust of government information about COVID-19. “Nearly all (97%) participants held at least one belief showing mistrust around COVID-19, related not only to healthcare providers, but also to government information around COVID-19,” says Dr. Bogart. “There was a strong sentiment that information from the government cannot be trusted and that the government is intentionally lying, with malicious intent, to Black people. Almost one-third of participants believed that a COVID-19 cure was being withheld from Black people, and about one-quarter believed that when it comes to COVID-19, doctors do not have the best interests of Black people in mind. Only one-half felt that there is equitable medical care for COVID-19 for Black people and people of other races/ethnicities (Table).”  

Addressing Medical Mistrust

Individual healthcare professionals will not be effective in addressing medical mistrust among Black Americans with HIV, notes Dr. Bogart, unless they approach the topic sensitively, acknowledging mistrust and providing transparent information about COVID-19 prevention and the vaccine’s safety and efficacy. “Providers must also answer patients’ questions in a non-judgmental way,” she says, “and acknowledge the reasons for mistrust as being rooted in discrimination and racism and as inequities in healthcare.”

Dr. Bogart and colleagues concur that research is needed to develop and test interventions to train healthcare professionals about addressing mistrust in a sensitive, non-judgmental manner. “The good news is that, with more awareness of this issue, especially within the context of the COVID-19 pandemic, there is great interest in determining how to reduce mistrust by directly targeting discrimination and racism as reasons for inequities,” says Dr. Bogart. “We need to reframe the conversation about medical mistrust to be about how our healthcare system needs to change in order to increase trustworthiness. We also need to make sure that the conversation doesn’t come across as ‘blaming the victim’ for being ‘hesitant’ to take the vaccine or to receive healthcare.” It is important to develop messaging around the COVID-19 vaccine that acknowledges systemic racism as a justifiable reason for mistrust, prior to providing accurate information about the vaccine, she adds. “Only after we start the conversation by meeting people where they are, acknowledging why they feel the way they do, and listening to their concerns can we then offer accurate scientific information about the COVID-19 vaccine.”