Photo Credit: Fizkes

Among Black women with HIV, who experience care disparities. U=U messaging is underused, and tailored interventions are needed to improve outcomes.

Black women with HIV continue to experience disproportionate disparities in care and outcomes despite significant progress in reducing HIV incidence in the US, according to a scoping review in AIDS and Behavior.

Researchers identified a significant gap in intervention research specifically tailored to support Black women with HIV. Although the evidence-based messaging strategy “Undetectable=Untransmittable” (U = U) can help reduce stigma and encourage Black women with HIV to engage in their care, it is underused.

The systematic review of peer-reviewed intervention was published from 2018 to 2023. Of the 669 participants, the mean age from studies was 45.4 years, and 91% of the participants were Black women with HIV.

“Despite the emphasis on U=U as a key HIV prevention strategy since 2016, none of the included studies explicitly described U=U or U=U messaging as an intervention component,” the researchers wrote.

The researchers recommended including community members in intervention design, healthcare systems, and policies. They also advocated including BWLH as co-investigators, community advisory board members, or staff members who can contribute to research design, implementation, and evaluation.

 An Outside Expert Shares Her Perspective

 Nadine Harris, MD, who was not involved in the study, spoke with Physician’s Weekly (PW) about the results and ways to provide optimal care to Black women with HIV.

PW: Why was it important to do this study?

 Nadine Harris, MD: Despite current efforts, significant inequities in HIV acquisition persist in the United States. The Southern US accounts for more than half of all new HIV diagnoses, and in Georgia, where I practice, new HIV diagnosis rates in 2022 were seven times higher among Black women than White women and two times higher than among White men.

 This study highlights that Black women with HIV are an important and deeply impacted demographic that is often overlooked when planning interventions to improve HIV outcomes. It is important to target interventions for HIV prevention and treatment to the groups that are most impacted.

Why has U=U messaging not been used in interventions for Black women with HIV?

U=U is a very relevant and necessary message that should be part of any intervention that addresses ART adherence, viral load suppression, stigma, and mental health. While we have accumulated a significant body of evidence over the last 10 years that supports U=U messaging, many clinicians still hesitate to convey this message, especially in the setting of viral blips or intermittent low-level viremia.

I tell my patients that, based on our large body of evidence, if their HIV viral load is consistently below 200, they will not transmit HIV sexually. This message should be incorporated into counseling during routine clinic visits, especially for people recently diagnosed with HIV.

How can clinicians apply intersectionality to their care of this population?

Clinicians need to acknowledge that structural inequalities that Black women with HIV face affect their access to care and health outcomes, often driven by social determinants of health. It is also imperative that clinicians provide culturally sensitive care, recognizing that Black women may have elevated levels of caregiving stress, elevated internalized stigma, and high rates of trauma.

What are some strategies for integrating mental health support?

This study mentions some interventions that have data for addressing the mental health of Black women with HIV. This includes telemedicine-administered psychotherapy to address depression symptoms and cognitive behavioral therapy to potentially decrease trauma symptoms.

A lot of data are available on the potential benefits of peer support in reducing isolation and increasing engagement in HIV care, although most studies have not specifically focused on Black women or mental health outcomes.

Finally, collaborative care models where the HIV clinician, mental health professional, and case management work as a team can help improve mental health outcomes in Black women.

PW: How can clinicians promote greater ART adherence?

Long-acting injectable ART administered in the clinic every two months (with the likelihood of greater intervals between dosing in the near future), has the potential to significantly decrease the fear of exposure that many patients unfortunately still experience. In addition, improving their mental health by removing the need to take a pill and be reminded of their HIV status daily can be life-changing.

PW: How can clinicians improve the care of these patients?

It is important to identify organizations willing to work closely with healthcare professionals where there is opportunity to get to know their leadership and mission and where there is transparency about goals, an easy referral process, and even warm handoffs. Community-based organizations led by Black women may be even more impactful.

It really matters that patients see that people who look like them take care of them. Patients are in a very vulnerable state when they enter the healthcare setting. Black women living with HIV who carry a high burden of structural inequalities, internalized stigma, and trauma are more likely to receive more culturally sensitive care from someone of similar race and gender. If institutions want to improve or enhance their HIV outcomes, it is important that they consider this.