Leandro Mena, MD, MPH is founding Chair of the Department of Population Health Science at the University of Mississippi and serves as the STD Medical Director for the state of Mississippi.
Q: You’ve spent most of your career leading research about HIV and PrEP use, specifically focused on young Black men who have sex with men (MSM) in the South and other marginalized communities affected by HIV. How did you come to select these topics as the focus of your career?
I trained in infectious diseases in New Orleans because I wanted to become an HIV specialist. I worked with my mentor Dave Martin, who specializes in sexually transmitted diseases (STDs), and I gained appreciation for the importance of doing research around sexually transmitted infections (STIs) and sexual health. By the time I came to Mississippi as STD Medical Director, in many ways, I didn’t see the difference between STD prevention and HIV prevention.
When pre-exposure prophylaxis (PrEP) and PrEP data became available, I felt that I could significantly help by offering effective protection to individuals who are disproportionally affected by HIV. PrEP was a form of protection that no longer required a controlled, co-collaboration with a partner as condoms do – people could use PrEP on their own time. Granted, we know at least with men who have sex with men (MSM) and certainly with transgender women, PrEP allows for less than perfect adherence, and yet it is very effective.
Q: According to your 2020 article, “A Mobile Intervention to Improve Uptake of Pre-Exposure Prophylaxis for Southern Black Men Who Have Sex With Men: Protocol for Intervention Development and Pilot Randomized Controlled Trial,” Jackson, Mississippi has “the second-highest AIDS diagnosis rate in the nation and the highest rate of HIV infection for young, urban Black MSM.” What additional barriers to PrEP uptake and HIV care do young Black MSM face?
In the South, many of our states have not expanded Medicaid—which complicates the ability for high-risk populations like MSM and transgender women of color who do not have health insurance to access PrEP. It represents a significant poverty barrier that goes against the efforts of public health professionals working hard to bridge treatment gaps in high-risk communities. Clinical carriers are also often in the position to provide PrEP because they see high-risk HIV-negative patients who could benefit from treatment. However, these providers often do not provide services in a culturally competent and sex-positive environment.
In addition to these structural barriers, there is still a lot of patient hesitation and social stigma associated with HIV treatment and prevention. The care continuum for people living with HIV, compared to those working to prevent HIV, is slightly different. When living with HIV, you know that you have a disease and it is easier to convey the idea that without treatment, bad things can happen. With prevention, individuals that otherwise live as healthy people do not have much of an incentive or desire to take medication.
PrEP, at the end of the day, is an intervention that requires people to access and use our health care system—but our health care system itself is an uphill battle in many ways. For those who are HIV-negative and are trying to access PrEP, their motivation to overcome these challenges is less intense because they do not have a disease.
In my experience, oftentimes when I use the word “risk,” I feel that it gives an opportunity for my patients to exclude themselves and say, “Well, I’m not really at risk.” At that point, it becomes an issue about patients’ competing priorities, which may not allow them to access PrEP. Young people may be busy with school, their relationships, or their own lives in general. In particular, their relationship status can impact how people navigate the PrEP process as individuals sometimes feel the need to hide the medication from their partner.
Q: Additionally, in your 2019 study entitled, “Intervention Messaging About Pre-Exposure Prophylaxis Use Among Young, Black Sexual Minority Men,” you found that targeted PrEP messaging for young Black MSM actually discourages PrEP use due to enhanced feelings of marginalization. The study concluded that “broad and inclusive messaging would be just as relevant and cause less stigma.” How can we apply these findings to improve culturally competent HIV testing, health literacy, and PrEP services for this high-risk group?
Although we are familiar with community-based participatory research, we must ensure that our interventions and approaches are informed by the communities we are trying to serve. We must bring the conversations to our target communities and directly ask how they want to engage with these topics. One of the things that we learned in Jackson was that Black men did not want to hear about PrEP as just something for Black MSM. Rather, these men wanted to reduce further stigma by learning about PrEP through a more holistic approach and hearing it spoken of as a benefit for all people who are at risk for HIV.
In our clinics, we talk about HIV prevention in the context of many other things, which include cardiovascular risk, obesity, depression, and other diseases and conditions. This makes HIV prevention stand out less among other potential diseases for these high-risk populations. Through efforts like these, we must work to avoid further harm to these communities from our interventions and approaches.
Q: The theme for World AIDS Day this year is “Ending the HIV/AIDS Epidemic: Resilience and Impact” and one of the indicators used to measure progress is PrEP coverage, underscoring the importance of increasing PrEP use among underserved populations. What would be your message to the HIV community on World AIDS Day?
I think that this year has been a year of reckoning. COVID-19 has emphasized that despite previous efforts to eliminate the HIV epidemic, we must be even more deliberate in making sure our approaches are equitable. No population should be left behind – we need to invest in these communities that have not benefitted from all our scientific advances.