Adaora Adimora, MD, MPH, is a Professor of Epidemiology at the UNC School of Medicine and Co-Director of the Center for AIDS Research.
Q: Your career has largely focused on the epidemiology of STDs and HIV in women and minorities. What drove you towards this specific line of research?
A: For a long time, we have observed marked differences in the rate of STIs between Blacks and whites. Soon after HIV came on the scene, differences between Blacks and whites were observed with HIV as well. Back in the 1980s and early 1990s, there was an emphasis on “risk behavior” and “risk groups”. An underlying implication was that Black people in general had “higher risk” sexual behavior than whites. As a Black person with involvement in the Black community, that generalization just did not ring true to me. One thing I noticed was that a portion of Black people I saw with HIV, especially women, had behaviors that did not differ significantly from those of the general population. Some of them had few sexual partners, no drug use. Many didn’t have partners who use drugs or partners who were men who have sex with men (MSM).
Around the same time in the early-to-mid 1990s, there was increasing interest in sexual network patterns and the spread of infection through networks of connected people. Martina Morris, for example, was publishing her groundbreaking work about concurrent partnerships, which is when an individual has overlapping sexual relationships with more than one person. It seemed to me that this could be contributing to the higher rates of HIV and other STIs among Black people. To be clear, this is not saying that Black people have different moral standards, or that whites don’t engage in these behaviors. Rather, it was clear from my own lived experience as a Black person—and from the work of sociologists like William Julius Wilson—that larger social forces like macroeconomics, racism, and their associated effects likely influence behaviors that increase the vulnerability of Black Americans to HIV and worsen health outcomes.
Importantly, the work of the late Paul Farmer introduced me to the idea of structural violence, which is a concept that was first written about by Johan Galtung in the 1960s. This concept stresses that these forces are structural, that they are baked into the system, and that they damage people in a way that limits their life chances. These forces are also so ordinary that they’re almost invisible. The idea is that, although people’s individual behaviors affect their likelihood of getting HIV and other STIs, there are larger systemic forces that affect groups of people unequally and increase their vulnerability to these infections, as well as worsen their outcomes once they have them.
Q: As part of a six-paper series in The Lancet, you authored a paper titled “HIV and women in the USA: what we know and where to go from here”. In it, you address the U.S. plan to end the HIV epidemic by 2030. What are the unique factors impacting women in the HIV epidemic and how will addressing those specifically help us reach our goals?
A: Black and Hispanic/Latina women are disproportionately affected by HIV compared to white women. The factors that impact women in the HIV epidemic are mostly those, in my view, that are associated with being an oppressed racial minority in the United States. In addition, there are strong intersectional and probably synergistic links between race, poverty, sexism, and HIV. While men who have sex with men bear the lion’s share of the burden of HIV in this country, almost one in five new HIV infections in the U.S. are among women. We will never end the HIV epidemic without attending to HIV among women, as well as the socio-economic factors that contribute to it.
Q: Part of your paper focuses on PrEP use among women. You mention that although the annual percentage change in PrEP use among U.S. men increased by 68% from 2012 to 2017, use among women during the same period only increased by only 5.4%. What factors did you identify that account for this drastic difference?
A: There are several major reasons. First, many women haven’t heard about PrEP at all. In addition, many of those who have heard of it do not think its use is applicable to them, so they don’t ask for it. Second, I suspect that some providers are not comfortable prescribing PrEP at all. Third, some providers do not think of offering PrEP to their female patients or exploring whether its use is warranted. I think some providers make assumptions about their patient’s behavior and the behavior of their patient’s partners or aren’t comfortable talking about sex in general. Consequently, they may not realize that the female patient in front of them might benefit from PrEP.
Fourth, cost is an issue and for uninsured people, and the paperwork required to get free PrEP may be a barrier. Fifth, and this is a huge reason, there is often too little time in the office visit or clinical encounter. Providers are supposed to talk about smoking, screening exams, exercise, mental health, and intimate partner violence, as well as the patient’s existing medical problems, and anything else the patient wants to talk about. You can therefore imagine that providers may have difficulty prioritizing sexual health—including PrEP—during an office visit that is 30 minutes or less, especially if it is not obvious to them that the patient needs or wants PrEP.
Q: Your paper also notes that women are under-represented both in HIV research and as subjects in clinical trials. What effect does this underrepresentation have on health outcomes for women? What recommendations do you suggest for increasing the inclusion of women in this field?
A: It is important to note that women are not just men with estrogen. In addition to hormonal and physiological influences that differ by sex, the context of life differs substantially between men and women. The paucity of women in research means that there is less data to understand the health outcomes and conditions that affect them, how these conditions manifest, and how to treat them. We also need to understand how women feel about biomedical products and whether they can access and use them. Products cannot work if they’re not used. A lack of data on women puts them at risk for being left behind by biomedical advances.
In terms of what can be done to increase the inclusion of women in this field or in research generally, researchers need to remember that participation in a clinical trial is a tremendous act of altruism. Research staff should approach them with respect and consideration, and women need to be properly compensated for their time and the unique difficulties that they may have with transportation, childcare, and jobs. Many women may not have the autonomy that men with higher incomes or higher status jobs might have to easily take time off from work to participate in a trial. Working with community-based organizations and others from the community is also essential in terms of getting women into trials. Funding agencies need to consider all of this as well. They can use carrots and sticks to strongly incentivize researchers to ensure that they include women in research that they’re funding.
Inclusion in clinical trials is critical, but the funders need to make sure that they properly consider other types of research, including qualitative and social science research that explores questions that are meaningful for women. Including, for example, how and why interventions do or don’t work, and their effects on quality of life.
Q: March 10 is National Women and Girls HIV/AIDS Awareness Day (NWGHAAD), which highlights the impact of HIV and AIDS on women and girls. What message do you have for women, girls, and their support community on this day?
A: While new infections among women in the US have decreased in recent years, now is not the time to be complacent. We need to continue our efforts, and in particular continue our fight for social and reproductive justice. One issue that we can all get behind is the need for healthcare coverage and access for all men and women. It is a disgrace that most of the states that have not expanded Medicaid are in some of the poorest areas with the highest rates of HIV, STIs, and other comorbid conditions. We need to vote in our own best interests and encourage others to do so as well.