Dr. Russell Brewer currently serves as a Research Associate Professor at the University of Chicago Medicine and Director of Health Equity Research at the Chicago Center for HIV Elimination. From 2011-2017 he was the Director of the HIV/STI Portfolio at the Louisiana Public Health Institute in New Orleans, Louisiana.
Your research and programmatic efforts have been focused on addressing the “socio-structural” barriers to HIV prevention and care among Black men who have sex with men (MSM) and people living with HIV. What drew you to this line of research?
I was always interested in public health growing up. I went on to pursue a master’s and doctorate in public health. My interest in HIV prevention grew when I served as a Program Manager at AED in Washington, D.C. This was back in 2008, when I was working on an initiative to build awareness and support for HIV vaccine research among populations most impacted by HIV in the United States including Black and Latino men who have sex with men. I became increasingly interested about how incarceration impacted the health and lives of Black men who have sex with men (MSM). I applied for the HIV Prevention Trials Network (HPTN) Scholars Program. As part of that program, I examined the impact of incarceration among Black MSM in the U.S. enrolled in one of the largest studies (HPTN 061) conducted among this population from 2009-2011 in 6 US cities. I discovered that about 60% of participants enrolled in the study reported a history of incarceration. From that study, I wanted to not just document the impact of social factors such as incarceration, but also develop programs in response to those factors which serve as major barriers to HIV services.
AIDSVu’s new PrEP data shows that in 2021, Black people represented 40% of all new HIV diagnoses, but only accounted for 14% of PrEP users in 2022. Based on your research, what do you see as the biggest contributing factors to this disparity in PrEP use?
We have to look at this from multiple levels. At the individual level, we must ask ourselves, “What do I know about PrEP, and is PrEP for me?” I recently presented on PrEP implementation in jails and afterwards one of the participants in the room approached me and asked, “Is PrEP for me?” It made me realize that there is not a saturation of PrEP information in general and there have been a lot of missed opportunities to talk about or provide PrEP information in multiple settings such as provider offices, schools, correctional settings, you name it. People need to know if PrEP is the right option for them and how it can potentially benefit them.
Next is looking within health care settings and our communities. Stigma and discrimination, particularly PrEP stigma and intersectional stigma are contributing factors to this disparity in PrEP use. Numerous studies among Black people have documented how stigma and discrimination serve as major barriers to getting an HIV test, accessing PrEP, and staying on PrEP. No one wants to be judged or treated differently. That is why building trust and creating a welcoming practice or environment is crucial to supporting PrEP use among Black people. Other factors such as limited transportation, lack of health insurance, unstable housing, and unemployment also serve as major barriers to PrEP initiation and continued use. All of those factors—which may also be co-occurring—impact whether Black people are going to access PrEP or take it for an extended period of time.
Something else I’ve thought about, particularly as it relates to the South is that there must be a strong “culture of health.” When reviewing America’s Health rankings, many of the jurisdictions that have poor health rankings are located in the South. How can we expect to see health improvements or increases in PrEP uptake among populations that may benefit the most from it if there is not a strong culture of health in those jurisdictions?
You co-authored a paper last year on status-neutral interventions to support health equity for Black sexual minority men. What is a status-neutral intervention, and how does it differ from other approaches?
A status neutral approach is a whole person approach. It aims to bridge the divide between HIV treatment and HIV prevention. It recognizes that many of the factors that impact access and retention with these services are similar client-to-client, regardless of their HIV status. With the status-neutral approach, individuals can conveniently access a comprehensive range of HIV treatment, prevention, and essential services within a unified setting. By integrating HIV treatment and prevention efforts, the approach normalizes both aspects, contributing to the de-stigmatization of HIV and promoting a more inclusive and supportive environment.
In terms of how the process works, those with a positive HIV test will be directed towards the treatment pathway, prioritizing prevention of further HIV transmission. This involves connecting them with a healthcare provider who will facilitate access to necessary medications and treatment options. On the other hand, individuals who receive a negative HIV test result will actively participate in HIV prevention efforts, including the provision of effective tools like PrEP. By adopting a status neutral approach, every patient is afforded quality care and support, regardless of their HIV test result.
Some of my work in this area focuses on examining PrEP implementation in jails. I have been working on expanding HIV navigation services within correctional facilities for people with HIV. When looking at how we can support PrEP implementation in jails, we have done a subpar job about providing a comprehensive or status neutral approach—both while people are incarcerated and particularly after release given that the post release period is a vulnerable period for HIV acquisition.
The CDC has stated that social determinants of health impact risk of acquiring HIV, and that the status neutral approach aims to provide “comprehensive support and care to address the social determinants of health that create disparities, especially as they relate to HIV.” What are some of these social determinants of health, and how do they impact HIV prevention and treatment efforts?
I mentioned earlier several social factors that impact PrEP use among Black people. Many of those factors are the same for HIV treatment. Some of those social determinants include unemployment, unstable housing, lack of health insurance, and limited or unreliable transportation to go to doctor’s visits. Stigma also plays a major role. These factors just make your life so much more complicated and uncomfortable. These stressors impact your mental and physical health. They deter you from seeking services, from going back at all or regularly, from taking medications, you name it. They impact every aspect of the HIV care and prevention continua.
I remember years ago when I went to get an HIV test. This was back in 2009 or 2010. The provider at the time was very judgmental as I responded to her intake questions. Needless to say, I never went back for my HIV test results. I found a more affirming or welcoming provider even though they were located further away. At least I could take the train to get there. An affirming environment is important, and these social factors all play an important role in whether someone is going to access and continue to use HIV services.
June 27 is HIV Testing Day, a day to encourage people to get tested for HIV, know their status, and get linked to prevention, care, and treatment. What message do you have for the community on this day?
Prioritize your health and get an HIV test. It’s important for you to know your status. Make HIV testing an important part of how you take care of you for you. I get an HIV test every year as part of my regular physical.
