Chari Cohen is the Senior Vice President at the Hepatitis B Foundation.
Chioma Nnaji is the Director of the Multicultural AIDS Coalition.
For National African Immigrant and Refugee HIV and Hepatitis Awareness (NAIRHHA) Day, Vu spoke with Chari Cohen and Chioma Nnaji about the challenges of addressing the needs of immigrant/refugee communities through targeted public health measures.
Q: African immigrants are disproportionately impacted by both HIV and Hepatitis B. However, awareness, prioritization, and funding for HIV and Hepatitis B have historically under-emphasized these populations. How can we ensure this population is included in the national conversation around viral hepatitis and HIV elimination?
Chioma Nnaji: First of all, we have to recognize that these efforts require a multi-pronged approach; it’s not just one strategy. On one end, we need to think about what it means to support communities and get them engaged. On the other, we should consider how we are creating spaces in which communities can be engaged. Often, we say, “well, we just need to get communities engaged,” without thinking about how to support their readiness so that they can be meaningfully engaged in a way that makes sense for them.
When I think about this as it relates to African immigrants, I particularly think about the need to build capacity. We tend to perceive vulnerable communities in this helpless kind of framing instead of thinking about these communities in a more strength-based or asset-based framing. African immigrant communities across the board create these ethnic enclaves where they’re able to gain support from each other once they come to the U.S. Where I live, in Massachusetts, I can tell you about several cities that have very solid African communities where they own businesses and have a strong cultural identity. We should be looking at these particular assets and thinking about how we can build the capacity of what’s already there to engage in the work. That way we know we’re ensuring community buy-in and ensuring there’s a sustainable plan.
Q: The Centers for Disease Control and Prevention (CDC) recommends Hepatitis B screenings for people born in countries with a moderate or high prevalence of Hepatitis B. However, African immigrants to the United States continue to face barriers to accessing screening, prevention, and treatment for Hepatitis B. Can you elaborate on the nature of the social and structural barriers that they face?
Chioma Nnaji: One of the challenges that comes to mind is the barrier around language and health literacy, not just in terms of translating word for word, but also translating concepts. The concept of prevention, the concept of our health care system, and how it works is sometimes hard to translate. Even those of us who were born here get frustrated with the health care system, so imagine communities who are coming from another place. In addition to learning a language, now they have to navigate this big system and all of its challenges.
I also think about culture: the different ways in which folks are socialized. Africans’ culture is more focused on communal space. When I do HIV testing here at my agency, we might end up having three people from the same family come to get tested. How do we embrace that? How do we ensure that African immigrants are able to come with community moral support, still get services, and still maintain confidentiality? It’s up to our workers and public health providers to accommodate these cultural needs.
Within this current environment, anti-immigrant rhetoric and policies have been harmful to not just African immigrants, but most immigrants in general. When needing to make health choices, some immigrants make conscious decisions to not see their doctors or to not have any connection to a health care facility in fear of being deported. In the past five years or so we’ve seen the impact of immigration policies on our populations and people’s ability to get prevention and care services.
Q: According to the CDC, about 862,000 adults were estimated to be living with Hepatitis B in the U.S., yet only 34% of those cases are currently diagnosed. Further, Hepatitis B disproportionately affects African Immigrant (AI) communities in the U.S., with a reported infection rate of 15%. What steps can policymakers take to encourage testing and prevent future HIV and Hepatitis B infections in the African immigrant community?
Chari Cohen: There are a number of studies that point to a much higher prevalence of chronic Hepatitis B in the U.S. than 862,000. We actually think there are more like two million people in the U.S. who have chronic Hepatitis B infection. It’s still highly underdiagnosed.
There are some very specific policy steps we can take in the U.S. Step one would be to encourage both the CDC and the U.S. Preventive Services Task Force to adopt universal Hepatitis B screening recommendations rather than the current, risk-based, recommendations. Right now, recommendations for Hepatitis B screenings are risk-based and very difficult to follow. Because current Hepatitis B screening and vaccination recommendations are risk-based, providers are required to seek answers to questions about risk, many of which are highly sensitive (for example, sexual and drug use behaviors) and others for which the answers may not be known (for example, are you living with someone who has chronic Hepatitis B infection?) or not readily apparent (is the country of your origin one which has a high to moderate level of Hepatitis B?). Practice has shown that risk-based criteria can often impede the provision of services—like Hepatitis B screening and vaccination—because providers don’t have time to perform an adequate assessment and patients/clients may be unaware or unwilling to share information about personal risk.
From a community perspective, it is not just federal-level policy. It’s also the local policy system. There are some local health systems, for example, St. Barnabas Medical Center in New Jersey, that have started to make Hepatitis B testing more of a priority and have incorporated screening reminders into their electronic medical records (EMRs). They’ve brought testing into emergency rooms too. If more health systems incorporated these strategies, there would be an increase in Hepatitis B screenings across the U.S.
Q: What strategies can health care workers adopt to help reduce stigma and encourage health care access to the African immigrant and refugee community in the U.S.?
Chari Cohen: We need to do a better job of understanding why that stigma is happening among African immigrant and refugee communities. Hepatitis B is a highly stigmatized disease, but the stigma comes from different places in different communities. Not all stigma is the same, and it cannot all be addressed the same. Stigma is not just coming from one area for Hepatitis B; it is also coming from health care beliefs and health literacy in general.
As public health professionals, we need to do a better job educating health care providers and community health care workers about Hepatitis B in general. We just finished a three-year project with CDC developing specific culturally relevant educational tools for health care workers to more effectively speak to their communities about Hepatitis B to normalize the discussion. We’re hoping that those tools are going to be useful, and we will be disseminating them widely.
Q: National African Immigrant and Refugee HIV and Hepatitis Awareness Day (NAIRHHA) was created to unify medical providers, policy makers, African immigrants, and refugees in the pursuit of creating culturally sensitive health services and programming for effective HIV and viral hepatitis care. On this day, what is the main message you’d like to share with African immigrants and refugees and the health care and social service providers caring for these populations?
Chioma Nnaji: I think for me the message is that we have to do something. There’s no way that we’re going to eliminate HIV or Hepatitis B without engaging and being intentional in addressing the issues in this community. When we look at the numbers, and where they’re taking us, there’s no way that we can ignore this population anymore. We have to address it if we’re serious about eliminating HIV and serious about eliminating Hepatitis B. We have to do something and there’s no better time than now.
Chari Cohen: This is the time to share your voice. This is the time to become engaged and share your story and become part of the movement because Chioma’s right. We can eliminate HIV. We can eliminate Hepatitis B. We can seriously lessen the impact on African immigrant communities and save lives, but we can’t do it without people. We’re not going to be able to change policy by ourselves. It’s the people who are impacted, who need to join us, and we hope that they do.
Q: Beyond awareness days, how can we emphasize HIV and viral hepatitis elimination efforts both locally and to the broader public health community?
Chioma Nnaji: We call it an awareness day, but it’s not fully recognized as an awareness day yet at the federal level. The reason why we’re pushing for it to be federally recognized is because we know the value it holds in terms of advocating for African immigrants and refugees and advocating for services for this population.
Chari Cohen: I think awareness days are a great jumping-off point. You can use NAIRHHA Day to start a conversation, but if you only talk about things once a year, the conversation is not going to go anywhere. We need to keep the message going. We need to be talking with our policymakers. We need to be engaging providers and communities every day. We have developed patient and provider education materials that can help to support these efforts, which can be found here.