During the COVID-19 pandemic, Americans got accustomed to regularly answering a series of questions about our risk of exposure to COVID and our possible symptoms. For more than two years, our country remained laser-focused on this protection, demonstrating our health care system’s ability to mount a strong response to a public health crisis. So why haven’t we taken similar precautions in the face of other crises, particularly HIV?
For too long, we have failed to ask every patient the simple but crucial routine questions that could help identify and treat HIV. One of the issues is the stigma associated with HIV. Research published in 2018 looked at patients’ comfort level with HIV testing and whether physician recommendations can help overcome any discomfort with testing. It found that negative attitudes among patients are actually uncommon and that even among those who said they didn’t want HIV testing, more than half said they would likely accept it if their physician recommended it. Patients are open to receiving this kind of testing – but we cannot help them unless we begin to routinely offer it.
If we are to achieve the CDC’s goal of decreasing the number of new HIV infections to 9,300 by 2025, we’re going to have to make intentional changes in primary care practice. Additionally, if we want to continue our success with the COVID vaccines, we must shift the battle from a public health crisis response to a systemic change in how we screen for diseases.
COVID-19 and HIV have significant factors in common that can make it difficult for primary care practitioners and their patients to discuss either of these diseases. But the answer to these twin problems could be as simple as making both screenings a routine part of any primary care visit.
Both are highly stigmatized.
For both HIV and COVID, patients are often uncomfortable talking about exposure, disease status, and the factors that put them at risk. Unfortunately, many clinicians—rather than focusing on exposure to the five bodily fluids that transmit HIV—instead choose to emphasize and question the personal behaviors connected to these fluids. The taboos related to sexual intercourse and injection drug use result in shaming people who could become infected with HIV. This was most evident in the original 1981 naming of HIV as GRID or Gay-Related Immune Deficiency. While COVID does not spread in the same way, it also retains a stigma associated with its origins and transmissibility around masking, quarantining, and getting vaccinated. The stigma associated with both diseases stems from fear and misinformation – two things that could be simultaneously confronted in the primary care setting.
They impact the same populations.
HIV and COVID disproportionately impact minoritized patient populations. According to the CDC, in 2020, 71 percent of HIV diagnoses in the U.S. were among gay, bisexual, and other men who reported male-to-male sexual contact. This fact necessitated our four-step national response to HIV during the COVID era. Additionally, despite data that indicates that Black and brown people are more likely to follow universal COVID precautions than other groups, vaccination rates have lagged partly because of historical abuse in medical research, scientific racism, and ongoing socioeconomic disparities. These structural risks are coupled with well-documented bias that can lead to patients feeling dismissed or profiled in clinical encounters.
Routinizing screening for HIV and for COVID vaccination status could help reduce the stigma associated with both conditions and ensure that the most vulnerable populations are reached. It would help make the screening questions commonplace and comfortably routine. This would prevent vulnerable patients from feeling targeted or judged by the questions.
Routine HIV screenings at community health centers serve as a model for how this can be done in the primary care setting. It can also be a model for how to roll out routine COVID vaccine screenings in primary care settings. Various states have already demonstrated success in lowering new HIV infections through routine HIV testing in emergency departments. Similarly, recent CDC recommendations to provide pre-exposure prophylaxis (PrEP) in the same clinical visit as the HIV test establishes a continuum of care that can curb its spread. Screening for COVID vaccines and administering them in the same visit would likely yield similar positive outcomes.
We also need on-the-ground training programs for clinicians so they can better approach patients with these screenings. For instance, my team at George Washington University is working on a research-informed educational initiative called the Two in One: HIV + COVID Screening and Testing Model that will provide primary care practitioners with training so they can routinize HIV screening and COVID vaccine screening for all patients, alongside culturally responsive communication with racial, ethnic, gender and sexual minoritized patients, in particular. Hopefully, this model will change the stigma attached to HIV and COVID vaccine screening and the discomfort patients and clinicians face in talking openly about risks, protective factors, barriers to care, and ongoing support.
The primary care setting is a powerful place in the fight against both HIV and COVID-19. Making screening for both conditions routine practice for every patient will help reduce stigma, reach the people who need help the most, and help the country get closer to eventually ending the unfair outcomes that can stem from HIV and COVID.
Maranda C. Ward is a clinical research assistant professor.
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