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In this episode, we welcome clinical research assistant professor, Maranda C. Ward, to discuss the importance of routine screening for both HIV and COVID-19 in primary care. During the COVID pandemic, we became familiar with answering questions about our risk of exposure and symptoms, yet we have failed to make the same routine screening for HIV a priority. This lack of screening is due in part to the stigma associated with both diseases, which disproportionately impact minoritized populations. Maranda will share her research on how to reduce the stigma by routinizing screening in primary care, and the impact this could have in decreasing the number of new HIV infections and improving vaccination rates. Don’t miss this opportunity to learn about the important role of primary care in the fight against HIV and COVID-19.

Maranda C. Ward is a clinical research assistant professor.

She shares her story and discusses her KevinMD article, “Why HIV and COVID-19 vaccine screening should go together.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Maranda Ward. She is a clinical research assistant professor. Her KevinMD article is titled “Why HIV and COVID-19 vaccine screening should go together.” Maranda, welcome to the show.

Maranda C. Ward: Really looking forward to it.

Kevin Pho: We’ll get into the article a little bit, but first off, briefly share your story and journey to where you are today.

Maranda C. Ward: Yes. So as a Black woman who grew up in urban America, I really care about how the health workforce is trained to care for the communities that I represent. I also care about how faculty are trained to teach about the community that I’m from, and how my programs are designed to include and support students who look like me. So basically, it’s really my identities that explain my interest in amplifying the voices of those who live in historically disinvested communities, and that also includes brown folks, queer folks, and systemically excluded students in health fields.

So yes, I’m engaged in anti-racism work. I’m engaged in diversity, equity, inclusion, and justice-based work. I don’t get to just hang that up when I get home, or wait to think about it when I log in for a meeting. I’m always either experiencing or observing threats to justice, including in my own health care. That’s why I teach, I design curriculum, and I administer programs as an assistant professor, as a community-engaged scholar, and as director of equity in the work that I do at GW in the School of Medicine and Health Sciences.

But if I just back up a bit, I did want to say that my training is actually in sociology and anthropology, which does include an undergraduate degree from a small liberal arts historically Black college for women. Yes, the illustrious Spelman College. But my training is also in public health, with a maternal and child health graduate degree from Tulane, and my doctoral degree is in curriculum and instruction from GW. But these degrees, they don’t protect me from discrimination, from mistreatment. And again, that explains why I’m so committed to preparing the health workforce to address the challenges of both health and racial equity, and basically translating my research and training on health disparities into practice. So I’m especially interested in really challenging the narratives about Black and brown communities as it relates to why we’re disproportionately burdened by the HIV and COVID pandemics specifically.

Kevin Pho: All right, so we’re going to get into that a little bit. But let me ask you, when it comes to disinvested populations like you mentioned, you are involved in the education of future health care professionals. So tell us what more needs to be done. What can we do to better educate our future health care professionals?

Maranda C. Ward: Well, first off, I think it’s all about framing. I think that it’s really important to understand that we really are never going to eliminate health disparities without first eliminating racism. When we talk about health disparities, there’s a tendency to always focus on what individual patients need to do. Health disparities actually don’t exist in individual people and patients; they exist across entire populations. It’s patterns, these are trends, and it happens to be that the only populations that even experience health disparities are the ones that are socially disadvantaged. So we know it’s not natural. We know it’s structurally engineered. And so we know that we need to be having conversations about the role and impact of racism.

And I know that when we talk about things like COVID, especially COVID vaccines and participating in clinical trials, there’s a tendency for us to focus on vaccine hesitancy, and I’m intentionally using air quotes when I talk about that, and even medical mistrust. But what we really should be talking about, again, is racism. So ultimately, clinicians cannot afford not to have a racial equity lens, one that’s intersectional in nature. They can’t afford not to be engaged and care about anti-racism, and about policies and practices that are anti-Black or anti-people of color.

Kevin Pho: All right, let’s talk more about your KevinMD article, titled “Why HIV and COVID-19 vaccine screening should go together.” So tell us, how did this article come together?

Maranda C. Ward: So believe it or not, the similarities between HIV and COVID are not as intuitive for some people, right? So this is why I wrote the piece and titled it “Why HIV and COVID-19 vaccine screening should go together.” In the article, basically, I’m focusing on why PCPs specifically should be addressing these two very stigmatizing health disparities as part of the standard screening that they offer day to day.

So this explains why in the article I’m really emphasizing the importance of having screening conversations with all patients. The reason I say this is because right now, the CDC HIV screening guidelines suggest that PCPs ask patients between the ages of 13 and 65 at least once about their HIV risk, and therefore get a test. But the inherent flaw in that guidance is that risk doesn’t work like that, right? Risk behaviors need to be addressed on an ongoing basis, not just once, depending on somebody’s life. I mean, it literally takes one decision to get exposed to HIV.

But that’s not just it, right? The current HIV screening guidelines do focus squarely on risk, or should I actually say, on a PCP’s perception of your risk. So that means that a patient older in age, or a patient who’s in a 20-year marriage, may actually be assumed to have no risk, and therefore be a missed opportunity to actually get tested. What that does is it actually opens the door for profiling of patients, whether it’s intentional or not. And we know this is not about intent; this is about impact, and impact is real.

So patients are oftentimes being cherry-picked by PCPs for who they believe are at risk, and therefore who they should take the time to ask about HIV testing, rather than posing a set of standardized questions to everybody, where their risk, and not bias, is actually the reason that they’re getting tested. So this current guidance, and the practice of this guidance, really, in my opinion, maintains stigma. Black and brown patients have told us through my research that they actually feel offended when a PCP asks them about HIV testing just, it feels like, out of the blue. And this is why it should really be couched as a set of questions about sexual activity, and depending on how you respond, that will determine if the PCP brings up HIV testing and PrEP.

And one thing I also want to note is that if a patient actually lives in an opt-out state, like I do in Washington, D.C., it’s actually the role of the PCP to share that: “You know what? Today we’re actually just going to go ahead and run an HIV test, unless you don’t want to do that.” That’s really important because right now, I have yet to have a PCP be really forthright and actually tell me that. And I know that I’ve been tested for HIV because I always get my Labcorp bill, and I read everything that I’m being charged for, and I look at my patient portal. I’ll see all the labs that were run, and HIV testing is always among them.

Now, trust and believe, I have no problem with being tested. I promote testing, and I also believe in informed consent. And so do the patients who’ve enrolled in our study, who tell us they want PCPs who are going to be transparent and explain all the tests that are being run. So basically, in the article I mention HIV stigma alongside COVID stigma, why it exists, and how that kind of gets baked into practices like that. So it’s just really important that there are open, honest, and ongoing conversations about both.

Kevin Pho: So tell me, in your ideal world, how would that conversation go when it comes to addressing HIV screening? Obviously you have an audience here of primary care clinicians. So how would you like to see it done? Just give us a case study or an example.

Maranda C. Ward: That’s a really great question. I would say that the thing is, when we talk about PCPs and patients, we’re talking about having rapport, having a relationship, right? So on the one hand, we need to actually have patients establish a medical home, and then actually have a PCP that they see, the same PCP, so they can have that relationship. And then when you have that relationship, of course, you can start posing questions: “Are you sexually active? And when I say sexually active, what does that mean?” right? Instead of just saying, “Have you had sex?” and then relying on someone’s interpretation of what that means. So again, instead of making assumptions, you’re asking them.

And then when they start to tell you the forms of sexual activity they’re having, that will kind of trigger for the PCP, “Oh, look, they mentioned this form of sex. Maybe they’re being exposed to this particular fluid,” right? So then that’s where you can start to ask a higher level of questions related to whether they would be a good candidate for PrEP, for example. And we know PrEP obviously is for patients who are HIV negative but are potentially having sex with people who are exposed to HIV or have HIV. So then when you’re having those conversations, it’ll come out in that way.

And actually, believe it or not, next week, on Thursday of next week, we’re having a grand rounds on culturally responsive communication. I’m literally moderating its discussion with two clinicians, one’s a PA and the other is an MD, and they’re going to be talking about specifically what they do in their practices to do just this.

Kevin Pho: So tell us more about that connection between HIV screening and how that would lead to improved COVID screening.

Maranda C. Ward: Well, I guess what I’m saying is it’s not that one type of screening is going to improve the other screening. It’s the fact that both HIV and COVID are stigmatized, highly stigmatized, right? And both HIV and COVID disproportionately impact the same patient populations, right? So given those similarities, it makes sense. We know that there’s the overlap. There’s lots of misinformation, there are myths, and we already know that we’re in the era of disinformation, people not believing science, and things like that. So for those reasons, it just makes sense to talk about these two very stigmatized infections in the same visit. It’s not to say that if you do one, then automatically you’ll do the other. It’s just saying that there’s so much overlap and parallel between the two that it makes sense to talk about them both.

And when I say COVID, I realize that a lot of people are getting COVID vaccines outside of the primary care setting, in community settings. So that’s why we’re not saying you should talk about COVID treatment and COVID care. It’s just posing the questions: Do they actually have the COVID vaccine? Do they have the booster? Because this is the place to talk about prevention, the primary care setting, and then moving into where they can go if it’s not at your clinic.

And that’s actually one of the things that some of the PCPs in our research did mention: “Why even bring up the COVID vaccine when I know that my practice, my clinic, doesn’t even offer them? I’ll spend all that time answering all their questions, and maybe even convincing them that this vaccine will offer them some level of protection, just to be like, ‘Oh, here’s a list of places to go, because we don’t even offer it here.'” So now it’s also a barrier.

So I realize there are clearly policy implications for what we’re promoting, and that’s why, literally, in the work that we’re doing, we’re doing research, we’re offering some policy recommendations, but we’re also doing some advocacy messages. Because one, we need to make the case for the value of even doing this in the primary care setting for PCPs. They’re so inundated with all these things they have to do and remember. But then also for what patients can do too, because I’m not putting this squarely on PCPs. Patients also can pose questions that they have about HIV and all the things they heard about how you get it, how you can’t get it, and the same thing with COVID, right? So I think it’s definitely a shared responsibility.

Kevin Pho: So one thing you said earlier is that one of the ways to tackle the disparities that we have in health care is that sometimes you have to see things through a racial lens. Now, how can one go about doing that? Where can we get education about taking that step?

Maranda C. Ward: So basically, I think we can start off with the legacy of race-based medicine. We can start off with the legacy of medical research abuse, right? And I feel like that is so very well documented in the literature. There are just so many trainings on those very topics, right? I know I lead a lot of these trainings at GW, and they’re all free, and we actually offer CME for clinicians to actually learn that history. So you can definitely go to GW, the School of Medicine and Health Sciences, our site, to actually get free, self-paced courses on these very topics. So I think that’s just really important to think through.

But I also think that from that racial lens, it really does remind me of the story of Dr. Susan Moore. For your clinician audience who may not be familiar with who she is, or let me say who she was: She was a Black woman who was also a physician, who actually video-recorded herself from the hospital bed because she had a COVID diagnosis, and she wanted to literally document live her mistreatment from her care team, and it literally went viral, right? She was sharing how they were dismissive of her symptoms, of her pain. And we know, again, speaking of being well documented, pain bias is very well documented in the literature, and that’s coupled with this racist trope of being an angry Black woman. That got attached to her because in the video you saw her asserting herself. She was advocating for her rights, but none of that was to her benefit, because she ended up dying from COVID complications despite being a doctor herself.

And this is why I even opened with that: OK, here I am, I got this degree and that degree, and I’m doing this and that, and at the end of the day, none of that’s protecting me, right? That didn’t protect her. And actually, a recent study on maternal mortality just showed that the more money that Black pregnant women actually make, the worse their birth outcomes. And that’s because this was never only about poverty, or lack of prenatal care, or “Oh, you don’t have a medical home,” or “Oh, you don’t have health-seeking behaviors,” or “Oh, you don’t have education.” No, this has always been about racism.

So that’s why I’ve just always been so passionate about the enduring impact of racism on health. Like I said before, we’re not going to eliminate health disparities without eliminating racism. So clinicians really do need to tune in, and I know more and more clinicians are starting to have these conversations, self-educating themselves and not putting the labor on their colleagues of color. Self-educating yourself and seeking out this information is really important. There are lots of books. There’s Medical Apartheid. There are so many books that I can talk about. I can give you a reading list. If you want to add some show notes, I can literally send you a reading list. So I think that’s going to be really super important.

Kevin Pho: We’re talking to Maranda Ward. She’s a clinical research assistant professor. Her KevinMD article is titled “Why HIV and COVID-19 vaccine screening should go together.” Maranda, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Maranda C. Ward: Oh, there were a lot of things that I learned. I know that PCPs are just so inundated, and let me just share that, because this is not about putting any blame on PCPs, like, “You should know better, right? You should know about this.” I love the work that primary care general practitioners do. It’s incredibly valuable, and we’re partners in this, right, me being an educator, a medical educator. So there’s lots of pressure, and literally general practitioners are getting hit up to do everything, right? Screen for depression, screen for substance use, screen for abuse, and now here I am, also screening for HIV and COVID vaccine experience. It’s a lot to hold, right?

And I recognize there are time constraints, there are limited resources, and some clinicians actually feel like it’s not in their wheelhouse to know who’s a candidate for PrEP, and they feel like that’s the role of the infectious disease doc. So I will say the take-home message is that the primary care setting is the setting for primary prevention. Yes, right? Specialists, they do tertiary care, and they want to keep you from dying or get you the treatment. It is this setting where we do need to have the conversations about how to prevent HIV, and testing is prevention, right? So this is the setting. Same thing with COVID vaccines: This is the setting to get those questions answered, to get them plugged into resources and research opportunities.

And I just feel like it’s really important, because there’s the Health Equity Tracker that the Morehouse School of Medicine houses. They literally have all of this data from the CDC, so they’re not creating the data on their own; they’re literally collating it on their site. They literally show that Hispanic patients, Asian patients, and Indigenous patients are actually leading the nation in COVID vaccine rates. And I feel like media stories and narratives often paint the picture that people of color, and that’s another thing, they lump us all together, that people of color aren’t out here trying to take the vaccine, or have any health-seeking behaviors, or pursue COVID precautions. And it’s just not true. So with them leading the vaccination rates, we know it’s possible, right? There are models there that show that they’re not the hard-to-reach populations that they get dubbed as.

So I just think that medical educators alongside primary care clinicians can work together to really improve community and population health alongside individual patient health. And I welcome your clinician audience to learn more about the work that we do. It’s called the Two-in-One model. They can go to our website, two-in-one, all words, no numbers, dot smhs, which is the School of Medicine and Health Sciences, dot gwu.edu. And you can also follow GW SMHS on all our social media platforms, and you’ll learn about all of our free training webinars, where we offer free CME.

Kevin Pho: Maranda, thank you so much for sharing your time and insight, and thanks again for being on the show.

Maranda C. Ward: Thank you.