Chapters Transcript Video The Impact of Implicit Bias and Stigma on Care Within the HIV Continuum The Impact of Implicit Bias and Stigma on Care Within the HIV ContinuumOriginally Broadcast: October 29th, 2020 | 12:30 PM - 3:00 PM ET good day, everyone. Welcome. I am so excited that you're joining us for our third Blueprints for Success Training Institute. I would like to first introduce myself. My name is Beth Sheba Johnson. I'm senior director for HIV prevention at Gilead Sciences, and I'll be your moderator today. Today's program will highlight the importance of addressing stigma and implicit bias in HIV care settings. This program will explore how these two phenomena reinforce existing health disparities that occur among communities impacted by HIV. So let's take a quick look at our agenda. As you can see, we'll have to 20 minute presentations and 2 30 minute workshops are first. Presentation will be given by Dr Kiyoshi Bond and is called the impact of implicit Bias and Stigma on HIV Care. Ah, workshop will done follow on micro aggression and after our second presentation, which will be given by the Reverend Dr Tommy Watkins Jr. It's called tackling stigma in the community. We will have a workshop on best practices and identifying strategies to address and mitigate implicit bias and mitigate stigma. I'm sorry. I'm kind of lost my train of thought there, so forgive me so all as you know, If you've attended some of these programs before, we will be working with a button at the bottom of your screen, and you can actually press that button to ask a question or submit a question. Posed a question in at any time during this particular workshop. So we are going to have also a discussion Q and A and panel, and then we're going to look at the fourth part of our Siri's. This is the third, but we also on the screen have another final date, and that is training Institute number three, stigma and bias that is today. And then we'll have our final program on November 19. Coming up. All the programs follow the same format as today's program. Will will have presentations, workshops followed by discussions, so I hope you will join us for November. So moving on our first presentation today will be given by Dr Keogh Shavon. Dr. Bond is an assistant medical professor at the Department of Community Health and Social Medicine at Cooney School of Medicine in New York. She's a behavioral scientist and sexual health educator who has centered her work on complex intersections of race, sexuality, social justice and health disparities among module, eyes, population Dr Bonds. Primary research interests have folks based on understanding how social, structural and cultural factors really influence the transmission of HIV and using rigorous, rigorous formative research to develop culturally appropriate interventions to address these factors. Now I would like to turn it over to Dr Bond for her presentation. I'm sorry I couldn't resist that. Hello, everyone and welcome again and thank you, Dr Johnson, for that lovely introduction. Um, my name again to everyone is Doctor Kiyoshi Bond, and I will be speaking to you today about the impact of implicit bias and stigma and HIV care. So let us get started before going to detail about the impact of implicit bias, the stigma and HIV care. I just wanted to provide everyone with some important definitions related to stigma, bias and prejudice. First, implicit bias means favoring one group over another and another in and unconscious for unintentional way. Explicit bias is favoring one group over another in a conscious or intentional way. Micro aggression means brief, commonplace daily, verbal or non verbal sites or insults. Stereotype means an oversimplification fix and widely held belief about a whole group of people and prejudice is an hourly expressing negative attitudes towards a different social group. All of these biases contribute to stigma against certain people, and stigma is defined as a mark of shame or disgrace associated with a particular person quality or circumstance. So let us continue to explore how implicit bias works. Implicit biases rooted in unconscious thinking. Dual system theory holds that there are two types of thinking. Systems. One in system, too. With system One is unconscious and automatic, fast and effortless thinking a system to is a conscious, deliberate, slow effort for thinking implicit bias is a product of the system, one thinking, and we act our on our implicit biases without awareness. Therefore, they can undermine our true intentions. Implicit bias are beyond our awareness or intention of control. And having a desire alone toe act without bias does not necessarily ensure that you one will be successful acting without bias. We act on our implicit biases without awareness, Thus they can undermine our true intentions. I've outlined these key points in the next slide. First, implicit biases go to beyond stereotyping and can include positive or negative perceptions about groups of people, implicit biases are the results of normal human processes that take place in a unconscious level, and we all have them, and they do not make us bad people. Implicit Association don't necessarily align with openly held belief. Yes, they can more accurately predict behavior, according to research and research has shown that implicit pro white and anti black bias is most is in most Americans, and we can lead in an inequitable healthcare, education and criminal justice treatment. Implicit biases are malleable. That means that can be unlearned and replaced with new associations. And today, implicit bias is widely understood to be the cause of unintended discrimination that leads to racial, ethnic, social, economic and other inequities. And as we move along, we could see how implicit by manifest itself in health care. Experiments have shown that providers perceptions and treatments and recommendations for hypothetically black versus white patients with the same symptoms and patients. Sexual orientation can be a factor in bias healthcare, and a 2000 and four study has shown that medical students so Latin X in American Indian patients as less cooperative and engaging in riskier sex behavior than white people as no rage at the ethnic and racial minorities report more dissatisfaction with health care providers, especially when providers are not the same ethnicity as their patient. And in a meta analysis of 15 studies and show that most healthcare providers appears the whole pro white. An anti black implicit bias is similar to the general population providers. Bias may lead to pour a patient provider interaction, which may impact follow up in adherence to treatment plans. Let's continue to the next model. Thats model shows a path in which provider implicit bias may contribute to health disparities. With Path A. It shows that implicit bias on part of the providers may lead to judgment and decisions about patient care that can result in poor patient engagement and adherence to treatment and ultimately to health disparities. With Path be, it shows that implicit bias can impact communication and trust with patients. And this, in turn, can potentially lead to patients. Lack of engagement in adherence to treatment and ultimately again lead to health disparities. And as we move on, we could see the connection between implicit bias and health disparities. Now, as we focus now on race, we know that about 42% of the people living with HIV identify as being African Americans unfollowed by 28% of Latin X. And this is problematic because African Americans compromise only 13% of the population and Latin X people compromise only 18 of the population. The race of HIV infection among African American women in 2000 and 18 with 13 times higher than that white women and four times higher that Latin X women. Now, when we look at gender, we know that 78% of the people living with HIV identify as being men and 22% identifies being women. But we also have found out that from 2000 and 14 to 2000 and 18, the largest percentage increase at 24% and the number of people living with HIV was among transgender women, and the HIV prevalence and transgender women is 14% compared with less than the 140.5% among US adults overall. And lastly, when we look at sexuality, sexual orientation, we know that 67% of the individuals who are diagnosed in the U. S are identified as being sexual minority males, and the new transmission among women is 85% and that is all due. Toa heterosexual contact. Why don't we continue the discussion by reviewing engagement in the HIV neutral status Neutral care continual for people living with our risk for HIV? It should be status is just one element of the person's health. Comprehensive behavioral and biomedical risk reduction services for prevention of HIV and treatment for those living with HIV required engagement and care. The steps along the care continue are similar. Sustain engagement and care is important to achieve and maintain health and HIV negative individuals may not be accustomed to the importance sustained engagement in care. However, stigma and other social determinants can influence HIV care. Continue before an HIV diagnosis has even made. Let's continue. And when we look at the racial and ethnic disparities and HIV treatment and care, we could see that these disparities and health related outcomes among people living with HIV or well documented. In a 2000 and 12 survey of 544 black and S m 29% reported experience racial and sexual orientation stigma from health care providers in 48% say they didn't trust medical institutions. Layers of discrimination among black and Latin X m s m. Based on race, sexuality and HIV status resulted in the worst health outcomes. Initiation of HIV prevention services is much lower among black men. Latin X men and women compared toa white men and less than 50% of Latin X with HIV are on treatment. And about 3/4 of the men who have scripts for for prep medicine are white and only 9% are black. Let's move on to see how certain groups experience more HIV stigma and as it relates to in the United States. So, according to the CDC s Medical Monitoring Project, a surveillance system designed to learn more about the experiences and needs of people living with HIV, overall stigma was higher among women compared to men and people with low income experience. Stigma more and that includes people who are experiencing poverty and homelessness. A stigma related to disclosure. HIV status and the public's attitude around HIV was higher among black people compared with white people. On lastly, we found that stigma was higher among persons who were not taken antiretroviral medications. So let us just continue with this discussion, okay, we know that HIV stigma, particularly associated with disclosing the status of others is highly prevalent. And as stated before the the disclosure and public attitude about stigma will hire among black people compared with white people. And stigma was higher among those who miss HIV care visits. The stigma was higher among those who visited the emergency room. So what does that tell us? Continue. Stigma is rooted in the fear and myths that arose around the epidemic in the 19 eighties, and this continues to today. 40 years later, HIV and AIDS are equated with death. HIV is associated with behaviors that some people disapprove off, such as being homosexuality, drug use, sex work and infidelity. HIV is Onley transmitted through sex, which is a taboo subject in some cultures. And HIV is a result, a moral failing or weakness. And the following quote basically sums up the roots. The roots of HIV sigma Nothing is more punitive than to give a disease a meaning that means, and that meaning beating invariably a moralistic one. So let's continue to review the many levels where sting makes this At the first. There are six levels that we were going to explore today, and at the first level we're gonna look at self stigma are also known as internalized stigma, and that may prevent people with HIV from getting tested disclosing their HIV sadists are seeking medical care. And at the next level, we're gonna look at the community and homes, and that could be seen as a rejection by family and community and sometimes people within the l. G B T Q community. They experiences thes things as well, and also their segregation between people with HIV and people who do not have HIV. Now, when we look at health care stigma, this could be seen in many forms. The health care provider may conduct mandatory testing without counseling or consent, and they may minimize contact or care of people living with HIV. They also can't deny treatment and isolate people with HIV from other patients. Also, discriminatory attitudes on the part of health care providers may lead them to make judgments about persons, HIV status, behavior, sexual orientation, gender identity. It may result in the patient not being treated with dignity or respect, and with the next level, which is employment, stigma from co workers and employers can occur, and this can translate into social isil, ization, termination or refusal of employment. HIV status can because of unemployment in our society. And then we're looking at restrictions and travel. And in some countries they have large restricting travel for people living with HIV. And, lastly, the government laws and policies thes air discriminatory laws, policies and rules that can exclude people living with HIV and perpetrate HIV step stigma. Thes laws and policies can criminalize affected people, for example, out lowering, same sex activity, drug use or sex work. And that brings us to the layers of stigma. The first layer is an act of stigma, and that's the real experience of discrimination as a result of HIV status. Then we have anticipated stigma, and that's the fear, prejudice or discrimination. And it's expecting to be treated badly or to be oppressed. And we also have normative stigma, which is the perceived surveillance of HIV stigma in the community and, lastly, internalized the self stigma as we mentioned before, is the feeling of shameful worthlessness, inferior or fault because of HIV status. Let's take a closer look at the relationship between stigma and HIV. There's a psychical relationship between HIV and stigma. Okay, People who experience stigma and discrimination are marginalized and become more vulnerable to HIV, and people living with HIV are more vulnerable to stigma and discrimination and some of the possible consequences of stigma our loss of income, our livelihood, poor health care, loss of marriage, relationships or childbearing options, loss of family caregiver support, feelings of worthlessness and loss of reputations. And in a study, findings from a recent study from 50 countries have shown that approximately one in eight people living with HIV is a night health services because of stigma and discrimination. And HIV stigma is associated with lower antiretroviral treatment, adherence and less access to health services. Let's continue to explore this in our next slides. So this diagram here shows a cyclical pattern that occurs when marginalized groups experience stigma due to HIV, sexuality, gender, drug use and sex work, which really highlights the intersectional sticking by that marginalized groups experience stigma can in turn lead to discrimination and harassment and abuse is that it can also lead to violence, risky situations and behaviors, poverty and ultimately poor health. And it can also lead to poor health services, access and uptake and poor social and emotional well being, which in turn can lead to poverty and sickness. And as we continue we here we see that Sigma prevails in the health care system. Lack of awareness among health care workers of what the stigma looks like and why is damaging in fear of the cause of casual um, contact stemming from incomplete knowledge about HIV transmission Association of HIV with improper or immoral behavior. Assumptions about client based on their HIV status intervention must be focused on the individual environmental and policy levels. At the individual level, there's an increasing awareness that among health care workers of what the stigma is and the benefits of reducing it is critical, raising awareness about stigma and allowing for critical reflection on the negative consequences of stigma for patients, such as a reduction quality of care, patients are willingness to disclose their HIV status and adherence to treatment regimens are important. First steps in stigma reduction programs. The physical environment programs, um need to ensure that health care workers have information supplies and equipment necessary to practice universal precautions and prevent occupational transmission of HIV in the lack of specific policies clear are clear. Guidance related to the care of patients with HIV reinforces discriminatory behavior among health care workers. So a sui continue in summary, implicit bias causes unintended discrimination and can lead to racial, ethnic and social, economic and other inequalities. Healthcare provider bias leads to poor patient provider interaction, resulting in less follow up and less adherence to patient um to treatment plants. And implicit bias and stigma undermines health outcomes for people living with HIV. Research shows that individuals with HIV from marginalized groups experienced high levels of stigma, and this is a psychical relationship between HIV and stigma. So I thank you today for your time, and I hope that you found that this lecture was useful and it relates to, as it relates to your understanding of implicit bias and stigma and HIV care. Thank you so much, Dr Bond, for that great, shaken but not stirred overview of implicit bias and the six levels of stigma where it exists and the layers of stigma its relationship thio HIV as well as its effect on health. Really, I would like to now remind everyone that you can ask questions by pressing the button at the bottom of your screen at any time to submit the question. So now we're gonna move into our first workshop of the program, and I know you're excited about that. You should have received your worksheets in your email earlier today. But if you didn't will provide a link to the worksheets in each of the workshop rooms. So please click on the button on the lower part of your screen now to join the workshop breakouts, and I'll see you later. I hope everybody enjoyed their first workshop with our dynamic Gilead moderators, Denise and Blake, and that you came away with a different perspective on Microaggressions. I want to remind all of our attendees that they can submit questions for our faculty members through the button at the below below the bottom of your screen at any time during this presentation. So our next speaker is the Reverend Dr Tommy Watkins Jr He will be giving you a very high overview of a very important topic. Dr. Watkins is an adjunct professor at the University of Alabama Birmingham School of Social Work, and he's also a rector at ST Andrew's Episcopal Church in Birmingham, Alabama. The good Reverend Dr Watkins was the first ordained openly gay black priests in the Episcopal Diocese of Alabama on November 11, 2016, which means he's coming up on his fourth year anniversary because of the gaps and resource is and research among black non heterosexual identified males. Reverend Watkins was highly motivated to go back to complete a PhD degree. To become a researcher primarily concerned with religion and spirituality is health outcomes among black, gay and bisexual meals. Now I would love to turn it over to the Reverend Dr Watkins. Good afternoon. Thank you. Achieve A for the wonderful introduction. I am honored and privileged to be with you all this afternoon and to discuss tackling stigma in the community. Dr. Bond did a great job of introducing us to stigma defining. And so if we waved a magic wand, what might be the impact of reduce stigma outcomes could be the greater willingness to get tested. Mawr disclosure Mawr inclined people to enter and stay into HIV care and also other health care in general, motivated to start antiretroviral therapy and and adhere to it, we would have more social support for people living with HIV and an improved quality of life So this presentation will shine the light on the many aspect, uh, negative living, uh, negative impacts of living with HIV and stigma and look at the multi layered components of stigma and how noting in addressing each of the layers could contribute to the reduction in HIV stigma. We also gonna look at the supportive role that community organizations, faith based organizations and also look at the programs that target individuals living with HIV and can facilitate the reduction in HIV stigma. Many impacts, uh, that stigma have on living with people living with HIV. We know that studies have shown that it the internalized and anticipated stigma can worsen mental health outcomes, contributing toe higher rates of anxiety, depression or even unmedicated mental health issues like bipolar disorder or schizophrenia. Also, the increase in internalized stigma can contribute to denial this cognitive dissonance on thinking and behavior where individuals abuse substances mawr and look at self blame and shame to work, uh, increased psychological stress. We also conceive the intersection of how an individual's race or their ethnicity, country of origin, their sexuality and sexual orientation can be also ways. That stigma is exacerbated in an individual's life. these layers then conspire to exacerbate the internal as well as external stigma. And Dr Bond told us very clearly that stigma is defined as the mark of shame or disgrace. Associate it with particular individuals, piers or outside circumstances. It is those. It is the marriage, if you will, of guilt and shame that conspired to increase stigma, internal and external, with people living with HIV. So let's look at some of those, uh, impacts it. We see that stigma may work be worse in other rural areas where there's less experience and less tolerance. Where individuals are encouraged to live a certain predisposed way or adopt identities. That may not be congruent to the internal way that they feel there is a greater fear of HIV disclosure and less anonymity, where individuals, families, um, and peers are already known. And so the idea that to disclose their sexual behavior or sexual orientation then is exacerbated and individuals live quietly or may live a double life based on that internalized homophobia and shame, it contributes then to the intersectional approach of the impacts of individual living with HIV, where we see self esteem. Family stigma also contributes to the poor health outcomes and higher sexual risk behavior. Let's look next at the impact of HIV stigma on the family. HIV is called some people with familial negative ideas that HIV is caused by bad decisions or the individual deserves, then is a bad person who needs to become good after the pressure of living with HIV can bring those family members to, um to be ones that kick one out or a person living with HIV. As you can see. The quote by Shana that their family were embarrassed and didn't want to talk to them, and her mother essentially said, Good luck. You're on your own. Often in rural areas or components, people feel living with HIV, the stigma that they live mawr isolated, which then exacerbates the depression and anxiety. So let's look at the external factors. Then they contribute and the layers to stigma. HIV stigma, then, is layered with the against racial and ethnic minorities. Gay and bisexual identified individuals. The stigma against trans identified individuals, stigma against women, people with low income stigma against sex workers, and stigma against people who use drugs or other illicit substances. As you can see that, there's an intersection and not just one facet intersection of identities or layers for addressing if we're going to look at reducing HIV stigma. So let's look at the internal components often end communities where individuals have already been suppressed or rejected or discriminated, as in the LGBT Q Plus communities, Cerrell, discordant Couples or this idea of someone not being HIV positive paired with someone living with the HIV. There's also in within communities a higher labels and higher levels of stigma in non heterosexual or gay identified communities. Violence, ageism, social exclusion, rejection, discrimination based on physical appearance or ability and disability status, mental health status and can contribute to the increase in stigma within that community. For example, one study 62% of men diagnosed with HIV agreed there was discrimination against people living with HIV and openly identified as M S M individuals, then may be more readily not to identify with their HIV status or even claim their sexual orientation are the congruent with their internal thinking with their HIV status or sexual orientation. So let's next look a a ways that we're reducing stigma and HIV can impact HIV care. We know that stigma is linked with less treatment adherents. Individuals will say that maybe they deserve, um, what they're getting or they deserve the negative attitudes and health outcomes because they're stigmatized by their chronic illness and their behavior. This suggests that stigma reduction, then on interventions, need to be multi layered and address many layers of the individual in the community as well as internal. We understand that reducing stigma, then, is that key to acquiring or reducing our increasing adherents and to people living with HIV. If we look next at that multipronged approach, it could be at the acronym here, you and I. We can help institutions recognizing stigma, expand antiretroviral therapies, address the social stigma and the environment. We can bend, respond to the needs of stigmatized populations. Use the media to show that HIV has a human face. And it's not just those people over there, but people living within our communities and maybe within our own households. That way we can involve people living with HIV in the service delivery, so let's look at each of these the community wide interventions. A multi pronged approach tends to be the most successful way of reducing stigma of people living with HIV addressing the preconceptions, the stereotype and uttering of people living with HIV. The multilayered and pronged approach can show that people living with HIV and induced reducing stigma, using mixed media and creating opportunities are the best ways and most effective ways. Let's look at how the community alliances can come together and help people living with HIV. An example of this alliance is the C. D. C s Act Against AIDS, the Leadership initiative and partnership with the Centers of Disease Control and Prevention, where the leading national organizations that represent the partnership that represent individuals hardest hit by HIV, including blacks in Latin, ex gay and bisexual men's men. And this could be replicated at local and the state level form an alliance with to come back. Stigma also empower people, particularly communities most affected with HIV HIV status and reducing the HIV negativity and living with, uh, the stigma. Combating informing those alliance then living with persons looking at government faith and other community based and health departments can be the most effective way of forming those alliances to decrease HIV stigma. So let's look at some of the components and of some of these layers as a flower. It's kind of pushed out. You can see that these is closed up with the individual, but when opened up, you can see the multilayered flowers, the multipronged approach and identities that individuals have our education or age group. The sex identified a male female or intersects someone. Sexual orientation, gender identity, faith based organizations can and social cultural networks and peer networks are the best ways Thio influence and effectively address the multi flowered, a prone approach and identities of people living with HIV. Let's look at a few of those components. We know that families, and often it's not biological families. It could be families that people form, uh, in social circles, blood relatives and non blood relatives. You can share that burden of the person living with HIV. The family can give strength to that individual to provide the environmental support that an individual living with HIV needs to overcome the discrimination and the negative narratives associate it with the stigma of living with HIV. Combating stigma, then, is a community effort, So let's look at some of those examples. One very successful one is project change, and the other one is the cut the stigma. Project change was in the community level, multi component, anti HIV AIDS stigma and anti homophobia campaign, looking at the internalized shame and reducing shame and stigma. There were three primary components of this program. The workshops with local residents, businesses to identify and discuss openly what HIV and education around HIV. There was a storefront or space bay or drop in center, where people living with HIV could come in and feel supported and also have education around living with HIV. The research on the campaign found it to be feasible and very much acceptable to different communities because it's specifically targeted the internalized stigma and homophobia internalized by individuals living with HIV. The Cut The Stigma Campaign was launched by the Black AIDS Institute in 2018, and it coincided with the camp campaign to cut the stigma and to influence community organizations to not denounce and stigmatize people living with HIV. We can look their next at how community level stigma reduction strategies work. We can do testing sport at sports events or weekend gatherings, identify other youth clubs and youth serving organizations, and look at how collaborating with community organizations at length specifically youth to services for HIV and HIV testing. Another way we can look at next is reducing the stigma with community organizations, engaging schools, businesses, detention facilities and churches after school programs are looking at sports events to also address the mental health and substance abuse components of people living with HIV, where a multi prone health approach is used. This can be successful in incorporating other school nurses, and those trained in health care can be then ass and to look at HIV and and reduced HIV stigma. Next, we can look at the contact with the inclusion of people living with HIV. Often people see uh in their communities that they do not know an individual impacted with HIV or living with HIV. And we can see that fostering community support or putting a face to individuals living with HIV reduces the stigma that the person is not someone over there but is within our communities and does need help. Next, we can look at the digital and marketing campaigns that have been successful in addressing youth in living with HIV. We could look at the look different campaigns, which was a public service announcement aimed at raising awareness. Others include the bodies hashtag HIV stigma on blast where individuals, another youth tell their specific stories of living with HIV. You can see next on this side that showing the human face in the community, which is a a successful approach. HIV, then, can be seen as something a person lives with and not dies with a chronic illness such as diabetes or depression, on anxiety and not to be overly stigmatized. Or have people think that because they're living with HIV, it is a death sentence. The evidence shows that people are more likely than toehold, stigmatizing attitudes when they don't perceive other people living with HIV or anyone that they know. So a component comport an important component is offering those platforms, for example, act Against AIDS and the We Are AIDS Campaign. These initiatives seeks to reduce HIV stigma by showing people normal, typical people that we may know of various ages and sexual orientations. Two. And using traditional online and social media platforms to then encourage HIV testing. Encourage HIV Care and adherents. The greater Than AIDS initiative sponsored by the Kaiser Foundation in 2009, More than 250 individuals living with and affected by HIV as well as clinicians and other leaders share their stories. And it was storytelling and the idea of an individual's own story that others could relate to. That show that this person is living with HIV and not to be stigmatized. Another strong component of combating stigma is the faith based community, and we can look that faith based community. And when we think of a faith based, many of us may think of religion, which has to do with dogma or a, uh, manmade ideology versus spirituality. And I think spirituality has to do with the connection to a divine other. And we see that many people identifies being spiritually rather than religious. And so those faith based organizations not just Christian but Islamic Judaism or even practicing internal meditation and yoga can intervene at the family levels, can shape public opinion and also can influence human rights groups to decreased stigma among people living with HIV. If we look more closely at the role of faith based organizations, they had played a key role in mitigating and lessening the stigma by education to educate around HIV. Maybe the world, the national HIV Testing Days or World AIDS Day, The Black Church Week of Prayer, which we'll get to in a moment. But faith based organizations can endorse prayers and openly and pamphlets for people living with HIV and in the community to lower and less than the HIV stigma and also faith based organizations. Organizations can encourage individuals to enter care and remain in care. We HIV, uh, faith based organizations can then be ones that talk about the holistic health approach and the intersectional approach that proves to be most effective in decreasing stigma among people living with HIV. If we look in at the black church, which is often perceived as the most powerful entity in the black community, we understand that the black church week of prayer that began in March years ago can open and preach, if you will, a ideology of liberation and can be then a place of healing and support and acceptance and refuge, often sermons that endorsed holistic approaches, one in particular about a person and the criminalizing and de stigmatizing individuals where individuals are not bad people that need to become good but unhealthy people who need health like us all shame, then and fear becomes those co factors of people living with HIV and canon, enshrine and exacerbate, then the stigma. If we look at one approach to how faith based organizations, one idea is that individuals are need to live more open and be vulnerable. A sermon I heard about that is what Adam and Eve were created and they were naked and felt no shame, and then ideas that the creator came along and said, Well, where are you? Adam and Adam said, Well, I hid because I was afraid because I was ashamed because I was naked. The question was asked, Who told you that you were naked? Often faith based organizations can be the foundation to keep individuals from thinking that they're naked, that we're all created to live healthy. So faith based organizations can root out those causes the intersectional and social determines of health around education, employment and job security. Health services, by including mental health and counseling, even spiritually direction and pastoral care can also mitigate those factors that increase HIV stigma. Faith based organizations are also ones that can look at and mitigate social inclusion by holding conferences and faith based or based based initiatives that encourage all individuals living with HIV or not to be part of a health curriculum. So in summary, we see that stigma along with exacerbated by fear and shame, negatively impacts the people living with HIV and that people at risk for HIV. In many ways, reducing stigma begins with the family, community based organizations, faith based organizations and people living with HIV to determine and know that they are not naked. But they are love in those ways. Families then can combat and mitigate stigma. Thank you. Thank you, Reverend Dr Watkins, for that heavily presentation and giving us that strong overview of that multi pronged approach or, in your words, the layers of the onion to reduce stigma. So your dedication and Dr uh, Bonds dedication makes me want to just dawn my armor and go forth and fight the good battle on implicit bias and stigma stigma. So now let's move on to our second workshop of the program again, you should have received your workshop program. If not, you can get them in the work room now, So please click on the button on the lower part of your screen to join the workshop. breakouts. Welcome back, everyone from that last break out, we're going to take this out with a bang, I hope, with some robust discussion. So I want to remind you to submit questions via the button on the bottom of your screen. And so the questions will be popping in and we'll get to them. If not, I've got a few questions of my own. We're August panel today. Do we have any questions? Okay, here we go. What steps can we take away from today to make sure that combating stigma is an integral part of our HIV programs? And I would like both of you to address this Dr Bond, Why don't you go first? Oh, is she muted? I apologize for that. I'm so used Thio not running my mouth all the time. Eso That is a very good question about what kind of steps we need to take to ensure that we are addressing HIV stigma and HIV care in general, I think the first step we need to take us to acknowledge that it does exist like we have this discussion today and it's been talking about the different layers as it relates to HIV stigma. And the next thing is to think about what are good approaches. Because one thing about intersectional stigma is that, yes, there are negative. There's a negative side to it. But if we look on the other side of Intersectionality, what are the protective factors of all those different criteria that is closely related to stigma? There are some things we talked about it today, such as family and support, spirituality, you know, and even our own. I just embracing our own identities in general. So there's different components and and the steps need to one acknowledge it and then refocus it in channel and looking at the protective factors that our communities have at this point and how we can capitalize off of that. That was an excellent answer. I love that. You're saying we have to acknowledge that stigma does exist. A lot of times we want a barrier heads in the stand, and we don't want to be uncomfortable and have these deep conversation. So I love that you said that and to really embrace our identities. I I love that you said that, Dr Bond. So the Reverend Doctor, what would you How would you answer this convention stigma Question. Um, well, I can't just say did him and move on. I think it's, uh, you know, in reducing the Sigma Tau, look at it as part of a holistic approach that already, you know, maybe being of color and discriminated based on gender. It's one more thing. And I think we need to focus on interventions that look at resiliency. Look at the positive aspect of our community or individuals living with HIV and encourage a holistic approach if you need, you know, mental health care. Looking at spirituality as a moderator in in health outcomes, Um, and to look at the internal factors and biases that individuals hole, um, in being already of color or, you know, discrimination based on their gender or their race Already looking at how HIV, uh, it can be a chronic illness and not a death sentence or something else to live with. And and I think the holistic approach is really one of the better ways. I love that with your holistic approach to really look at the glass half full, and that's talking about the results of the community, and we know that we are resilient you can see that now, with the racial injustices that air going on and we're still here and striving to do better. So beautiful answers beautiful answers. So let me take this a step further. Um, Doctor, Reverend Dr. You mentioned a statistic on 62% of people in stigma and sexual orientation. How do you personally reduce stigma in that population that's so high living with HIV or the family? And that stigma, I think, to directly look at, uh, the individual and to encourage them to do more self reflection. I think many times, uh, individuals live their lives based on the opinion of other people. And the story that I told about creator and creation of allowing other people toe tell them that their naked, that something's wrong with them. And I think going to step further is to help people internalize our appeal, the layers, the onions of oppression and discrimination they may have because of their race or their lower socioeconomic status. Or, you know, to really look at the narratives that individuals have imbibed from society the negative narratives and supplant them with the positive that our community, especially of color, have been have at our disposal the resiliency in the history of overcoming. And I think HIV is one that we need to stop being silent about and to really tell our stories and talk about it. No one can negate a person's experience. Uh uh, And I think the more that people are comfortable living and being open and seeing themselves as being affirmed is the best way to overcome stigma on Do you know, let me just say this real quick. I think stigma is married. They live in the same house, uh, to fear and shame. And, you know, guilt is what I did is wrong. And shame is who I am is wrong and who I am is bad. So I think stigma pro anti stigma programs have to look at that deeper level of shame. That topic shame that individuals carry because of their HIV status. Wow, that is amazing. I mean, we're going to revisit some of it. I have a question for Dr Bonds and she talked a lot on, you know, health inequities and research is about this. And she did a wonderful presentation on that. So the question is what small changes can we make in health care settings to make all patients feel welcome and heard this is something I struggled with as a nurse practitioner in HIV practice. I want to hear from you, Dr Bond, on that look as you may think, it's a simple step. There are small, but it means a lot. I think, um, if we just acknowledge people and you know, just a little thing of saying hello in creating them as a person can change their perception off where they're going in there, the environment that they're going into and they will be more open to talking to providers and disclosing different information if they feel they're respected. I know in my work with young adult women and when they're talking about going to the sexual health provider G Y n or going to the regular, um, just for a regular physical. One of their biggest um, barriers to talking to their providers is if they don't feel acknowledge if they don't see them, if someone doesn't treat them as a person and our respect, the things that they're telling them, you know, and it's one thing I think as providers, that's very important is to listen to your clients and your patients. They know who they are. They know their bodies. And so you need to be mindful of that and respect the things that they're saying to you because they are the experts on themselves. They're there to help you figure out what their issues are, whatever their diagnosis is. And I think if we have that approach with our with the public, if you are a health care provider off, just acknowledging them and treating the respect and you think that you do because you just said here, come in, you know your next person that's not treating your client as with respect or your patient with respect, acknowledge them, acknowledge what their issues are, talk to them as if they're a person and talk to them with mindful of that. They are the experts of their own body, and they have questions and concerns, and you should be respectful of that. There's, you know, one of the biggest, uh, and I was remembering this this data from a focus group that I did this, a discussion, one of the biggest challenges that, uh, one of my participants had was she encountered a provider who laughed at her question. And that's the wrong thing to do with any type of setting from the receptionist to the provider. There should be, ah matter of, of respect for the patient and who they are and confidentiality and privacy, and they should be able to feel that they're coming into a trusted environment. So totally so in a healthcare studying. I would I would strongly suggest that people leave their own biases out. You're there to work with the patient. You're not there to judge them. We know, Reverend Doctor, that that is not the work that we do on this earth. That's for somebody else to dio whether you're in religion or not, we are not to judge were there to help. And that requires that act of listening that Dr Bond is discussing. But this also comes up to me when I think about the talk you gave and you're both talked about internalized stigma, how that really may also be a barrier toe having the these patients heard and the changes, um, and you know that they're undergoing when they come in, Maybe they have internalized that. So what would you say? to that, um, about internalized stigma and how toe open them up to get them to talk about their health care concerns or their sexual concerns. E r both of us are Who wants to go? You could go because I just spoke, e. I think you know the client senator approach. I do feel, uh, that well, I feel, um, practitioners, you know, already kind of stuck some or less competent than others dealing with HIV, or they see just the medical part. Here's your prescription, and we need you to hear the medication. And I think, uh, doing maybe an opt out approach where the person comes in and you say, Okay, here's your mental health appointment. Here's your spiritual care appointment. Here's your, um, uh, you know, physical. Here's your diet, you know, speak with nutritionists and and really look at it as a holistic health issue, Um, and educating that person about HIV as well. I've encountered many individuals who, uh, live when working with people living with HIV who don't really understand there, uh, status, You know, the lab work or, um, just kind of What am I doing next? The fatal fatality. Many people still have that idea that I'm going to die, you know, in 2020. And I think it's because we have not educated individuals. And I still believe the self affirmation that often is not in care where you look at that person holistically and especially their spirituality. Uh, especially being in the Deep South. People have a hard time separating dogma and doctrine from the connection to themselves and a higher power. And I think spirituality, if you look statistically, The Pew studies show that most Americans now identify spirituals and not religious or but not religious s b n are they called. And I think the healthcare has missed a big opportunity to not talk about spirituality. We do it with addiction, 12 step program. But when it comes to sexual health, we're often silent. We don't really talk about the sexual and spirituality, and I think spirituality is one of the best mode modalities and interventions to ameliorate the internalized shame and stigma of living with a job. But I'm a little biased. Amen. Amen. Dr. Baden, do you want Thio? Add anything into that? Yes, One of the things that I think I said something about it is the tab. How sex is viewed as being taboo and so surprisingly, is still being viewed as being taboo in the health care setting. Um, we were supposed to be health care providers and proposed to be sexual health educators when we're talking to our patients, but we're not doing that. We don't normalize that. The conversation we're talking about sexual history are are engaging people and really honest, Normal, I would say I like to say, normalizing the conversations around sexual health care. We wait on our patients to talk to us about it or to come in with a problem instead of approaching it in a more preventative matter. Like, let's be up front about this. You are having sex. So, like, you know, let's have these conversations in general about this and how you can be healthier, like asked them, you know, say, you know, would you like s T I screening right now are HIV testing. Do not wait for your patients to come in with a problem with it. They're coming in for their regular check up, Talk to them about it, give them advice about what options for them at this time There's a lot of things that many people in the public our patients do not know about. And it's art role as providers to be the experts. And so we need to act as if we are and stop, you know, making our assumptions about what that person's experience. Maybe, you know, we look at people, we say, Oh, you're young, you must be doing this or you're gay You must be engaging in this type of sex or if you're married, then you're not at risk at all. So that's the wrong way for us to go about this. We need to talk more about sexual health and how to be healthy individuals. And that could be from the spectrum of being HIV negative or unknown until being HIV positive. How can we be healthy individuals? That is a mouthful? That's a lot of unpacking. You had a lot of tasty morsels in their providers not being comfortable doing sexual health histories or screenings, and the patient senses they're not comfortable, then they don't want to talk. They don't wanna be judged. They don't want you staring at them like you nasty thing. That's not what it's about. It's about healthy. It's about when you come in like you said, for your regular visit and doing touching base. How's your relationship going? Have you had any issues? It's not just the young, it's the older to you have a man coming in asking for your dysfunction drugs. You need to be talking. You need to have that discussion about sex. Something is, you know, if it's broken and you're fixing it and they're using it and needs to be a discussion around it before it's bad. And so I think it was a very valid point. This ties into another question that I have for the Reverend Doctor. There was a slide you mentioned that spoke on anonymous sex, and I want you to give us a little bit. MAWR. The audience wants to know a little bit. MAWR. In what way does anonymous sex increased transmission risk? Inherently, If someone is adherent to their pre exposed exposure prophylaxis or prep for HIV treatment, the risk is nearly zero or zero. Anonymous sex is not an innate Lee bad practice any more so than anal sex is. So can you address this? Why does anonymous sex tend to increase your risk of HIV? Um, e think mentioning prep. Some people feel when they're on prep or, um, taking it, that it's ah prevent them from getting HIV, and they forget it's part of a process for part of a whole intervention where condom use is expected along with prep. And I think anonymous sex is, uh is one where people feel Well, if I don't know the person or I'm on prep, I can let my guard down and I can engage in behavior and not really counted or accommodate it. Andi, you know, there are several assumptions that are not correct when it comes to, say, anal sex that Oh, I'm talking about sex and I'm a reverend Uh uh. That, uh, that on Lee, you know, men who have sex with men, it ain't no anal sex, but heterosexuals. I mean, I think that when you look at the ways of which people encounter six and have text, many people use substances. And you know, unfortunately, when people are high or drunk, they become, try sexual, they'll try anything with anybody. And you know you have meth, which increases the libido. But for men, often the front part doesn't work. So they end up, you know, engaging in more anal intercourse. And I think they negation of talking about Dr Bond said, uh, talking about sex as a sacred gift as a positive thing that we all it's a natural natural to do without it, none of us would be here. And I think that we have to reframe the narrative and, um, you know, and talk about sex is a be very sex positive. You know, when I engage clients center approaches, I'd say when the last time. So I, you know, assume that you're sexually active and you have to tell, you know, I'm not active now, but when was the last time you had sex and was a male female or both, And and I think it normalizes behavior where people don't feel Or I can't tell you about this type of behavior, Orel Sex included. I'm just gonna tell you about this on Dr Bond also raised a great point. That marriage does not mean monogamy and that many people feel if they're in a marriage where they don't use, uh, condoms, then if they go out one partner and have anonymous sex that somehow that doesn't count or because I didn't use a condom, it doesn't count. And so I'm coming back into my main partner and, you know, in the South, Alabama in particular, is higher. No, y'all can't believe that. But the average sex partners will think for Americans is four, and then Alabama is five and now mix. And so in the South we do a lot more brand, give the other, and so I think that's what you have to look at. It is really concurrent sexual partnerships and encouraging people to know their status and take care of their bodies, including when they have anonymous encounters. And and that's a very valid point. And I agree totally with Dr Bond and you regarding marriage doesn't protect you, regardless of your gender, same sex marriage, whatever the marriages about it does not protect you from anything if somebody else is not protecting themselves and then coming back to you. So I think that's important to talk about. But it's also something that we don't want. Thio, you know, look upon frown on our patients on how they handle their relationships because some people do have open relationships and this was another question had come in that's very tied to this. It says. How could we de stigmatize HIV if we continue to re stigmatize sex, which is what you have been talking about? And that included drug use and others in the process? And they said that anonymous sex is not a bad thing to state in ultimate ways, that is stigmatizes those who have it. So not all read desire relationships based on the standard societal norms. And that's what that person had to say. And you spoke. Both of you spoke to pieces of this, But it does seem like, you know, like you said, if we're married, then you're not at risk. That is a societal norm, and it's not necessarily what people do. And all across the world, when polygamy is alive and well and people have multiple concurrent relationships, so not judging people is important. Do you have anything else you want to add into that? I do feel that it's not important, is really important to not judge people. And when I talked to whether you're 12 years old, are you 65 years old about sex? I always say Think about CCP and I talk about consent, communication and pleasure. At the end of the day, when it comes to sex in order for us to have a sex very healthy approach in a sex positive approach where we are focusing on how to be healthy individuals we have to think about is this person that I'm having sex with Is this consensual? Is it are we both on agreements with about this? Are we communicating about sex like what type of sex we're gonna have? Have you had, you know, RST I status HIV status, those type of things. Is there room for that toe happen and then pleasure like, yes, you do enjoy sex is not This bad thing is not the enemy, you know, and we and and just because you may have it s t I doesn't mean that that's something bad that you did something negative, you know? So it's all about how we approach it. Because if we de stigmatize having it s t I, then that means more people are more likely to go to get tested and and B and adhere to treatment, you know? So let's let that go and think that That's the worst thing that can happen to you when you're having sex. That's not the worst thing that could happen to you. You may not have a good sexual experience overall, so think about it that way. So I always go with a consent, communication and pleasure approach. And no matter what you're talking about, when it comes to sex, it can all relate right back to that. I love the CCP. I learned something every time I do one of these sessions. This is wonderful. I want to take a minute to remind the audience that we're still looking for questions. Happy to answer them if you just submit on that little button below your screen so that we can keep the conversation going, I'm really loving this. Um, I have to go back to a point that the reverend doctor said about asking if you have sex with a man, woman or both. I have moved from that because it was very big back in the day when we said that, But now to include my brothers and sisters living the trans experience, I say, what body parts do you use to have sex? And so that again de stigmatizes some of this stuff around what we're doing because you could make assumptions that all gay people have anal intercourse, and that's not true. All heterosexuals just have vaginal sex, and we know that's not true. When 30 something percent of women or almost 40% have anal sex, we need to be talking about what body parts do we use. And that way it lessens the stigma around what we're doing. And so I just wanted to kind of throw that out e real quick on that. I think focusing on behavior and like you're saying rather than the labels has been effective. Like you said, What body parts, Uh, what is your behavior? You know, when you have sex, you know, And and I think that, uh, looking at it holistically, you know, is a better approach than, um, you know, a lot of times those assumptions are very can be deadly. When you don't ask about behavior and assume based on somewhat sexual orientation or marital status. Theus assumptions made about their sexual behavior. Totally. So. I think a holistic treat every and universal approach to behavior. You know, the last time you had sex was at Orrell Anal vaginal. Like you're saying In what body parts or Dr Bob, What other things did you use the oh, pleasure and speak about it In that way? Yes, that goes back to the CCP. We leave pleasure out of the equation a lot, and we should be number one putting that in the forefront. It's not just about dysfunction. It's about Are you doing something you enjoy? If you're having bad sex, that's a shame. Way. Yes, there is your sexual behavior person. So, yes, we need to work on that. So I have another question here for the Reverend Doctor. How can we work with our religious and faith based organizations to help address the roots of stigma? I think to directly address that sex is positive and it's sacred. It's a gift and that individuals are not bad and need to be good. That sex and sexuality is part of one's overall health. And I think if you ask, uh, religious practitioners to look at it, uh, in that way, the human way and look at six as no more normative, they would open up on maybe change and also the fact that age. I mean that the you mentioned drugs that help individuals older man who normally would not be sexual active become sexual active. I know the mothers and the church to preachers don't wanna admit but that that older people are having sex. You know, I had my great aunt at the nursing home and when it took her a gift and she was given to the man down the hall who was Abu But she was in the room with some other man who's boo. So I ain't the one. The gossip. She hadn't heard that for me, but they help church folks understand religious people. Um, my colleagues that it it is our responsibility to care for our people, and we have to use a holistic approach. It's not a fragmented approach, Andi. Offer them in their sexual health, think about sexual health, emotional health. And they're spiritually physical health. And I believe that we church leaders have gotten away with fragmenting individuals in our pews, and we only wanna look at their spiritual health. Are they praying? Are they meditating? Are they giving? But I just say that that would they but But you want to make sure that we preachers, you have to talk to us about being more holistic in our approach. Amen. I am loving this because it just really hits me the sex positive. I think about age, too. I'm a older woman. We think about vaginal atrophy or dryness, those air discussions to be having with people. I've been to the nursing home speaking assistant Living programs. There are three good men in there and, ah, women and they are making the rounds. Diapers. They're flying walkers or being thrown down. It is on and praise the Lord. They can still some pleasure, but we need to have these discussions. You just don't assume because there's snow on the roof that there's no embers or fire blazing below. So it's really way have recognizes in all people because we are sexual beings. So I love the way both of you so eloquently put stated your sex positive messages. We have another question, and it is. Do you think that when s T. I status or sexually transmitted infection status and HIV status are separated? Does that re stigmatize HIV even when compared toa other s t I not sure if I quite understand that. But e think you know, I understand. I think I get what the person is trying to ask out, Um, and maybe this'll kind of clear some things up. Usually when we talk about HIV, there's no cure at this time. Um, you know, there's treatment, and so I think people still equate HIV with death with something that can't be cured and with the other S T. I s. With the exception of herpes, there's, You know, you could you could go to the doctor and you could receive treatment and it could go away. And, um and I understand why it can't come up in the sense there's still that stigma in our society when it comes to HIV. And as I stated before, you know, this has been about 40 years now, and we still are hearing the same conversations. People don't understand that is more of a chronic disease now than it was before in the 19 eighties. You can live and have a healthy life with HIV. You can have a healthy sexual life with HIV, and I think that that that is the issue at this time that we still are still 40 years in the past, when we talk about HIV in the community and I think it with more sessions like this and just talking, I'm talking with people that we could change that perspective. Thank you so much. We are at that time. Unfortunately, Justus, the conversation was getting even better and more lively and robust. I have a few housekeeping reminders here for you that as our virtual audience, you will receive a follow up survey. Along with that, you'll receive a certificate of attendance, as well as a tool kit that includes some vital takeaways from the program and where to look for additional information. Don't forget the next and final program in this Siri's and ending the HIV epidemic will be on November 19th. Now, I would like to give heartfelt thanks to Dr Kiyoshi Bond. The Reverend Dr Tommy Watkins Jr are wonderful. Gilead moderators Blake and Denise, as well as Chauncey Watson, the mastermind of the Siri's clinical minds and broadcast Meet Med and especially, you are fabulous virtual audience for your wonderful questions. I hope you enjoy the rest of your day. Be blessed and be safe. Thank you Created by
