Mosaic Intersections

For some time, I have contemplated about the paucity and invisibility of Black trans and non trans women in the promotion and utilization of Preexposure Prophlyaxis, PrEP, [a method of preventing the acquisition of the Human Immunodeficiency Virus (HIV) by HIV negative individual taking daily antiretroviral medication before exposure].  Most of the PrEP trainings  I attend are facilitated by non Black women.  The key population to engage and enroll in PrEP conversations and care usually excludes any reference to Black women.  Thus, I wrote and submitted an analysis of the integration (or lack thereof) of PrEP into health care for Black trans and non trans women on September 11, 2016 as  part of my application for a feminist writing fellowship.  My hope is to obtain mentorship and guidance as an emerging author hoping to carve out a niche in a health journalism utilizing a sexual AND reproductive health, rights, and justice framework . In light of current events and “our” story, centering Black trans and non trans women and girls in this work is an active form a sexual liberation, resistance, and resilience to succumbing to the devastating impact of HIV/AIDS in the Black community. After the debut of my blog, I continued to wonder whether or not to share my thoughts about PreP and Black women,  as I can only imagine the response, especially given the historical and modern day omission and disregard for Black women in the feminist movement and in conversations and analyses about sex positivity and sexual pleasure. And then today, I read a Facebook post from my dear sister-comrade-friend who shared the words of her friend, that validated the intent and content of my analysis from September 11, 2016:

“Black women choosing to live is resistance.  Black women choosing ourselves is resistance.  Black women choosing joy is resistance.  Black Women loving Black Women is resistance.  Anyone loving Black Women is resistance. Black women being is resistance.  I am resistance simply because I’m here. <3”

– Kimberly Gaubault

Today, I add my truth.

“Black women having sex, regardless of the intent, and living are an acts of resistance and resilience.”

With the focus on reproductive justice, health and rights, at the exclusion of the pursuit of sexual health equity, rights, and justice, we as a community are failing to call out the unjust and inequitable policies, practices, and programs that continue to support white male patriarchy and white supremacy in sexual and reproductive health care, specifically in sexually and HIV prevention and intervention strategies.

Based on the evidence, we must call out the presence of white patriarchy and white supremacy when 74.5% of PrEP users are white; mostly composed of young white men who have sex with men, a group with falling rates of new HIV infections, when surveillance data demonstrates the following disparities and inequities:

• Of the more than 1.1 million people living with HIV in the U.S., more than 270,00 (24%) are women.
• Women represent one in 5 (20%) new HIV diagnoses in the US.
  • In 2010, Black women comprise 64% of all new HIV infections among women and girls while only representing 13% of the US female population.
  •  In comparison, White women comprise 18% of new HIV infections among women and girls and Latinas represent 15% of new HIV infections.
  • In 2014, American Indians and Alaska Natives (AI/AN)  represent 44,073 (1%) new HIV diagnoses in the United States which is similar 1.2%  of AI/AN persons living in the US population.  Of those AI/AN persons diagnosed with HIV, 77% are men and 22% are women.
• Women are most likely to be infected with HIV through heterosexual sex, representing 84% of new infection in 2010.
• The majority (60%) of women living with an HIV diagnosis are Black, 19% are Latina, and 18% are White.
• The rate of new HIV infections for Black women are 20x higher than the rate of white women; the rate for Latinas is 4x higher.
  • Rates of women living with HIV diagnosis follow a similar pattern.
• In 2010, Black women represent 60% of the deaths among women with HIV followed by White women (18%) and Latinas (12%).
• Although recent data show that new infections among women overall and among Black women are on the decline, differences in the lifetime risk of HIV diagnosis for Black women are rather striking in comparison to White women. Based on a study from the Centers for Disease Control and Prevention released in February 2016 (check out http://redproject.org/wp-content/uploads/2015/04/Lifetime-Risk-of-HIV-Diagnosis-in-the-United-States_2016.pdf ), the lifetime risk of HIV diagnosis for  by race/ethnicity among men and women is
  • 1 in 20 for Black men
  • 1 in 48 for  Black women
  • 1 in 48 for Hispanic men
  • 1 in 227 for Hispanic women
  • 1 in 132 for  White men
  • 1 in 880 for White women
• Among women who died from HIV in 2010, 64% of deaths occurred among Black women, followed by White women (18%) and Latinas (12%).
• In 2010, HIV was the 7^th leading cause of death for Black women ages 25-44, but did not rank among the top 10 leading causes of death for white women 25-44.
• With respect to age, Women aged 25-44 represented the largest proportion (29%) of new infections in 2010.
  • The new infections among Black and Latina women are more likely to be younger in age in comparison to White women. More than 1 in 5  Black women (23%) and Latina women (21%)  infected with HIV are youth and young adults aged 13-24 years of age, compared to 16% of new infections among White women.
• Most women acquired HIV through sex with men, or heterosexual contact (84% of new infections in 2010) followed by injection drug use (16%).
  • The pattern is consistent across racial and ethnic groups.
  • Black (87%), Latina (86%), and White (76%) women with new HIV diagnoses acquired HIV through heterosexual contact
• Previous studies have shown that HIV is spread more efficiently from men to women during sexual intercourse.
• Women with other STIs and bacterial vaginosis are at greater risk for acquiring HIV.
• Although more than half of women (55%) in the U.S. report having had a prior HIV test at some point in their lifetime, a little more than 1 in 5 (22%) women report being tested in the past year.
  • More Black women report being tested in the past year compared to White women, (52% compared to 12%).
• Analyses of the spectrum of access to care, from HIV diagnosis to viral suppression, reveals missed opportunities for engaging women.
  • First, let’s define viral suppression, when a person’s viral load (HIV RNA) is reduced to an undetectable level through the use of antiretroviral therapy (ART).  Viral suppression does not mean a person is cured as HIV still remains in the body. However,  viral suppression in a person with HIV is beneficial to both the individual and the public as a means to achieve improved health and prolonged for the individual and decreased risk of new HIV diagnoses in the public.
  • Among women living with HIV in the U.S., 85% have been diagnosed but only 70% have been linked to care.
  • Only 2 out of 5 women (41%) are retained in regular care.
  • Nearly 1 in 3 (36%) are prescribed ART
  • Just 1 in 4 (26%) are virally suppressed
    • Black women are least likely to achieve viral suppression at 21%, compared to 26% of Latina/Hispanic women and 30% of White women.

The context of HIV, race, gender, and age reveals differences that are rather noteworthy of a greater attention and analysis, especially as women overall and Black women, are not yet the focus of PrEP campaigns.  If Black women are more likely to acquire HIV from heterosexual encounters, then our ability to choose and access partners who are HIV negative is limited based on the evidence. Likewise, we are more likely to participate in sexual networks with  higher prevalence of  HIV, usually undetected, as a result of a host of structural barriers. Consequently, we as black women have limited to no sexual agency or autonomy to encounter partners who are low risk for HIV or HIV positive on ART AND virally suppressed. Our ability to freely engage in sexual interactions for the sole pursuit of sexual pleasure, without perceived or real harm, is not equal to that of white men who have sex with men (MSM), who do not appear have to worry about the dual consequences of unprotected sex – undesired STI/HIV and pregnancy.

A reproductive health, justice, and rights (RHJR) approach broadens access to PrEP to discordant couples (where one is HIV positive and one is HIV negative)  who now have the capacity to have sex for purpose of  becoming pregnant  and/or parenting a HIV negative child with a similar freedom as other couples and families not affected by HIV. However, a RHJR only approach could convey to trans and non trans women that health care and public health systems are only concerned for their safety and well-being with respect to reproduction, pregnancy, and parenting, while continuously dismissing the impact of pursuing sex for pleasure and partnering with freedom and safety.

If we develop a sexual AND reproductive health, rights, and justice (SRHRJ) approach to PrEP then we could possibly create new paradigms where we imagine, celebrate, and support the pursuit of sexual pleasure in the absence of and/or beyond romance/love, reproduction, and monogamy. How can we move towards acceptance that individuals seek sex with different partners, sometimes concurrently, and that sometimes women are either suspicious or aware, and continue to have sex for a host of reasons, that we in academia, public health, healthcare and policy may never understand and/or have the means to characterize or evaluate? How do we then reframe from perpetuating stigma and shame, and instead facilitate improved sexual agency, autonomy, communication, decision making, and hopefully health care seeking behaviors in a manner, that not only assumes consent and mutual pleasure (if possible) but also safety, with respect to preventing the acquisition and/or transmission of HIV in meaningful and sustainable ways that places power in the hands of women, including trans women, Black women, and Black trans women?  Why must sexual liberation and choice without fear of HIV  be restricted only to white MSM, a group with continuously falling rates of HIV?

Imagine the long term impact of a SRHRJ approach to PrEP:

• Increased options for partnering
• Decreased fear, shame, stigma and anxiety associated sex
• Increased pleasure
• Decreased numbers of children born with HIV
• Increased options to have healthy children by preferred partners, regardless of HIV status

More concerning is when we examine the relationship between the combined epidemics of substance abuse, gender based violence (GBV) and HIV/AIDS, known as the SAVA syndemic, we are able to better appreciate the ways in which overlapping and reciprocating factors contribute to the disparities in HIV acquisition and transmission and inequities in access to care based on race, gender, and age. In my subsequent blog post, I will further characterize SAVA syndemic and its association with HIV risk taking behaviors, mental health, healthcare utilization, combination ART adherence, viral suppression, and regulation of immune system. If we cannot immediately alter the context of sex and gender based violence, mental health, poverty  and the need for persons, particularly trans and non trans women, to participate in sexual exchanges for protection, money, food, housing, or drugs, then I hope to utilize the blog as one platform to disrupt the notion that PrEP is only for MSM through education, awareness, and advocacy. Additionally, I am also particularly invested in building a body of work with other like-minded SRHRJ educators, evaluators, epidemiologists, scientists, clinicians, thought leaders, and activists that:

1) expands upon the critique of the dominance of the “race, class, gender” triad in the US which excludes, ignores, and/or devalues the significance and implications of an additional intersectional analysis, inclusive of religion, ethnicity, age, nationality, and other social locations (i.e. barber shops, beauty salons, faith based organizations);

2) challenges the lack of critical and compassionate examinations on sexual pleasure and intimacy in the absence of romance and reproduction and the intersections between sexual & reproductive health, sexual & reproductive justice, sexual and reproductive rights, sexual & reproductive health equity, and sexualities in the plural;

3) increases representation of varying levels of analysis, particularly at the level of organization, systems, places, and dyads (i.e., educator-health care provider, health care provider – patient, patient -partner, peer-peer); and

4) calls out and challenges the reinforcement of  biases about individuals and groups as a result of the omission and/or minimization of analyses of historical and present day factors and socioeconomic and sociocultural contexts that inform sexualities.

The above points from Dworkin, Lerum, and Zakaras 2015 have resonated with me and validated my own notions and concerns about sex and sexuality research and evaluation. In my heart of hearts, I am a nomad social scientist, warrior activist, and empathic healer who sees, feels, and analyzes the world through an intersectional lens, hoping to better understand and share the ways in which social, psychological, political, cultural, and economic circumstances influence sexual and reproductive agency, autonomy, communication, decision making, health care seeking behaviors, and health outcomes, particularly among all women, girls, and youth of color.  Although I continue to struggle to find safe spaces and relationships to fully actualize my divine potential and purpose, I remain committed to challenging and critiquing the continued omission of race, sex, gender, age, and trauma in the narratives and examinations of STI/HIV and sexual health disparities.

Intersectionality provides the vision and framework by which public health, health services research and health care systems can develop, monitor, evaluate and adapt policies, programs, and services as means to move STI/HIV and sexual health care towards safety, diversity, inclusion, and equity.

Thank you for accompanying me on this journey of resistance and resilience.

“When I dare to be powerful – to use my strength in the service of my vision, then it becomes less and less important whether I am afraid.”  

– Audre Lorde

 

Until we meet again,

Scotty

 

References

Kaiser Family Foundation. Women and HIV/AIDS in the United States.  March 06 2014. Retrieved from http://kff.org/hivaids/fact-sheet/women-and-hivaids-in-the-united-states/ on September 11, 2016.

Dworkin SL, Leru, K, and Zakaras JM.  Sexuality in the Global South: 50 Years of Published Research in the Journal of Sex Research – Inclusions, Omissions, and Future Possibilities. The Journal of Sex Research 2015; 00(00):1-6. DOI: 10.1080/00224499.2015.1106433.